What is endometriosis ?
It is a serious topic of concern especially for females who go through this most distressing and unpleasant disorder.
Definition: Presence of functioning endometrium (glands and stroma) in sites other than uterine mucosa is called endometriosis. It is not a neoplastic condition, although malignant transformation is possible.
It is a benign but it is locally invasive, disseminates widely. Cyclic hormones stimulate growth but continuous hormones suppress it.
PREVALENCE OF endometriosis
The prevalence is about 10 %. However, prevalence is high amongst the infertile women (30–40%) as based on diagnostic laparoscopy and laparotomy.
The disease has a prevalence in women mostly during the reproductive age i.e., 30-45 years.
Female reproductive system: anatomy and physiology
FEMALE REPRODUCTIVE ORGANS
The female reproductive organs include the ovaries, fallopian tubes, uterus(womb) and vagina.
a)OVARIES : The ovaries or “egg sacs” are a pair of female reproductive organs located in the pelvis, one on each side of the uterus. The ovaries have two functions to perform : they produce eggs(ova) and female hormones i.e., estrogen and progesterone to control the development of female body characteristics and regulate menstrual cycle and pregnancy.
Female reproductive system: anatomy and physiology
b)Fallopian tubes : The fallopian tubes, one on each side of the uterus, transport the egg or ova from the ovary to the uterus(the womb) through small hair-like projections called cilia on their lining.
c)The uterus : The uterus is a hollow, pear-shaped organ located in a women’s lower abdomen, between the bladder and rectum. Functions of uterus include nurturing the fertilized ovum that develops into the foetus and holding it till the baby is muture enough for birth.
Endometrium : anatomy and physiology
Endometrium: The most important part of the reproductive system related to Endometriosis.
It is the innermost layer of the uterus out of all the three layers namely-
- Serous-the outer one layer.
- Myometrium-the middle layer.
- Endometrium-the inner layer.
Functions: The functional layer of endometrium during the menstrual cycle or estrous cycle, grows to a thick, blood vessel-rich, glandular tissue layer. This represents an optimal environment for the implantation of a blastocyst upon its arrival in the uterus.
CAUSES OF ENDOMETRIOSIS
Causes still remain unclear and is full of theories. The principal ones are:
a)Retrograde Menstruation (sampson’s theory) :
There is retrograde flow of menstrual blood through the uterine tubes during menstruation. The endometrial fragments get implanted in the peritoneal surface of the pelvic organs (dependent sites e.g., ovaries, uterosacral ligaments). Subsequently, cyclic growth and shedding of the endometrium at the ectopic sites occur under the influence of the endogenous ovarian hormones. But this theory can explain pelvic endometriosis, it fails to explain the endometriosis at distant sites.
b)Coelomic metaplasia (Meyer and ivanoff) theory :
Chronic irritation of the pelvic peritoneum by the menstrual blood may cause coelomic metaplasia which results in endometriosis.
c)Direct implantation theory :
According to the theory, the endometrial or decidual tissues start to grow in susceptible individual when implanted in the new sites. Such sites are abdominal scar following hysterectomy, caesarean section, tubectomy and myomectomy. Endometriosis at the episiotomy scar, etc. can also be explained with this theory. This theory however, fails to clarify endometriosis at sites other than mentioned.
CAUSES OF ENDOMETRIOSIS
d)Lymphatic theory (halban) or invasion:
It may be possible for the normal endometrium to metastasize the pelvic lymph nodes through the draining lymphatic channels of the uterus. This could explain the lymph node involvement.
e)Vascular theory or invasion :
This is sound at least to explain endometriosis at distant sites such as lungs, arms or thighs. This theory suggests that the endometrial tissue “travel” through the body via blood vessels or pelvic vessels. It then reaches various tissues, implants, and then grows, causing pain.
f)Genetic and immunological factors :
Genetic basis of endometriosis probably accounts for less than 10 percent of the patients. There is 6–7 times increased incidence in first degree relatives. Multifactorial inheritance is thought of. However, a defect of local cellular immunity may be responsible for the ectopic tissue to grow in abnormal sites only in susceptible women.
g)Environment theory :
This theory suggests somatic mutations of cells due to environmental factors (pollutants, dioxins). Ovarian and deep infiltrating endometriotic lesions are explained with this theory.
Thus, it is certain that, not all cases of endometriosis at different sites can be explained by a single theory.
DEVELOPMENT OF DISEASE and ITS CONSEQUENCES
The normally grown endometrium undergoes certain changes during menstrual cycle under the effect of ovarian hormones.
In a women with abnormally grown endometrium, the pathology occurs as follows :
- The endometrium ( glands, stroma) in the ectopic sites has got the potentiality to undergo changes under the action of ovarian hormones.
- While proliferative changes are constantly evidenced, the secretory changes are conspicuously absent in many; may be due to deficiency of steroid receptors in the ectopic endometrium.
- Cyclic growth and shedding continue till menopause. The periodically shed blood may remain encysted or else, the cyst becomes tense and ruptures.
- As the blood is irritant, there is dense tissue reaction surrounding the lesion with fibrosis. If it happens to occur on the pelvic peritoneum, it produces adhesions and puckering of the peritoneum.
DEVELOPMENT OF chocolate cyst
Chocolate cyst in endometriotic lesion:
- If encysted, the cyst enlarges with cyclic bleeding. The serum gets absorbed in between the periods and the content inside becomes chocolate colored. Hence, the cyst is called chocolate cyst which is commonly located in the ovary. Chocolate cyst may also be due to hemorrhagic follicular or corpus luteum cyst or bleeding into a cystadenoma and occur in 20-40% of women with endometriosis. For this reason, the term endometrial cyst or endometrioma is preferred to chocolate cyst.
CLINICAL FEATURES INVOLVED IN ENDOMETRIOSIS
About 25 percent of patients with endometriosis have no symptom, being accidentally discovered either during laparoscopy or laparotomy.
Symptoms most commonly experienced by the womens are as follows:
- Dysmenorrhea (70%) : There is intensively increasing secondary dysmenorrhea. The pain starts a few days before menses; get worse during menses and takes time, even after that to get relief of pain. Pain usually begins after few years pain-free menses. The site of pain is usually deep seated and on the back or rectum. Increased secretion of PGF 2α, thromboxane β2 from endometriotic tissue is the cause of pain.
- Abnormal menstruation (20%): Menorrhagia is the predominant abnormality. If the ovaries are also involved, poly-menorrhea or epi-menorrhagia may be pronounced. There may be premenstrual spotting.
- Infertility (40–60%): About 40–50 percent patients with endometriosis suffer from infertility.
- Dyspareunia (20–40%) or Difficult/painful sexual intercourse : The dyspareunia is usually deep. It may be due to stretching of the structures of the pouch of Douglas or direct contact tenderness. As such, it is mostly found in endometriosis of the rectovaginal septum or pouch of Douglas and with fixed retroverted uterus.
- Chronic Pelvic Pain : The pain varies from pelvic discomfort, lower abdominal pain or backache. The cause may include—(i) Inflammation in the peritoneal implants and release of PGF, and also due to adhesions and ovarian cysts. (ii) Action of inflammatory cytokines released by the macrophages. (iii) Invasion of nerves or involvement of bladder and bowel. The pain aggravates during period.
- Nausea: Nausea during menstrual bleeding.
- Painful Micturition:
- Painful urination during menstruation.
- Painful defecation:
Painful bowel movements during menstruation.
- Patient with endometriosis may experience constipation during menstrual bleeding.
Females with endometriosis may also experience diarrhea during menstrual bleeding.
TREATMENT FOR ENDOMETRIOSIS
All treatment will be aimed at relieving your pain and preserving your ability to have children some day.
Once a diagnosis of endometriosis has been made, treatment falls into the following categories:
After an evaluation and before beginning hormonal therapy, you and your gynecologist (Gynea) may decide to keep track of your symptoms and try mild pain medicine. This is usually the first step for patient with mild endometriosis.
- Birth control pills contains estrogen and progesterone taken regularly (to stop periods) relieves symptoms in many patients.
- Progesterone medicine alone (progestin–only) birth control pill or regular pill that comes in a bottle Norethindrone acetate to stop your pain and bleeding.
- GnRH agonist(Leuprolide acetate) Shut down estrogen level (one of the hormones) made by the ovaries and temporarily stops your period.
Laparoscopy is the only good line of treatment to destroy visible endometriosis. After this procedure, many patients find relief from symptoms i.e., pain. Many patients may experience pain again.
D.NUTRITIONAL HELP :
Women with highest intake level of omega-3 fatty acids, vitamin B1, B3, and E, and magnesium has 22% lower risk of endometriosis, pelvic pain and also reduces the need for additional medication unlike trans fatty acids .
Managements : endometriosis
D.LIFESTYLE CHANGES :
To reduce pelvic pain and menstrual cramps-
- Exercising to relieve or lessen pelvic pain and menstrual cramps.
- Balanced diet and getting enough rest.
- Relaxation techniques yoga and meditation help to ease pain too.
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