Ovarian endometriosis is a form of external genital endometriosis in which ovarian tissue is affected. It is manifested by chronic pelvic pain, copious painful menstruation, dyspareunia, dysuria, dyschesia and infertility. For diagnosis, bimanual palpation, transvaginal ultrasound, CT and MRI of pelvic organs, diagnostic laparoscopy, blood testing for the cancer marker CA-125 are used. In the conservative treatment of the disease, hormones, analgesics, sedatives are used. Surgical treatment involves enucleation of cysts, laser vaporization or electrocoagulation of endometriosis foci, resection or removal of the ovary.
N80.1 Ovarian endometriosis
The development of endometrioid formations in ovarian tissue is the most common form of endometriosis. The disease is diagnosed in every third woman who complains of gynecological problems. The pathological process can be both one-sided and two-sided. Ovarian endometriosis is most often detected in patients aged 22 to 45 years, while asymptomatic forms are found even in 10-14-year-old girls.
Due to the latent course of the initial stages, the disease is usually detected only 5-7 years after its occurrence, when the organ damage is already significant. At the same time, it is timely diagnosis that allows you to prevent infertility — the most common complication in such a pathology.
The proliferation of endometrioid foci in ovarian tissue is preceded by the introduction of endometrial cells into the pelvis. Although the etiopathogenesis of the disease has not been definitively established, a number of factors have been identified that increase the likelihood of developing endometriosis. The main ones are:
- Inflammation and neoplasia of the genitals. With cervicitis, endometritis, salpingitis, adnexitis, volumetric neoplasms of the body and cervix, the excretion of menstrual blood into the vagina may be disrupted and its retrograde casting may occur.
- Immune disorders. Normally, endometrial cells trapped in the pelvic cavity are destroyed by macrophages. Genetic predisposition, autoimmune diseases, weakening of protective forces in chronic diseases and taking immunosuppressive drugs lead to a decrease in such an immune response.
- Invasive interventions. Endometrial cells can enter the pelvic cavity during abortion, gynecological operations, diagnostic curettage, hysterosalpingography, other therapeutic and diagnostic procedures, when using an IUD for 5 years or more.
- Endocrine disorders. Dishormonal disorders in diseases of the ovaries, thyroid gland, adrenal cortex, failures at the hypothalamic-pituitary level affect the contractile activity of the fallopian tubes. As a result, the risk of retrograde withdrawal of menstrual blood increases.
The risk group also includes women who lead a sedentary lifestyle, are obese, eat irrationally, and often experience stress. The disease is more often diagnosed in patients with disorders of the ovarian-menstrual cycle in adolescence, unrealized childbearing function or late first pregnancy. The development of inflammatory processes, against which endometriosis occurs, is facilitated by promiscuity in choosing sexual partners and sex without barrier contraceptives.
If the endometrial cells that got into the pelvis with a retrograde discharge of menstrual blood were not destroyed by macrophages, there is a possibility of their introduction into the ovarian tissue. At first, endometriodic foci are small in size and are located superficially. Subsequently, endometriosis affects an increasing area of the ovary and spreads deep into the tissues. The cells of endometrioid growths are subject to the same cyclic changes as the uterine mucosa. Successive proliferation, secretion and rejection form characteristic anatomical changes and the clinical picture of the disease.
Multiple cysts form in the ovaries, the size of which increases with each menstrual cycle. Due to incomplete resorption, clotted blood accumulates in them, which has a characteristic “chocolate” color. The spread of the process to the follicular tissue leads to a violation of endocrine function. Regular blood flow into the pelvic cavity causes the formation of adhesions between the ovaries and nearby organs.
When determining the form of the disease, the structural features of the endometriodic tissue, the size of the lesion and the degree of involvement of other organs in the process are taken into account. Based on histological characteristics and clinical manifestations, specialists in the field of gynecology distinguish:
- Glandular-cystic endometriosis. The foci contain many glands, the size of cysts usually does not exceed 50 mm, the symptoms are clearly expressed.
- Endometrioid cysts. The formation has dimensions up to 120 mm and is located on the surface of the organ. This form is often asymptomatic.
Taking into account the stage of development of ovarian endometriosis, there are 4 degrees of the disease:
- I (small forms): single flat endometrioid foci have dimensions less than 10 mm and are located on the surface of the ovaries.
- II (light forms): multiple implantation sites in the form of surface plaques with a diameter of up to 10 mm.
- III (medium forms): multiple surface implants and enometriomas up to 20 mm in size, fallopian tubes are involved in the adhesive process.
- IV (severe forms): the diameter of the cysts exceeds 20 mm, the fallopian tubes are impassable, the ovaries are connected by adhesions to the intestines and / or urinary tract, on which foci of endometriosis can be determined.
Symptoms of ovarian endometriosis
More than 2/3 of patients have pain syndrome of varying intensity, duration and localization. Women complain of recurrent painful sensations in the lower abdomen, groin and lumbar region, soreness and discomfort during sexual intercourse, urination, defecation. Irradiation into the sacrum, vagina, rectum is possible. As endometriosis develops, painful sensations occur not only during exercise, but also at rest. Their duration and intensity increase, but the severity depends on the phase of the menstrual cycle. Before the onset of menstruation, the pain is usually dragging or aching, with the onset of menstruation it becomes cutting.
30% of patients have signs of algodismenoria — menstruation, accompanied by sharp pain, weakness, dizziness, nausea, vomiting, chills and fever to subfebrile figures. With endometriosis of the III-IV degree, a violation of the menstrual cycle is possible due to endocrine dysfunction of the ovaries: menstruation lengthens, becomes more abundant, spotting spotting occurs a few days before and after them. In more than half of cases, hormonal imbalance and adhesions in the pelvis cause infertility.
The pressure of large volume cysts can disrupt the function of the pelvic organs. In such cases, the woman notes bloating, constipation, increased urge to urinate, cyclic pain in the legs. When exposed to nerve bundles and plexuses, signs characteristic of lumbosacral sciatica may appear – lumbago in the leg, sharp pain in the lumbar region when the body changes, etc. Sometimes, against the background of pain and hormonal disorders, tearfulness, irritability, a depressed state appears, sleep is disturbed, the skin becomes flabby, dry or, conversely, acne occurs.
The main complication of ovarian endometriosis is a violation of reproductive function that occurs against the background of an imbalance of sex hormones and adhesive disease. More than 60% of patients cannot get pregnant, and even with the onset of pregnancy, such women have an increased risk of spontaneous abortion or premature birth.
With large endometriomas, the functions of nearby organs are disrupted, up to the development of urinary incontinence, intestinal obstruction and severe neurological disorders, and rupture of cysts can lead to the development of peritonitis and sepsis. Heterotopic endometrial cells are prone to malignancy. At the same time, malignant neoplasms are characterized by a high degree of aggressiveness, quickly spread to neighboring organs and metastasize with the flow of blood and lymph.
Most of the symptoms of ovarian endometriosis are characteristic of other gynecological diseases, therefore, a comprehensive examination is prescribed to the patient for accurate diagnosis. As a rule, it includes:
- Examination on the chair. During a bimanual examination, the tenderness of the appendages is determined from one or two sides. With 3-4 degrees of the disease, heaviness is palpated, sometimes — compacted volumetric formations with limited mobility.
- Transvaginal ultrasound. Ultrasound examination shows deformation of the ovarian contour, thickening and compaction of its capsule, the presence of round or oval foci on the surface with clear boundaries and a homogeneous structure. Cystic formations are characterized by increased echogenicity and a doubled contour. There may be echo signs of adhesions and fluid in the pelvis.
- MRI and CT of the pelvis. Obtaining a layered three-dimensional image of the pelvic organs allows you to determine the extent of the spread of the process, identify adhesions in the pelvis, exclude neoplasia.
- Diagnostic laparoscopy. The most reliable diagnostic method, in which it is possible to visually assess the condition of the ovaries, the features of endometrioid formations, the involvement of adjacent organs in the process, to obtain a biopsy for histological examination and perform therapeutic manipulations.
- Blood test for oncogenes. Specific for endometriosis is the cancer marker CA-125, the level of which can increase by one and a half times.
If endometriosis foci are suspected in various organs, the patient is prescribed ultrasound hysterosalpingoscopy, hysterosalpingography, colposcopy, hysteroscopy, ultrasound with a rectal sensor, etc. Differential diagnosis is performed with gynecological inflammatory diseases, cysts and ovarian cancer, tubovarial formations and pelvic organ neoplasia. With a possible rupture of the endometrioid cyst, it is necessary to exclude ectopic pregnancy, acute appendicitis, and other surgical pathology. Oncogynecologist, surgeon, urologist, reproductologist, according to indications — anesthesiologist-resuscitator, therapist may be involved in the examination and management of the patient.
Treatment of ovarian endometriosis
The choice of treatment regimen depends on the age of the woman, her reproductive plans, the severity of clinical manifestations and the degree of spread of the process. If the disease is asymptomatic and detected by chance, dynamic monitoring with a gynecologist’s examination and ultrasound 2 times a year is recommended. Patients with endometriomas up to 40 mm in diameter are indicated for drug therapy:
- Hormonal drugs. Women who are planning pregnancy are prescribed progestins and combined oral contraceptives. During perimenopause, gonadoliberin agonists, androgens, aromatase inhibitors can also be used.
- Analgesics. Severe endometriosis-associated pain syndrome is an indication for the appointment of nonsteroidal anti-inflammatory and other pain medications.
- Sedatives. In the presence of concomitant emotional disorders, soothing plant extracts, magnesium preparations, etc. are effective.
The combination of pharmacological and physiotherapy reduces the intensity of pain, improves the results of drug treatment, reduces the risk of adhesions. In endometriosis, electrophoresis of magnesium, vitamins B1 and E, percutaneous electrical stimulation of nerves, magnetic therapy and pulse treatment are indicated.
In the presence of endometrioid cysts with a diameter of 40 mm or more, inefficiency of medications, persistent and severe pain syndrome, infertility, surgical treatment is recommended. Depending on the size of the endometriomas , the following interventions are indicated:
- Enucleation of cysts. It is performed through laparoscopic access to remove small-sized formations. With the help of a special probe, the cyst shell is delaminated, after which the endometrioma is exfoliated.
- Laparoscopic laser and electrocoagulation. Endometrioid growths on the ovaries can be cauterized, which leads to destruction and stopping the growth of heterotopias.
- Resection or removal of the ovaries. With a significant lesion of the ovarian tissue, the organ is partially or completely removed. Taking into account the volume of intervention, laparoscopic or laparotomic access is selected.
After the operation, the appointment of a course of hormone therapy is recommended. This approach is the “gold standard” in the treatment of endometriosis and minimizes the risk of relapse.
Prognosis and prevention
With timely treatment, the prognosis is favorable. The appointment of drug therapy in most cases allows you to stop the growth of endometrioid foci and reduce pain. With laparoscopic treatment of ovarian endometriosis of I-II degree, the probability of pregnancy increases, regardless of the method chosen. Removal of endometriomas in the third degree of the disease also improves fertility. Surgical treatment in severe cases usually does not allow to restore reproductive function, but facilitates the course of the disease.
To prevent endometriosis, it is recommended to refrain from heavy physical exertion during menstruation, use barrier methods of contraception, plan the onset of pregnancy, regularly visit a gynecologist (especially if there are predisposing factors).