Endometriosis - Signs, Symptoms And Treatment

Active endometriosis may occur at any age, including adolescence. As many as 50% of infertile women may have endometriosis; however, the true incidence in both fertile and infertile women remains unknown.

Severe symptoms of endometriosis may have an abrupt onset or may develop over many years. Infertility occurs in 30% to 40% of women with endometriosis. Endometriosis usually manifests during the menstrual years; after menopause, it tends to subside. Endometriosis affects more than 5 million American women, including teen girls. It's not always diagnosed right away in teens because at first they or their doctors assume that their painful periods are a normal part of menstruating. But continuing, excessive pain that limits activity isn't normal and should always be taken seriously. Because severe endometriosis can make it complicated for a girl to have children in the future, it's a good idea to get medical help for endometriosis and not wait too long.

What causes Endometriosis ?

The cause of endometriosis remains unknown. The main theories that attempt to explain this disorder (one or more are perhaps true for certain populations of women) include:

• retrograde menstruation with implantation at ectopic sites (although retrograde menstruation alone may not be sufficient for endometriosis to occur because it occurs in women with no clinical evidence of endometriosis)
• genetic predisposition and depressed immune system (may predispose one to endometriosis)
• coelomic metaplasia (repeated inflammation inducing metaplasia of mesothelial cells to the endometrial epithelium)
• lymphatic or hematogenous spread extraperitoneal disease).

Signs and symptoms of Endometriosis

Signs and symptoms of endometriosis Include:

• dysmenorrhea, abnormal uterine bleeding, and infertility (classic symptoms)
• pain that begins 5 to 7 days before menses and peaks and lasts for 2 to 3 days (varies among patients), all hough severity of pain isn't indicative of extent of disease.

• infertility and profuse menses (ovaries and oviducts)
• deep-thrust dyspareunia (ovaries or rul-de-sac)
• suprapubic pain, dysuria, and hematuria (bladder)
• lower back pain
• abdominal cramps, pain on defecation, constipation; bloody stools due to bleeding of ectopic endometrium in the rectosigmoid musculature (large bowel and appendix)
• bleeding from endometrial deposits in these areas during menses; pain on sexual intercourse (cervix, vagina, and perineum).

• infertility due to fibrosis, scarring, and adhesions (major complication)
• chronic pelvic pain
• ovarian carcinoma (rare).

Diagnosis information

The only definitive way to diagnose endometriosis is through laparoscopy or laparotomy. Pelvic examination may suggest endometriosis or may be unremarkable. Findings that suggest endometriosis include:

• multiple tender nodules on uterosacral ligaments or in the rectovaginal septum (in approximately one-third of patients)
• ovarian enlargement in the presence of endometrial cysts on the ovaries.

• empiric trial of gonadotropinreleasing hormone (GnRH) agonist therapy to confirm or refute the impression of endometriosis before resorting to laparoscopy (controversial but possibly cost-effective)
• biopsy at the time of laparoscopy (helpful to confirm the diagnosis), although diagnosis is confirmed by visual inspection in some instances.

Treatment of Endometriosis

Treatment of endometriosis varies according to the stage of the disease and the patient's age and desire to have children. Hormonal treatments of endometriosis (continuous use of hormonal contraceptives, danazol [Danocrinel. and GnRH agonists) are potentially effective in relieving discomfort (hormones stop ovulation, thereby decreasing inflammation and any menstrual tissue that may be distributed throughout the body), although treatment for advanced stages of endometriosis usually isn't as successful because of impaired follicular development. However, nonsurgical treatment of endometriosis generally remains inadequate. Surgery appears more effective to enhance fertility, although definitive class I evidence currently doesn't exist. Pharmacologic and surgical treatment of endometriosis may be beneficial for managing chronic pelvic pain. Conservative therapy for young women who want to have children includes:

• androgens such as danazol
• progestins and continuous combined hormonal contraceptives (pseudopregnancy regimen) to relieve symptoms by causing a regression of endometrial tissue
• GnRH agonists to induce pseudomenopause (medical oophorectomy), causing remission of the disease (commonly used).

No pharmacologic treatment has been shown to cure the disease or be effective in all women. Some disadvantages of non surgical therapy include:

• adverse reaction to drug-induced menopause (including osteoporosis if used for more than 6 months), high expense if used for an extended time, and possible recurrence of endometriosis after discontinuation of GnRH agonists
• high expense and weight gain when using danazol (Danocrine)
• lowest fertility rates of any medical treatment for endometriosis when using continuous hormonal contraceptive pills
• weight gain and depressive symptoms when using progestin (but as effective as GnRH agonists).

When ovarian masses are present, surgery must rule out cancer. Conservative surgery includes:

• laparoscopic removal of endometrial implants with conventional or laser techniques (no benefit shown for laser laparoscopy over electrocautery or suture methods)
• presacral neurectomy for central pelvic pain; effective in about 50% or less of appropriate candidates
• laparoscopic uterosacral nerve ablation (LUNA) also for central pelvic pain, although definitive studies supporting the efficacy of LUNA are lacking
• total abdominal hysterectomy with or without bilateral salpingooophorectomy. (Although success rates vary, it's unclear whether ovarian conservation is appropriate. This is a treatment of last resort for women who don't want to have children or for extensive disease.)

Special considerations or prevention

Minor gynecologic procedures are contraindicated immediately before and during menstruation.

• Advise adolescents to use sanitary napkins instead of tampons; this can help prevent retrograde flow in girls with a narrow vagina or small introitus.
• Because infertility is a possible complication, advise the patient who wants children not to postpone childbearing.
• Recommend an annual pelvic examination and Papanicolaou test to all patients.