WHEN WOMEN EXPERIENCES:
Painful menses ,Dull ache of lower abdomen , Menses irregularities,Painful coitus ,Infertility – then consider endometriosis
WHAT IS ENDOMETRIOSIS ?
- Presence of functioning endometrium ( inner layer of uterus ) in any other site, other than the uterus .
- It is not a cancerous condition. But in some cases in long duration,it may converts to cancer ( adenocarcinoma )
WHERE ARE THE OTHER SITES ,THESE ENDOMETRIUM SPILL ?
Ovary , Fellopian tube , Pouch of douglas,Recto vaginal septum , Utero sacral ligaments,Bladder ,Ureter , Umblicus , Abdominal wall, Surgery scars ,Lung ,Pleura , Vagina , Vulva , Intestines
HOW THIS ENDOMETRIUM REACHES THESE ECTOPIC SITES ?
Probable ways are :
- Retrograde menses : Spill of endometrial epithelium from uterus , when there is a backward flow of menstrual discharge through tubes in to the peritoneum
- Serosal cell metaplasia : Serosal cells of organs or peritoneum differentiates in to endometrial glands in response to biochemical factors
- Lymphatic and vascular embolism : Endometrial glands through lymphatic vessels and veins travels in the body and deposit in other sites
- Immunological : TNF ,Epidermal growth factors , Macrophage derived growth factor ,Integrins – promotes pelvic implantation of endometrial tissue . T and B lymphocytes helps in propagation of endometrial tissue
WHO SUFFERS MORE FROM ENDOMETRIOSIS ?
- Risk is more , if near relative has been effected from this disease
- Women between 30-40 yrs more prone
- It is a disease of rich .Late marriage ,late childbearing are the reasons -uninterrupted action of estrogen is responsible here
- 50-70% of the women suffering from this disease are childless
- Assosiation of infertility and endometriosis is known and proved but which is the cause and which is the effect ,difficult to say
- Pregnancy and menopause are the two stages of women’s life, where endometriosis regresses
WHAT HAPPENS IN ENDOMETRIOSIS ?
- Endometrial cells translocated from their normal site ( uterus ) and implant only in women with specific alterations in cell mediated immunity . Serosal cell metaplasia also responsible .Estrogen influence is essential to the development and continued activity of ectopic endometrium
- This ectopic endometrium produces prostaglandins same as normal endometrium of uterus .It effects the fellopian tube motility and ovum pick up.
- These islets of endometrium shows cyclical changes ,charecterstic of menses and decidual reaction of pregnancy .There is no outlet for its menstrual discharge, so blood and debris collect with in the tissues to form a cyst .With each menses collection increases but continuous absorption of some of the fluid elements causes the blood to become inspissated and dark coloured to produce tarry or chocolate cysts.
- Rupture of this cyst leads to spill of endometrial cells can lead to development of endometriosis in other areas .Peritoneum reacts sharply to the cyst material and causes dense adhesions ,fibrosis and scarring. Adhesions and fixation of adjacent tissues occurs
All above said are responsible for pain and discomfort to the women
- Painful menses- progressive pain before, during and after menses. Sometimes it is more severe
- Dull ache of lower abdomen-Low abdominal pain ,backache ,radiating to groin .Pain exaggerated during menstruation
- Menses irregularities- It may be heavy bleeding, increased frequency of cycles, increase duration of cycle.
- Painful coitus- Fibrosis and retroversion of uterus causes this.
- Infertility- Because of adhesions and distorted anatomy results in altered tubal movements. But tube will be patent. There will be impaired ovum pick up. Alterations in prostaglandins, macrophages and cytokines causes phagocytosis of sperm. Hormonal dysfunction leads to problems in egg release, leuteal phase deficiency, early pregnancy loss.
- Swelling on abdomen or nodules over incision scars in few
- General ill health,on and off fever ,pain on passing stool ,blood in urine ,ureter obstruction,intestinal obstruction,blood in cough ,blood in chest – seen in individuals ,depending on the site and severity of endometrial deposits
HOW TO CONFIRM THE ENDOMETRIOSIS ?
- In pelvic endometriosis-on internal assessment- nodular , fixed masses with retroverted uterus felt .Movements will be Painful .
- Diagnostic laparoscopy is useful to identify the endometrial deposits .Dark brown or blue nodules ,cysts ,red implants,scarring ,pseudocysts may be seen -described as “powder burn lesions “
- USG ,CT ,MRI – helpful in depending on the site and severity of the disease . Lesion appear in scan as ovarian cyst with irregular walls ,low level echoes with occasional high level echogenic areas with blood clots in chocolate cyst of ovary
- CA 125 levels elevated in endometriosis but less than the value in ovarian cancer
HOW TO GET RELIEF FROM PAIN AND OTHER PROBLEMS OF ENDOMETRIOSIS ?
- Progestins : MPA ( 30mg/dl) ,Inj .DMPA ( 150 mg /dl) 6-12 weeks intervals are useful . 6-9 months duration treatment has to be continued.Women can conceive during this period .Fluid retention ,weight gain ,break through bleeding are side effects
- OCP’s : continues administration of OCP’s can be useful .Response seen in 12-16 weeks.Treatment continues 6-9 months .Women can’t conceive during this treatment .Pseudopregnancy state is achieved with this treatment
- Danazol : it is an androgen.It produces pseudo menopause .With in 2-4 weeks response occurs .But undesirable side effects like hirsutism,acne,hot flushes ,liver problems .
- GnRH agonists : Leuprorelin -3.75 mg IM monthly ,Buserelin 400mcg and Nafrelin 20 mcg Intra nasal spray ,Goserelin 3.6 mg S.C ,Triptorelin etc Osteoporosis is a main side effect other than menopausal symptoms. 3-5% vertebral bone loss seen .
- Levonorgestrol IUCD -releives symptoms in 12 months .It is still under trial for its efficacy in treatment of endometriosis
- Mefipristone : potent Androgen .25-100 gm/d releives symptoms
- Surgical treatment: Laproscopic removal of endometrial cyst or adhesiolysis with bipolar coagulation or laser . It improves the symptoms and increase the pregnancy chances .
- In severe cases ,recurrent cases ,more than 45 yrs women can go for radical hysterectomy with bilateral salpingo oopharectomy .
- After laparoscopy,Artificial reproductive techniques improves fertility rates .Controlled ovarian hormone stimulation,IUI,IVF,Gamete intra fellopian transfer improves the chances of conception.