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ENDOMETRIOSIS

DEFINE ENDOMETRIOSIS

Endometriosis is a prolonged disease which lasts from adolescents to menopause. 

It is due to the endometrial cells implanting outside the uterine cavity by chance through retrograde spill through the fallopian tube during menstruation in to the pelvic cavity or the cells spreading through blood stream or lymphatic channel.

It is estimated to affect 176 million women across the world. In India over 32 millions are affected.

This affects women during prime year of their lives, a time when they should be finishing their education, starting and maintaining a career, building relationships and perhaps starting a family.

Endometriosis in the pelvis causes chronic pelvic inflammatory reaction leading to chronic pelvic pain.

What is its incidence?

  • Reproductive age group 10-15%
  • Infertile patients 4.5- 50%
  • Pelvic Pain / Dyspareunia 40 -50%

What are the classifications of endometriosis?

According to the  classification of American Fertility Sterility Society, endometriosis can be classified as : 

  • Minimal – Stage 1
  • Mild – Stage 2
  • Moderate — Stage 3
  • Severe – Stage 4

Who needs Treatment?

Patients with pain, pelvic pathology and Infertility

What are the signs and symptoms of endometriosis?  

Signs

  • Ovarian cyst / Endometrioma – The ovary is enlarged with chocolate like material
  • Mass in the abdomen
  • Adenomyoma – The uterus muscles swells with infiltration of endometriosis and so the uterus becomes big

Symptoms

  • Pelvic pain – lower abdominal discomfort
  • Dysmenorrhoea – Menstrual pain
  • Dyspareunia – Pain during sex
  • Abnormal bleeding – over bleeding, inter-menstrual bleeding
  • Infertility 

How is infertility caused by endometriosis? 

  • Distorted pelvic organs – relationship of tube & ovaries altered
  • Altered peritoneal function – the healthy fluid in the space around the uterus is altered
  • Altered folliculogenesis / Ovulatory dysfunctions – Ovulation is defective or impaired
  • Altered steroidogenesis – disturbance in the ratio of estrogen and progesterone
  • Granulosa cell dysfunction – cells supporting oocytes does not function properly
  • Oocyte abnormality / Decreased fertilizing capacity – oocytes not healthy and fertilization impaired
  • Sperm phagocytosis – sperms are engulfed by macrophages
  • Accelerated ovum transport – defective transport of ovum into the uterus
  • Disturbed early luteal function – hormones supporting embryos is defective
  • Hyperprolactinemia – Increased prolactin levels which upsets pregnancy 
  • Defective implantation – site where the baby grows is hostile
  • Embryo toxicity – Embryo is surrounded by hostile fluid
  • Last but not the least Immunological ! 

How does one make a diagnosis of endometriosis through USG?  

Ovarian Endometrioma 

  • Endometriomas  5  to 8 cm in size and have a echogenic to a loculated cyst depending  on  the  amount of coagulated blood material inside. 
  • The commonest finding is that of low level homogenous echoes uniformly distributed. 
  • The cyst wall is thick due to fibrosis. Other features are, bilateral in nature, multiple cysts, and peri ovarian adhesions. 

Uterine Adenomyosis 

  • Transvaginal ultrasound plays an important role in distinguishing adenomyosis from leiomyomata. That presence of unencapsulated, heterogeneous, myometrial areas within and round an echoic areas 1-3 mm in diameter.

How does one treat a young unmarried girl of 16 yrs who has a large endometrioma? 

  • The treatment depends on the size of the endometrioma and the amount of ovarian involvement .
  • For example if it is really huge and there is just a thin ovarian capsule then considering her age and the long wait before marriage, the other side being normal, it is best to remove that ovary since chocolate cysts reappear very fast. 
  • On the other hand if the chocolate cyst though big is encysted leaving a substantial healthy portion of functioning ovarian tissue then cystectomy can be done along with danazol (200mg twice a day) for 2-3 months to remove unseen pelvic endometriosis. 
  • Don’t lose her out of sight, call her for basal scan every 4-6th month and encourage for early marriage . 

What is the place of oral contraceptive pill in the treatment of endometriosis?

  • First medical treatments for endometriosis –  35 years ago started with only OC pills 
  • A combination of estrogen and progesterone, produce a pseudo-pregnancy state by causing anovulation.
  • The estrogen in the pill may actually stimulate activity in the endometriotic lesion and so low estrogen and high progesterone pills has to be used. 
  • Studies have proved that OC pills are only half as effective as danazol in relieving the symptoms and has side effects like breakthrough bleeding, nausea and vomiting 

What is the role of IUI in endometriosis? 

IUI can be tried in very early cases of endometriosis

What is the role of IVF in endometriosis?  

Indications for IVF in endometriosis

  • Moderate to severe endometriosis – failed medical or surgical therapy
  • Mild to moderate endometriosis with 4 – 6 IUI failures
  • Presence of other associated infertility factors 
    • PCOS
    • Male factor 
    • Tubal factor
    • Age factor 

Does endometriosis reduce the quality of oocytes and fertilization? 

Endometriosis causes 

  • Poor ovarian response, 
  • Reduced oocyte quality, 
  • Low fertilization and 
  • Low pregnancy rates
  • Increased miscarriages

World Endometriosis research foundation (WERF) has been created to provide a global platform where resources and intelligence are pooled to enable international collaboration in order to find answers, so the treatments for endometriosis can be improved and prevention can become a reality in further generations of women.

Conclusion

In short, endometriosis is an unresolved disease in which the natural history and precise mechanisms by which is causes pain and sub-fertility are not well understood. There is no known cure and most current medical treatments are not suitable for long term use due to their efficacy and/or side effect profile.