Endometriosis is a hormone-dependent pathological overgrowth of the glandular tissue of the uterus (endometrium) outside of it: in the ovaries, in the fallopian tubes, in the thickness of the uterus, in the bladder, on the peritoneum, in the rectum and other organs. Clinical manifestations depend on the localization of the process. Common symptoms are pelvic pain, enlarged endometrioid nodes, spotting from the external areas before and during menstruation. Diagnostics includes gynecological examination, ultrasound, hysteroscopy. Treatment – hormone therapy, surgical removal of gerotopias, in severe cases, hysterectomy is required.
ICD 10
N80 Endometriosis
General information
Disease is a pathological benign overgrowth of tissue morphologically and functionally similar to the endometrium (uterine mucosa). It is observed both in various parts of the reproductive system and outside it (on the abdominal wall, bladder mucosa, intestines, pelvic peritoneum, lungs, kidneys, etc. organs). Fragments of the endometrium (heterotopia), growing in other organs, undergo the same cyclic changes as the endometrium in the uterus, in accordance with the phases of the menstrual cycle. These changes in the endometrium are manifested by pain, an increase in the volume of the affected organ, monthly bloody discharge from heterotopias, menstrual dysfunction, discharge from the mammary glands. Genital form can cause the formation of ovarian cysts, menstrual irregularities, infertility.
Disease is the third most common gynecological disease, after inflammatory processes and uterine fibroids. Disease in most cases occurs in women in the reproductive period, i.e. at the age of 25-40 years (about 27%), occurs in 10% of girls during the formation of menstrual function and in 2-5% of women in menopausal age. The difficulties of diagnosis, and in some cases, the asymptomatic course suggest that the disease is much more common.
Causes
There is no consensus among experts about the causes of this patgology. Most of them are inclined to the theory of retrograde menstruation (or implantation theory). According to this theory, some women get menstrual blood with endometrial particles into the abdominal cavity and fallopian tubes – the so-called retrograde menstruation. Under certain conditions, there the endometrium attaches to the tissues of various organs and continues to function cyclically. In the absence of pregnancy, the endometrium is rejected from the uterus during menstruation, while micro-hemorrhage occurs in other organs, causing an inflammatory process.
Other theories of the development of this disease, which are not widely spread, consider gene mutations, abnormalities in the function of cellular enzymes and hormone receptor reactions as its causes.
Risk factors
Women who have such a feature as retrograde menstruation are predisposed to the development of this disease, but not in all cases. Factors such as: Increase the likelihood of endometriosis:
- Heredity. The role of hereditary predisposition to the development and its transmission from mother to daughter is very high.
- Surgical interventions on the uterus: surgical termination of pregnancy, cauterization of erosions, caesarean section, etc.
- Immunodepression.
- Metabolic disorders, obesity, overweight.
- The use of intrauterine contraceptives.
- Age after 30-35 years.
- Increased estrogen levels.
- Smoking.
Pathomorphology
Endometrioid foci can vary in size and shape: from rounded formations several millimeters in size to shapeless growths several centimeters in diameter. Usually they have a dark cherry color and are separated from the surrounding tissues by connective tissue whitish scars. Foci of endometriosis become more noticeable on the eve of menstruation due to their cyclic maturation. Spreading to the internal organs and peritoneum, areas can grow deep into the tissue or be located superficially.
Ovarian disease is expressed in the appearance of cystic growths with dark red contents. Heterotopias are usually arranged in groups. The degree is estimated in points, taking into account the diameter, depth of germination and localization of foci. Pathology is often the cause of adhesions in the pelvis, limiting the mobility of the ovaries, fallopian tubes and uterus, leading to menstrual irregularities and infertility.
Classification
Manifestations depend on the location of its foci. In this regard, disease is classified according to localization. By localization, genital and extragenital forms of endometriosis are distinguished. In the genital form of endometriosis, heterotopias are localized on the tissues of the genitals, in the extragenital form – outside the reproductive system. In the genital form of endometriosis , there are:
- peritoneal endometriosis – with damage to the ovaries, pelvic peritoneum, fallopian tubes
- extraperitoneal endometriosis, localized in the lower parts of the reproductive system – external genitalia, in the vagina, vaginal segment of the cervix, rectovaginal septum, etc.
- internal endometriosis (adenomyosis), developing in the muscular layer of the uterus. With adenomyosis, the uterus becomes spherical, enlarged in size up to 5-6 weeks of pregnancy.
Localization can be mixed, it occurs, as a rule, when the disease is neglected. In the extragenital form, foci of heterotopias occur in the intestine, navel, lungs, kidneys, and postoperative scars. Depending on the depth and spread of focal growths, there are 4 degrees of endometriosis:
- Grade I — superficial and single foci of endometriosis;
- Grade II — foci of endometriosis are deeper and in greater numbers;
- Grade III — deep multiple foci of endometriosis, endometrioid cysts on one or both ovaries, separate adhesions on the peritoneum;
- Grade IV — multiple and deep foci of endomeriosis, bilateral large endometrioid cysts on the ovaries, dense adhesions, endometrial germination into the walls of the vagina and rectum. IV degree is characterized by the prevalence and severity of the lesion, difficult to treat.
There is also a generally accepted classification of uterine adenomyosis, in the development of which there are four stages according to the degree of damage to the muscle layer (myometrium):
- Stage I – the initial germination of the myometrium;
- Stage II – the spread of foci of endometriosis to half the depth of the muscular layer of the uterus;
- Stage III – germination of the entire thickness of the myometrium up to the serous lining of the uterus;
- Stage IV – germination of the uterine walls and the spread of foci of endometriosis to the peritoneum.
Endometriosis symptoms
The course of endometriosis can be diverse, asymptomatic at the beginning of its occurrence, and its presence can only be detected in time with regular occupational examinations. However, there are reliable symptoms indicating the presence of endometriosis.
- Pelvic pain.
Accompanies disease in 16-24% of patients. The pain may have a clear localization or diffuse character throughout the pelvis, occur or intensify immediately before menstruation or be present constantly. Pelvic pain is often caused by inflammation developing in organs affected by endometriosis.
- Dysmenorrhea – painful menstruation.
It is observed in 40-60% of patients. It is maximally manifested in the first three days of menstruation. With this pathology, dysmenorrhea is often associated with bleeding into the cyst cavity and increased pressure in it, with irritation of the peritoneum by hemorrhages from endometriosis foci, spasm of the uterine vessels.
- Painful sexual intercourse (dyspareunia).
- Pain during defecation or urination.
- Discomfort and pain during sexual intercourse is especially pronounced when foci of endometriosis are localized in the vagina, the wall of the rectovaginal septum, in the sacro-uterine ligaments, utero-rectal space.
- Menorrhagia – copious and prolonged menstruation.
It is observed in 2-16% of patients with endometriosis. It often accompanies adenomyosis and concomitant diseases: uterine fibroids, polycystic ovaries, etc.
- Development of posthemorrhagic anemia
Occurs due to significant chronic blood loss during menstruation. It is characterized by increasing weakness, pallor or jaundice of the skin and mucous membranes, drowsiness, fatigue, dizziness.
In patients with endometriosis, it is 25-40%. While gynecology cannot accurately answer the question about the mechanism of infertility development in endometriosis. Among the most likely causes of infertility are changes in the ovaries and tubes due to endometriosis, violation of general and local immunity, concomitant ovulation disorder.
With this disease, we should not talk about the absolute impossibility of pregnancy, but about its low probability. Endometriosis dramatically reduces the chances of carrying a child and can provoke spontaneous miscarriage, therefore, the management of pregnancy with endometriosis should be carried out with constant medical supervision. The probability of pregnancy after endometriosis treatment ranges from 15 to 56% in the first 6-14 months.
Complications
Hemorrhages and scarring in endometriosis cause the development of adhesive processes in the pelvis and abdominal organs. Another frequent complication of endometriosis is the formation of endometrioid ovarian cysts filled with old menstrual blood (“chocolate” cysts). Both of these complications can cause infertility. Compression of nerve trunks can lead to various neurological disorders. Significant blood loss during menstruation causes anemia, weakness, irritability and tearfulness. In some cases, malignant degeneration of foci of endometriosis occurs.
Diagnostics
When diagnosing endometriosis, it is necessary to exclude other diseases of the genital organs that occur with similar symptoms. If endometriosis is suspected, it is necessary to collect complaints and anamnesis, in which pain, information about diseases of the genitals, operations, and the presence of gynecological pathology in relatives are indicative. Further examination of a woman with suspected endometriosis may include:
- gynecological examination (vaginal, rectovaginal, in mirrors) is most informative on the eve of menstruation;
- colposcopy and hysterosalpingoscopy to clarify the location and shape of the lesion, to obtain a tissue biopsy;
- ultrasound examination of the pelvic organs, abdominal cavity to clarify the localization and dynamic picture in the treatment of endometriosis;
- spiral computed tomography or magnetic resonance in order to clarify the nature, localization of endometriosis, its relationship with other organs, etc. The accuracy of the results of these methods in endometriosis is 96%;
- laparoscopy, which allows you to visually examine the foci of endometriosis, assess their number, degree of maturity, activity;
- hysterosalpingography (X-rays of the fallopian tubes and uterus) and hysteroscopy (endoscopic examination of the uterine cavity), allowing to diagnose adenomyosis with an accuracy of 83%;
- the study of tumor markers CA-125, REA and CA 19-9 and RO-test, whose blood counts in endometriosis increase several times.
Treatment of endometriosis
When choosing a method of treatment for this disease, such indicators as the patient’s age, the number of pregnancies and births, the prevalence of the process, its localization, the severity of manifestations, the presence of concomitant pathologies, the need for pregnancy are guided. Methods of treatment of endometriosis are divided into medical, surgical (laparoscopic with removal of foci of endometriosis and preservation of the organ or radical – removal of the uterus and oophorectomy) and combined.
Conservative treatment
Treatment of endometriosis aims not only to eliminate the active manifestations of the disease, but also its consequences (adhesions and cystic formations, neuropsychiatric manifestations, etc.). Indications for conservative treatment of endometriosis are its asymptomatic course, the young age of the patient, premenopause, the need to preserve or restore childbearing function. Leading in the medical treatment of endometriosis is hormone therapy with the following groups of drugs:
- combined estrogen-progestogenic drugs.
These drugs, containing small doses of progestogens, suppress the production of estrogens and ovulation. They are indicated at the initial stage of endometriosis, because they are not effective with the prevalence of the endometrioid process, ovarian cysts. The side effect is expressed by nausea, vomiting, intermenstrual spotting, tenderness of the mammary glands.
- progestogens (norethisterone, progesterone, gestrinone, didrogesterone).
They are indicated at any stage of endometriosis, continuously – from 6 to 8 months. Taking gestagens can be accompanied by intermenstrual bleeding, depression, breast tenderness.
- antigonadotropic drugs (danazol, etc.)
Suppress the production of gonadotropins in the hypothalamus-pituitary system. They are applied in a continuous course for 6-8 months. Contraindicated in hyperandrogenism in women (excess of androgenic hormones). Side effects are sweating, hot flashes, changes in weight, coarsening of the voice, increased fat content of the skin, increased intensity of hair growth.
- agonists of gonadotropic releasing hormones (triptorelin, gozerelin, etc.)
The advantage of drugs of this group in the treatment of endometriosis is the possibility of using drugs once a month and the absence of serious side effects. Releasing hormone agonists cause suppression of the ovulation process and estrogen content, leading to suppression of the spread of endometriosis foci. In addition to hormonal drugs, immunostimulants, symptomatic therapy are used in the treatment of endometriosis: antispasmodics, analgesics, anti-inflammatory drugs.
Surgical tactics
Organ-preserving surgical treatment with the removal of heterotopias is indicated in the middle and severe stages of the course of endometriosis. Treatment is aimed at removing foci of endometriosis in various organs, endometrioid cysts, dissection of adhesions. It is carried out in the absence of the expected effect of drug therapy, the presence of contraindications or intolerance to medications, the presence of lesions with a diameter of more than 3 cm, violation of the functions of the intestine, bladder, ureters, kidneys. In practice, it is often combined with medical treatment of endometriosis. It is performed by laparoscopic or laparotomic approaches.
Radical surgical treatment of endometriosis (hysterectomy and adnexectomy) is performed in patients after the age of 40 with active progression of the disease and ineffectiveness of conservative surgical measures. Unfortunately, radical measures in the treatment of endometriosis are required by 12% of patients. Operations are performed by laparoscopic or laparotomic methods.
Forecast
Endometriosis has a tendency to relapse processes, in some cases forcing to resort to repeated surgical intervention. Relapses of endometriosis occur in 15-40% of patients and depend on the prevalence of the process in the body, its severity, localization, and the radicality of the first operation.
Endometriosis is a formidable disease for the female body, and only its early detection and persistent treatment leads to complete elimination of the disease. The criteria for the cure of endometriosis are satisfactory well-being, the absence of pain and other subjective complaints, the absence of relapses within 5 years after undergoing a full course of treatment.
In childbearing age, the success of endometriosis treatment is determined by the restoration or preservation of childbearing function. With the current level of surgical gynecology, the widespread use of gentle laparoscopic techniques, such results are achieved in 60% of patients with endometriosis aged 20 to 36 years. In patients with endometriosis, the disease does not resume after radical operations.
Prevention
The earlier, when the first symptoms of endometriosis appear, a woman comes to a gynecologist’s consultation, the more likely a complete cure and the absence of the need for surgery. Attempts at self-treatment or wait-and-see tactics in the case of endometriosis are absolutely not justified: with each subsequent menstruation, new foci of endometriosis appear in the organs, cysts form, scarring and adhesions progress, there is a decrease in the patency of the fallopian tubes.
The main measures aimed at preventing endometriosis are:
- specific examination of adolescent girls and women with complaints of painful menstruation (dysmenorrhea) in order to exclude endometriosis;
- observation of patients who have undergone abortion and other surgical interventions on the uterus to eliminate possible consequences;
- timely and complete cure of acute and chronic genital pathology;
- taking oral hormonal contraceptives.
In relation to endometriosis, as well as many other gynecological diseases, a strict rule applies: the best treatment of the disease is its active prevention. Attention to your health, the regularity of medical examinations, timely therapy of gynecological pathology allow you to catch endometriosis in the very initial stage or even avoid its occurrence.