Endometriosis happens when the uterine endometrium that should grow in the uterine wall goes beyond it to the pelvic region. The occurrence of this condition is so rare in 1 out of 10women in their 20s age. More commonly diagnosed in women in their late 30s and nearer to the menopause stage.
Worldwide there are 10.8 million women affected with endometriosis in 2015 research. The endometriosis is noticed in the ovaries, fallopian tubes, tissues in and over the organs of the pelvic region. In rare instances, there is no impossibility for it to spread to other parts of the body.
The tissue acts normal similar to its role in the menstrual cycle. So it breaks apart and bleeds from the organs it has grown in. This bleeding goes nowhere and accumulates in the peritoneal cavity. This leads to scarring, lesions, injuries, trauma, inflammation, and swelling in the uterus. The most common site for endometriosis is the ovaries.
Signs and Symptoms of Endometriosis :
Infertility is the common sign of endometriosis, other than it various gynecological symptoms can be noticed. While in most of the cases it can remain asymptomatic, some symptoms still show off.
- Painful coitus or sexual intercourse happens, becoming infertile or trouble to become pregnant,
- Pelvic pain – this is the most debilitating and a recurrent symptom of endometriosis. In women during the menstrual cycle, pelvic pain or lower back pain would be a common issue. But in women suffering from endometriosis, the intensity of the pain depends on the extent of the condition.
- Endometriosis severity is categorized through one to four. But it’s not likely for women to always experience pain with respect to the severity of the condition. It starts a week prior to the onset of the menstrual period.
- Other such pains undergoing during endometriosis are pain during ovulation called a mittelschmerz condition. This sign is also seen in adenomyosis.
- An urgency or uncontrollable urination that is also painful is called dysuria. Most of the reproductive issues of any sort show all of these symptoms.
- Chronic lower back pain and pelvic pain during menstruation along with the abdominal pain occurs. Cramps that are seen during the menstrual cycle get severe and progressive in endometriosis.
- In women with severe endometriosis in rare instances, rectal pain is observed. Pressure can be experienced on the uterus from all sides.
- A sense of pulling pain downwards from the deep organs is noticed in the body. The pain arises when the endometriosis tissue and lesions undergo a response to the hormones of menstruation and bleeding. As there is no way to go outside, the blood accumulates, if not cleared this leads to swelling, inflammation, and pain. These lesions can develop their own blood and nerve supply and the control is by the central nervous system. This process is called neuroangiogenesis.
Endometriosis severity and stages:
Endometriosis can be classified into four stages.
Minimal growth of endometriosis in stage I that starts with little lesions.
Next comes the second stage of mild endometriosis with a bigger lesion which is a mass of cells that goes into tissues in other organs.
The third stage has smaller implants along with lesions which are considered a moderate growth of endometriosis.
In the severe stage of endometriosis that is the fourth stage, e shows deeper implants rooted in the organs. The extent, depth, and location of the endometriosis implant, scar tissue severity, and area occupied by the endometrial tissue are used as a measure to categorize the stages of endometriosis. These are associated with the scarring, superficial implants, and cysts formed. But infertility is common in stage four of endometriosis
Almost one-third of women facing infertility have endometriosis. The inflammation, swelling and uterus conditions make them infertile. In the advanced condition of the disease, the disturbed pelvic anatomy leads to impaired fertilization.
There are other issues that show up during endometriosis, nausea, severe headache, fatigue and weakness, the menstrual cycle becomes irregular. As in adenomyosis, endometriosis is also related to the ovarian cancers, non – Hodgkin’s disease and brain cancer and also unrelated to endometrial cancer. The peritoneum, ovaries, fallopian tubes, bladder surface, intestines, rectum, space behind the uterus are the affected areas with this condition.
Causes for Endometriosis:
- The exact reason for this condition is not specifically defined as far some researchers have taught that the menstrual blood flows backward into the pelvic region such as fallopian tubes and into the pelvic cavity. The menstrual blood gets adhered to the surface of the organs present in the cavity. This hypothesis is called retrograde menstruation.
- Genetical inheritance of the disease from mothers and sisters is possible. The severity of the disease increases as per the generations according to the research. The chance of inheritance with severity is six-folds.
- The endometriosis involves genetic mutations as in cancer. The chronic exposure to the estrogens levels as in menopause and obstruction in the menstrual flow as in Mullerian anomalies are also risks to endometriosis.
- Graves disease is an autoimmune disorder showing symptoms like goiter, dermopathy, hyperthyroidism. Women with such autoimmune diseases are linked to endometriosis.
- In women with endometriosis, increased possibilities for new nerve cells are seen. Though this is not fully explained by scientists.
- To explain the formation of the endometriosis, there are two theories proposed. A retrograde menstruation theory as we talked about and stem-cell theory which talks about endometriosis developing from the stem cells. There are certain other theories that could not fully establish all the questions about endometriosis like mullerianosis, vascular genesis, oxidative stress, neural growth, etc., to name a few.
Diagnosis of Endometriosis:
The endometriosis is not an easy condition to detect clearly. It may take years from consulting a doctor to establish the disease after diagnosis. Some of the procedures to diagnose a suspected case of endometriosis are
- Laparoscopy: It is a surgical process. A camera is utilized to have a look into the abdominal cavity and estimate the severity of the condition. It visualizes the externally visible lesions. If the lesions are not visible, a biopsy can be drawn. This process of diagnosis also allows for surgical treatment through laparoscopy. 6 to 13 percent of women have shown the invisible lesions of endometriosis in the biopsy.
- Ultrasound: a pelvic ultrasound detects the larger endometriotic cysts as in ovaries called endometriomas. However, it has no role in diagnosing smaller implants. Vaginal ultrasound is used in detecting deeper endometriomas and before operating on them. This is one of the most easily accessible, inexpensive and required no preparation.
- Magnetic resonance imaging: it is a noninvasive technique. But due to its limited availability and cost, it is not widely recommended. But it precisely and accurately diagnoses smaller lesions.
Staging of endometriosis is done into stage I(minimal), stage II(mild), stage III( moderate), stage IV( several). Pain quantification of endometriosis is done through VAS and NRS scales.
Treatments and prevention for Endometriosis:
- Hormonal therapy: pills for contraception reduces pain. Estrogen-progesterone birth control pill is the first line of treatment for most women with endometriosis.
- Progesterone: does not allow the growth of the endometrium. Progestin drugs are given through hormonal therapy. Dienogest is one such. When estrogen can’t be given alongside progesterone, only progesterone will be prescribed.
- Steroids: though having side effects of masculinization, these enzymes and steroids are given to inhibit the growth of the endometrium. Danazol and gestrinone are examples.
- GnRH agonists – leuprorelin and GnRH antagonist- Slavonic decreases the estrogen levels. But those have more side-effects than steroids and slightly ineffective too when compared to the prior.
- NSAIDs such as ibuprofen and naproxen relieves the pain. Morphine sulphate tablet an opioid is suggested as a painkiller. This mimics the action of endorphins.
- Surgery is largely effective in treating endometriosis than medications. The removal of endometrial tissue is done without any damage to the underlying organs.
Complications of endometriosis include thoracic endometriosis.
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- Uterine Fibroids
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- Endometriosis – ACOG
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