Reproductive System & Sexual Health >
Endometriosis
“Endometriosis is a benign and chronic disease that is characterised by the growth of endometrial tissue outside the uterus, inducing a chronic, inflammatory reaction”
Risk Factors
- Female + age (most common is 20-40 yrs)
- Family history + genetics
- Nulliparity
- Retrograde menstruation (backflow of menstrual fluid containing endometrial cells)
- Previous pelvic inflammation or infection
- ↑ Oestrogen levels
- Have periods longer than 7 days and cycles shorter than 28 days
Pathophysiology
The exact cause of endometriosis is unknown
- Retrograde menstruation:
- During menstruation, endometrial tissue flows backwards → fallopian tubes → abdomen. In some cases, the tissue can then implant in the pelvis → endometriosis
- Hormonal:
- ↑ Oestrogen production → encourages growth and shed of endometrial tissue
- Lymphatic or circulatory spread:
- Endometrial tissue travel via the lymphatic system or in the bloodstream → implant in areas such as the lungs
- Metaplasia:
- The substitution of one type of fully differentiated cell for another within a given tissue.
- Metaplasia usually occurs in response to inflammation to enables cells to better adapt to their environment.
- Potentially explains how endometriosis appears spontaneously inside the body,
- Potentially explains the appearance of endometriosis cells in women with no womb – or in men who have taken hormone treatments.
- Immune dysfunction:
- The immune system may not able to fight off endometriosis.
- Many women with endometriosis appear to have reduced immunity. It is not known whether this contributes to endometriosis or whether it is as a result of endometriosis.
- Toxin exposure:
- Toxins, such as dioxin, can impact the immune and reproductive system
- Surgical:
- Endometrial cells can move during a procedure such as a hysterectomy or c-section.
- Genetic:
- There may be an inherited component. A woman with a close family member who has endometriosis is more likely to develop endometriosis herself.
Clinical Presentation
- Asymptomatic
- Infertility
- Fatigue
- Cyclical (pain and GIT symptoms)
- Dysmenorrhoea
- Dyspareunia
- Dyschesia
- Chronic pelvic pain
- Endometriosis can be seen in other locations such as the lungs, umbilicus and skin (cells react in the same way as to those in the pelvis)
Investigations
- Laparoscopy and histological verification is the gold standard
- Ultrasounds scan
- Pelvic examination
- A diagnosis can be categorised as follows:
- Stage 1: Lesions are minimal and isolated
- Stage 2: Lesions are mild. There may be several and adhesions are possible.
- Stage 3: Lesions are moderate, deep or superficial with clear adhesions
- Stage 4: Lesions are multiple and severe, superficial and deep, prominent adhesions
Management
- Around 1/3 patients find their symptoms resolve on their own, and recede with menopause
- Medical:
- Nonhormonal
- Simple analgesia (ibuprofen)
- Hormonal
- Progestogens
- Combined oral contraceptive
- Hormonal IUD
- Gonadotrophin releasing hormone agonists +/ add back HRT
- Nonhormonal
- Surgical:
- Conservative – aim to destroy all visible endometriosis
- Diathermy
- Excision
- Laser
- Radical – remove uterus, ovaries and nodules
- Conservative – aim to destroy all visible endometriosis
Complications
- Up to 50% women present with infertility
- ↑ Risk of ovarian cancer or endometriosis-associated adenocarcinoma
- Ovarian cysts
- Inflammation → chronic pain
- Scar tissue and adhesion development
- Intestinal and bladder complications