The uterine cavity is lined by a layer called the endometrium; this layer grows and transforms throughout the cycle, preparing itself, as if it were a “nest”, to receive the fertilized ovum. The growth of the endometrium is due to the fact that the ovary produces hormones that stimulate its development and transformation.
If there is no pregnancy, this layer detaches, breaking blood vessels in the process known as menstruation. With the onset of the cycle, the formation of a new layer of endometrium begins again.
What is endometriosis?
The period is therefore the expulsion of the endometrium together with blood.
When this endometrial tissue is present outside the uterine cavity (heterotopic), and responds to the stimulus of hormones produced by the ovary, we are dealing with a pathology known as endometriosis.
Endometriosis usually appears at the pelvic level, although it can affect any organ. It can be found in multiple locations, such as:
- The surface of the uterus or its ligaments, in the tubes, in the rectum and in the bladder.
- The surface of the peritoneum (the layer that covers the inside of the abdomen).
- The inside of the muscular wall of the uterus (myometrium), a process called adenomyosis.
- The surface of the ovary, forming cysts (endometriotic cysts, endometriomas).
- In distant organs, much more exceptional, such as the lung, pleural cavity, diaphragm or digestive tract. Foci of endometriosis have been described in the abdominal wall in patients who have undergone some type of surgery, such as cesarean section, without the patient presenting visible foci of endometriosis before the surgery.
Incidence of endometriosis
The prevalence of the disease is difficult to assess, since there are patients who do not present symptoms; in others, these symptoms are very mild, and in many cases, although they do present symptoms, these are atypical and are not diagnosed as endometriosis.
Up to 50% of women with infertility problems have endometriosis, as do 70% of those with abdominal pain.
Risk factors for endometriosis
The risk factors associated with endometriosis are:
- Early menarche
- Late menopause
- Anovulatory cycles
- Short cycles
- Abundant menstruation
Protective factors for endometriosis
- Late menarche
- Pregnancies
- Breastfeeding
Causes of endometriosis
The cause of endometriosis is not known with certainty, since there are many mechanisms that can provoke it and there are different factors that, either in isolation or in combination, favor its appearance.
Once endometriosis develops, inflammation occurs with alteration of the nerves and modification of the anatomy that causes pain and sterility.
Symptoms of endometriosis
Heterotopic endometrial tissue also grows, detaches and bleeds under the stimulus of ovarian hormones, producing an inflammatory process.
The symptomatology is very varied and sometimes multiple, depending on the location of the endometriosis.
There are women who suffer from endometriosis, including ovarian cysts, and have no symptoms, while others have major symptoms with only small foci.
The most frequent symptom is pain in the lower abdomen, related to menstruation.
The pain may radiate to the lower lumbar area or to the rectum due to involvement of the ligaments that support the uterus.
When endometriosis affects the space between the vagina and the rectum (recto-vaginal septum), it can cause pain with defecation and sexual intercourse. It can also produce urinary symptoms with urinary bleeding coinciding with menstruation, and may cause sterility.
It can produce ovarian cysts that are palpable on examination, as well as nodules in the abdominal wall that increase and hurt with menstruation.
Diagnosis of endometriosis
The definitive diagnosis of endometriosis is surgery by biopsy of suspicious lesions, which is not always feasible or indicated.
The presumptive diagnosis is based on the patient’s anamnesis and gynecological examination.
Gynecologic ultrasound is used as imaging methods, especially in cases of endometriotic cysts. Magnetic resonance imaging can help in the diagnosis.
There are no specific changes in blood tests; although the tumor marker Ca125 may be elevated in endometriosis, it is not pathognomonic of the disease since other processes may cause its elevation.
Treatment of endometriosis
There is no specific treatment for endometriosis, but it will depend on the symptoms, the location, the degree of involvement, and whether gestation is sought or the gestational desire is covered.
It will be an individualized treatment that will be discussed with the patient and the different possibilities will be explained to her, assessing the symptoms, preferences, side effects and cost.
The best treatment is gestation, which is not always possible to achieve, since sometimes endometriosis itself is the cause of sterility.
Medical or surgical treatment can be applied.
Medical treatment of endometriosis
There are different options:
- Analgesics, used during the menstrual period, which in women with moderate or mild pain may be sufficient.
- Hormones, depending on whether the patient wants to become pregnant or not. Hormones can be the use of gestagens on a continuous basis or birth control pills on a cyclic or continuous basis.
- Gonadotropin analogs, which are drugs that cause an artificial menopause.
- The hormonal IUD with Levonogestrel has also been used to improve symptoms.
Surgical treatment of endometriosis
Surgical treatment may consist of removing ovarian cysts or foci, as well as endometriotic lesions, or may require removal of the uterus and ovaries.
In endometriotic cysts, the size, the risk of complications of the cyst and the risk of surgery must be assessed. It must be taken into account that the surgery on the ovary itself, even if it is only to remove the cyst while maintaining the greatest possible amount of ovarian tissue, can reduce a woman’s fertility. Sometimes it is advisable to remove the entire ovary.
In deep endometriosis or endometriosis that affects the bowel or bladder, trying to remove as much endometriotic tissue as possible may require partial resection of the bowel or bladder wall or vaginal wall.
In cases of endometriosis that are impossible to treat medically, it may be necessary to perform a hysterectomy and remove the ovaries as a definitive method.
Thus, endometriosis is a benign disease that affects women in their reproductive years, widely prevalent, with highly variable symptoms and with small or extensive organic involvement.
There are many possible treatments, both medical and surgical, which only goes to show that we have yet to learn much about the disease and find a more appropriate specific treatment.
For more information, please consult your gynecologist.