Endometriosis: Symptoms and Treatment
- What is endometriosis?
- Classification of endometriosis
- The main symptoms of endometriosis
- Causes of endometriosis
- Diagnosis of endometriosis
- Treatment of endometriosis
- Consequences of endometriosis
- Is there any prevention of endometriosis?
- Endometriosis and pregnancy
- Endometriosis and uterine myoma
- Endometriosis of the cervix
- Retrocervical endometriosis
- Endometriosis of the ovaries
What is endometriosis?
Endometriosis is a condition characterized by the appearance of ectopic areas of the endometrioid tundra. This means that the tissue that is histologically and functionally similar to the endometrium (the mucous membrane lining the uterine cavity) gets into tissues and organs for which its presence is not characteristic. The endometrioid tissue undergoes all the changes that are characteristic of the menstrual cycle. Gradually this tissue sprouts surrounding tissues. Endometriosis occurs mainly in women of reproductive age.
Factors and causes of the disease:
- Metaplasia (degeneration) of mesothelium cells into endometrioid
- Implantation of endometrial cells detached during menstruation or intrauterine manipulation. In this case, cells can get into the lymphatic way or through the bloodstream. Often the endometrium is thrown into the abdominal cavity through the fallopian tubes
When performing diagnostic laparoscopy in many women endometrioid heterotopies are detected, which independently disappear without any treatment and do not manifest themselves in any way, they are a "random finding". However, certain risk factors and a genetic predisposition to endometriosis contribute to infiltration and the formation of endometrioid ovarian cysts.
Classification of endometriosis
Endometriosis is classified as follows:
- The genital form. This means that endometriosis affects the genitals: the uterus, the ovaries, the tubes, the external genitalia, the cervix, the vagina and the peritoneum of the small pelvis.
- Extragenital form. The form of endometriosis, in which other organs are affected: intestine, lungs, scars after surgery, urinary system organs
- Mixed forms
There is another classification, according to the stages:
- affects only the mucosa
- affects the myometrium to the middle
- endometrium is affected to a serous (external) membrane
- endometriosis sprouts the entire thickness of the uterus and the peritoneum covering it
The main symptoms of endometriosis
- . Dysmenorrhea (painful menstruation) . Dysmenorrhea is expressed in varying degrees. In the initial stage, dysmenorrhea is often almost not expressed. Over time, the pain becomes more pronounced. The prevalence of endometriosis does not correlate with the severity of the pain syndrome. Often there is a pronounced pain syndrome in women with single heterotopia and minor pain in patients with advanced endometriosis. Pain appears before menstruation and intensifies during it. This phenomenon is associated with a menstrual-like reaction in endometrioid heterotopia.
Read more about dysmenorrhea here: Dysmenorrhea: causes and treatment
- . Dyspareunia (painful sexual contact) .
- . Spotting spotting before menstruation . This symptom is present in 35% of women suffering from endometriosis. A few days before the proposed menstruation.
- . Infertility .
When examined, foci of endometriosis can be found on the perineum and on the external genitalia, as well as on the cervix and vagina. The uterus is painful when displaced, it can be deflected posteriorly and tightly fixed in this position. Endometrioid cysts of the ovaries can be detected.
Endometriosis can affect not only the genitals, but also the urinary system: the bladder, the urethra, the ureters, the kidneys. This can lead to serious consequences, for example, hydronephrosis, blockade of the kidney and loss of its function.
Causes of endometriosis
At present, there are many different theories of endometriosis development, but none of them has been fully proven. Only the most probable risk factors that can contribute to the onset of the disease are elucidated. It:
- Intrauterine device manipulation
- Inflammatory diseases of female genital organs
- Cauterization of the cervix
- Unfavorable Ecology
- Metabolic disorders
Diagnosis of endometriosis
First of all, these are clinical manifestations and complaints of the patient. Essentially helps in the diagnosis of ultrasound. But the main method is laparoscopy, during which it is possible to diagnose endometriosis with reliable accuracy. All the outbreaks look typical and are visualized in the form of red, black or white foci. Red foci resemble the endometrium, and black and white foci are inactive. Classical for endometriosis are black-brown.
During the laparoscopy, a sequential examination of the pelvic cavity, ovarian surface, pelvic peritoneum, uterine ligaments, appendix, sigmoid colon, fallopian tubes is performed. To improve the quality of diagnosis, laparoscopy is supplemented with biopsy.
Endometrioid ovarian cysts are also called "chocolate", since their contents are dark brown in color. 90% of all endometrioid cysts are paraovarian cysts.
Endometrioid nodes are a manifestation of deep endometriosis. The nodes consist of fibrous tissue and smooth muscle cells, they are the basis of the node, and not the endometrioid tissue. Most often such nodes affect the sacro-uterine ligaments, retrocervical fascia, rectal-uterine septum and ovarian ligaments. All these structures form a ligamentous apparatus of the uterus and appendages, with the help of which they are kept in the physiological position in the small pelvis. Nodules are almost not characterized by necrosis and bleeding, in the 2 nd phase of the cycle they do not undergo secretory changes. Hence the endometriotic process can spread to the lateral walls of the pelvis, ureters and ileal vessels.
Treatment of endometriosis
Treatment of endometriosis is long and not always successful. After drug therapy, relapse occurs up to 50%, after surgical treatment in 20% of patients relapses within 5 years. Drug therapy does not eliminate foci of endometriosis and the effect, unfortunately, is temporary.
At the same time, drug therapy does not increase the percentage of pregnancy in women who are interested in this. The main goals of endometriosis treatment are: reduction of symptomatology intensity, improvement of quality of life, precise diagnosis. The choice of method of treatment depends on a number of factors. It is taken into account whether the woman wishes to maintain fertility, the severity of the symptoms, from what treatment preceded and what effect it was from the location of the foci of endometriosis.
Principles of drug therapy of endometriosis
Sufficiently high analgesic effect has general therapeutic measures - physical exercises, psychological support, relaxation, non-steroidal anti-inflammatory drugs, as well as paracetamol.
The greatest spread in the treatment of endometriosis has been the use of combined oral contraceptives, because they have less pronounced side effects. In this case, three-phase COCs are preferred.
Apply progestogens according to the schemes, this helps to reduce the level of estradiol.
Danazol is a synthetic derivative of 17alpha-ethinyl estradiol, its effect is to suppress ovulation and menostasis (the termination of menstruation). This drug causes atrophy of the vaginal mucosa and in the endometrium, the intensity of pelvic pain decreases, dyspareunia and menstrual pain decreases. The foci of the ectopic endometrium decrease, the germination of heterotopial foci ceases. Due to the reduction of blood loss, the level of hemoglobin increases. Side effects of the drug: irregular uterine bleeding, a slight anabolic effect, acne , hirsutism (increased body hair growth), swelling, weight gain, voice voice change, reduction of mammary glands. In connection with the phenomena of androgenization, patients often refuse treatment with danazol despite its high effectiveness.
Gestrinone is a synthetic steroid hormone with high antiprogestin activity. It acts on the hypothalamic-pituitary system and inhibits the action of the hormones of the central nervous system (gonadotropins). This drug also has antiestrogenic activity, too. As a result, there is a sharp decrease in the production of LH and FSH into ovulation and the peak does not occur. As a consequence, the ovaries produce less hormones, which leads to endometrial atrophy and, respectively, endometrioid heterotopia. The dosage is selected by the doctor. Despite the suppression of ovulation in some women, pregnancy may occur, therefore, reliable contraception is necessary for the period of treatment.
Another group of drugs used in the treatment of endometriosis are gonadoliberin agonists . The mechanism of their action is to suppress the development of pituitary luteinizing and follicle-stimulating hormones, which leads to a decrease in the production of estrogens by the ovaries. This leads to a pseudomenopause condition. These drugs can not be used for more than 6 months in connection with the demineralization of bones. Manifestations of hypoestrogenia can be significantly expressed, namely all the symptoms of menopause: dryness of the vaginal mucosa, hot flashes, palpitations and others. These drugs are quite expensive and use them only as an alternative method, when there is no effect from all other methods of therapy. Gonadotropin agonists are released in various forms: nasal spray, subcutaneous injections, intramuscular injections, depot formulations. Menstruation is resumed 2-3 months after the end of the medication. To reduce the expressed climacteric syndrome, hormonal replacement therapy is acceptable. Gonadotropin agonists can be called rescue in endometriosis 2 and 3 stages.
Mifepristone - a drug with antiprogesterone activity, when taken for 3 months reduces pain syndrome, with a positive effect observed at the end of the first month. The mechanism of action of mifepristone is that it prevents menstrual like bleeding in endometriotic foci.
Surgical method of treatment of endometriosis consists in the removal of heterotopia with maximum organ preservation. This is especially important for women who plan future pregnancy and childbirth. Relapses after such treatment occur in no more than 20% of cases for 5 years. Surgical treatment is very effective against persistent pelvic pain syndrome. Endometrioid cysts of the ovaries are removed together with their capsule.
As you know, severe endometriosis can lead to infertility. Surgical treatment in this case can play a big role. During the operation, the adhesions are cut, the cysts are removed, the anatomical structures are restored and their mutual relations relative to each other. But not always only the surgical method leads to the restoration of fertility. In some cases, modern reproductive technologies will be needed.
Consequences of endometriosis
Endometriosis can be low-symptomatic, and not affect the quality of life of a woman. On the other hand, in time unconfirmed endometriosis and the lack of adequate treatment can lead to complications. The most likely complications are:
- Adhesive process in the pelvis
- Impairment of fertility
- Anemia due to heavy bleeding
- Endometrioid cysts
Is there any prevention of endometriosis?
Since reliable causes of endometriosis are unknown, there is no effective prevention. However, it is possible to influence the development and outcome of the disease, if you follow a number of recommendations:
- Regularly visit a gynecologist as a preventive checkup
- Timely treatment of identified diseases
- Regulation of body weight and keeping it within the limits of normal values
- Sexual rest on "critical" days
- Reception of COCs as contraception
- Absence of abortions
Endometriosis and pregnancy
Endometriosis breaks the fertility of a woman, but this does not mean that pregnancy is impossible or contraindicated. On the contrary, many experts recommend pregnancy, as it has a beneficial effect on the course of the disease. The fact that during pregnancy there is a state of prolonged anovulation, menstruation is absent, and the body is under the influence of progesterone for 9 months. All these conditions contribute to the regression of heterotopies.
However, endometriosis itself is a risk factor for pregnancy, since it can cause a threat of miscarriage. Therefore, it is recommended to carry out pre-education training for women suffering from endometriosis, and during pregnancy to prevent miscarriages and fetoplacental insufficiency. For this purpose it is recommended to visit the gynecologist before the onset of pregnancy, and on the account to become as early as possible. On the child endometriosis has no direct effect, so the health of the baby can not be feared. However, the indirect effect can be manifested in the development of fetoplacental insufficiency, when the child does not receive enough nutrients and oxygen due to disruption of the placenta.
Endometriosis and uterine myoma
Often there is a combination of endometriosis with uterine myoma. Diagnosis to date has become more accurate, so this condition has become more common. The combination of uterine fibroids with adenomyosis causes more pronounced clinical manifestations, since one pathology aggravates another. Treatment is difficult and often the only method is surgical treatment. This approach to the problem deprives young women of the opportunity to become pregnant and successfully endure pregnancy. It leads to early menopause and severe climacteric syndrome (if you have to remove the ovaries). Currently, there are and are being improved minimally invasive methods of treatment, which aim not only to preserve the organ, but also to preserve its full functioning.
In some cases hormone therapy with progesterone preparations and agonists of gonadotropic hormones is used. They lead to a pseudomenopause and can reduce the myoma and heterotopia by half or more. This advantage is used in preparing a woman for surgical treatment with large sizes of fibroids in order to reduce her volume, which, in turn, will facilitate the technical side of surgical treatment. This method is not used in young women of fertile age, especially planning pregnancy.
Vegetable preparations and methods of traditional medicine do not have sufficient effectiveness. They are not able to eliminate myoma or endometriotic foci. With preventive maintenance, and in combination with other methods of treatment, they can be used, but as a separate method of treatment, the effect will not bring, but, on the contrary, can drag out precious time. The most optimal treatment for adenomyosis, combined with uterine myoma, of any site with a node diameter of more than 1 cm in women of fertile age is surgical treatment. Moreover, this is an absolute indication for the operation.
Endometriosis of the cervix
In endometriosis lesions of the cervix uteri endometrioid heterotopy are located on the cervix and are visualized by a doctor when examined on a gynecological chair. They look like small red formations. Since heterotopies are subject to cyclic changes in the menstrual cycle, they undergo the same changes in different phases as the endometrium. During menstruation, endometriotic foci are bleeding formations. Endometriosis can also be localized in the cervical canal. In this case, infertility may develop with time due to the formation of adhesions in the cervical canal.
On the cervix, endometriosis often occurs after manipulations performed on it and in the uterus cavity - moxibustion, scraping, abortion. Treatment of endometrioid heterotopies is the destruction of foci with the help of liquid nitrogen, radio wave therapy or laser.
Approximately 6-7% of all localizations of endometriosis are retrocervical endometriosis. The process is located in the posterior surface of the cervix at the level of the sacro-uterine ligaments. Heterotopies can germinate deep down, right up to the rectum and Douglas space. This form of endometriosis can lead a woman to total disability. It manifests itself in the form of pain in the lower abdomen and in the lumbar region with irradiation into the rectum during menstruation pain intensifies. At sexual contacts there can be bloody discharge (if the endometriotic foci are localized in the arches of the vagina). Если эндометриоз поражает прямую кишку, то присоединяется ещё один симптом во время менструации – кровяные выделения из прямой кишки во время дефекации.
Эндометриоз яичников длительно может не проявляться и протекать бессимптомно. Со временем в процесс вовлекается брюшина, очаги распространяются, формируется спаечный процесс. Как и при других формах эндометриоза появляются характерные боли внизу живота, усиливающиеся в период менструации. Боли отдают в прямую кишку, в пах. Менструации всегда болезненны, также присутствует диспареуния (болезненный половой акт).
Мелкие кисты постепенно увеличиваются, могут даже сливаться между собой, образуя эндометриомы, которые хорошо прощупываются при бимануальном исследовании, четко прослеживаются на УЗИ. Кисты содержат темно-коричневую субстанцию, благодаря чесу получили название «шоколадные» кисты. Лечение проводится преимущественно лапароскопически, объем операции зависит от репродуктивных планов женщины и степени распространения.