Endometriosis is a complex chronic disease that represents a major challenge for modern Gynecology and for all National Health Systems. Classically, endometriosis is defined as the presence of endometrial tissue outside the uterine cavity.
The endometrium is the tissue that lines the inside of the uterus and is responsible for the nourishment of the embryo until the formation of the placenta. If pregnancy does not occur, the endometrium sheds, producing bleeding, known as menstruation or menstruation. In the next ovulation cycle a new endometrium will grow waiting for a possible pregnancy.
Endometriosis is the most common pathology of the female reproductive system, along with the presence of uterine fibroids. It is a common gynecological disease that affects approximately 3-10% of women during their reproductive years, especially in the 28-35 years age group. In those women who suffer from period pain (dysmenorrhea) the incidence of endometriosis reaches 50%, and in those who suffer from infertility its incidence as a cause reaches 25-50%. This means that some 14 million women are affected in Europe and more than 150 million worldwide. Its economic impact is very important, as it is estimated to cost around 30 million euros per year in Europe.
This disease is considered one of the great enigmas of general pathology and especially of gynecological pathology. Despite constant research, with more than 5,000 scientific articles registered annually, its origin remains unknown. We can only say in general terms that it is an immunological alteration with a genetic basis. The natural evolution of the disease will depend on hormonal factors (the presence of estrogens favors its development) and on environmental factors that are little known and inconclusive to date.
The most frequent location of endometrial cell tumor implants is in the uterosacral ligaments, the pelvic peritoneum and the ovaries (endometriotic cyst or endometrioma). Deep implants (more than 5 mm), especially in the ligaments described above, are responsible for the severe dysmenorrhea and painful sexual intercourse (dyspareunia) described by those affected by the disease.
Diagnosis of endometriosis
The diagnosis of suspicion is based fundamentally on the recognition of the characteristics of the symptomatology of endometriosis by the family doctor or gynecologist. It is recognized that the average time to reach a diagnosis from the time the patient first sees a doctor is 8 years on average. This is due to the lack of specific symptoms or clear ways of diagnosing endometriosis.
Some capital symptoms such as infertility, chronic pelvic pain, dysmenorrhea resistant to medical treatment and dyspareunia, should lead to the suspicion of endometriosis as the first differential. Other symptoms associated with menstruation are dyschezia (pain on defecation during menstruation), dysuria (pain on urination with menstruation) and bladder urgency, rectal urgency, false irritable bowel syndrome or interstitial cystitis, intestinal pseudo-obstructive symptoms and renoureteral crises. This symptomatology is directly related to the depth of the implants. It can occur in the absence of ovarian endometriomas (10%) and there is no direct relationship between the magnitude of pain and the severity of the disease.
Infertility as a symptom
Currently, from the reproductive point of view, many clinicians recommend the practice of assisted reproductive techniques (ART) in patients with infertility and suspected endometriosis without laparoscopic confirmation. The pregnancy rate is clearly lower in patients with endometriosis, not only because of the local inflammatory effect, but also because of the poorer oocyte quality, the poorer quality of the embryos obtained and a lower implantation rate. This is a complex problem and, in the absence of conclusive studies, there is no consensus on the best course of action. All this leads other authors to recommend a laparoscopic approach for the treatment of endometriosis in these infertile patients, especially for those with suspected severe endometriosis with endometriomas >4 cm, in the case of several failed IVF cycles and prior to the offer of oocyte donation. Before any surgical approach, the woman’s oocyte reserve and the potential advantages and disadvantages of surgical treatment on the reproductive prognosis should always be assessed.
Pelvic examination by vaginal and rectal examination by the gynecologist should be the basis of the study of a patient with possible endometriosis, in addition to the creation of a map of selective pain points. In the case of large rectovaginal or lateral lesions, the possible severe involvement of the bladder, ureter and/or distal intestinal tract should be investigated preoperatively by means of the different imaging techniques available (Transvaginal Ultrasound, Transrectal Ultrasound, Pelvic MRI) for an adequate preparation of the possible surgery to be performed. All this will facilitate the patient’s understanding of the severity of her symptoms, the surgical complexity and the possible risks and sequelae of this treatment. Analytically there are no specific markers, therefore the use of the CA-125 antigen as a serum marker of endometriosis has little value in the diagnosis and prognosis. It only acquires importance in post-surgical follow-up.
Diagnostic laparoscopy is recognized as the “gold standard” process for diagnosis. A diagnosis of certainty should only be made after direct observation of the implant, generally associated with an anatomopathological confirmation. It is advisable to perform the diagnosis and treatment in the same surgical act, with prior information and consent of the patient of the procedures to be performed. In the case of lesions involving a greater surgical risk and it is not possible to perform a complete treatment, the process should be completed in the diagnosis and refer the patient to a referral center.