Endometriosis

Endometriosis

  

Endometriosis

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What is endometriosis?

The lining of the womb is called endometrium; if endometrial-type tissue is found outside the womb it is called endometriosis. Endometriosis is most commonly found in the pelvis notably on the ovaries and behind the uterus (Figure 23.2). It can involve the bowel and urinary tract. The diagnosis is confirmed by direct visualisation usually by laparoscopy. There is a very large spectrum in the severity of endometriosis: It may consist of no more than a few tiny spots or at the other extreme, there may be extensive disease with cysts filled with a chocolate-like material and scar tissue around the pelvis. The chocolate cysts are derived from blood released by the endometriosis at the time of menstruation. Endometriosis is essentially a condition occurring in the pelvis. There are rare occasions when it may occur elsewhere such as in the lung.

What is adenomyosis?

Adenomyosis is a medical condition characterized by the presence of ectopic endometrial tissue (the inner lining of the uterus) within the myometrium (the thick, muscular layer of the uterus). When the gland tissue grows during the menstrual cycle and then at menses tries to slough, the old tissue and blood cannot escape the uterine muscle and flow out of the cervix as part of normal menses. This trapping of the blood and tissue causes uterine pain in the form of monthly menstrual cramps. It also produces abnormal uterine bleeding when some of the blood finally escapes the muscle resulting in prolonged spotting. It more often occurs in the posterior wall of the uterus.

In studies of chronic pelvic pain in which women had hysterectomies, the incidence of adenomyosis is about 15% to 25%8801,9504.

The condition is typically found in women between the ages of 35 and 50. Patients with adenomyosis can have painful and/or profuse menses (dysmenorrhea & menorrhagia, respectively). Cyclic, cramping uterine pain beginning later in reproductive life (generally after age 35) and often associated with prolonged and heavy menses is the classic presentation. On pelvic examination there may be uterine enlargement from about 6-10 weeks pregnancy size.

Adenomyosis may involve the uterus focally, creating an adenomyoma, or diffusely. With diffuse involvement, the uterus becomes bulky and heavier. Patterns of adenomyosis as recognized by MRI seem to either be diffusely spread throughout the uterus (about 66%) or focal lesions (33%) that only occur in one or two places9401.

Cause is basically unknown although there seems to be an increased incidence associated with any child birth8001, pregnancy terminations2003, Cesarean sections and and even tubal ligations9403. Some say that the reason adenomyosis is common in women between the ages of 35 and 50 is because it is between these ages that women have an excess of estrogen. Near the age of 35, women typically cease to create as much natural progesterone, which counters the effects of estrogen. After the age of 50, due to menopause, women do not create as much estrogen.

The uterus may be imaged using ultrasound (US) or magnetic resonance imaging (MRI). Transvaginal ultrasound is the most cost effective and most available. Either modality will show an enlarged uterus. On ultrasound, the uterus will have a heterogeneous texture, without the focal well-defined masses that characterize uterine fibroids.

MRI provides better diagnostic capability due to the increased spatial and contrast resolution, and to not being limited by the presence of bowel gas or calcified uterine fibroids (as is ultrasound). In particular, MR is better able to differentiate adenomyosis from multiple small uterine fibroids. The uterus will have a thickened junctional zone with diminished signal on both T1 and T2 weighted sequences due to susceptibility effects of iron deposition due to chronic microhemorrhage. A thickness of the junctional zone greater than 10 to 12 mm (depending on who you read) is diagnostic of adenomyosis (<8 mm is normal). Interspersed within the thickened, hypointense signal of the junctional zone, one will often see foci of hyperintensity (brightness) on the T2 weighted scans representing small cystically dilatated glands or more acute sites of microhemorrhage.

MRI can be used to classify adenomyosis based on the depth of penetration of the ectopic endometrium into the myometrium.

There is no increased risk for cancer development. As the condition is estrogen-dependent, menopause presents a natural cure.

Treatment options range from use of NSAIDS & hormonal suppression for symptomatic relief to hysterectomy for a permanent cure. Like endometriosis and uterine myomas, adenomyosis presents the typical characteristics of oestrogen-dependent diseases. Although the two diseases have distinct epidemiological features, they have the same 'target tissue' for hormonal therapy, namely ectopic endometrium. Recognized approaches are systemic hormonal treatments, which are generally used for endometriosis and are capable of suppressing the oestrogenic induction of the disease, and local hormonal treatment that targets the ectopic endometrium directly. Gonadotropin-releasing hormone agonists, danazol and intrauterine levonorgestrel- or danazol-releasing devices have been used in the treatment of adenomyosis.0803 Despite the solid rational basis for its hormonal treatment, few studies have been performed on medical therapy for adenomyosis. The Mirena IUS has been shown to provide benefit.0802

 

Recommended Books:

Endometriosis and Other Pelvic Pain

 Endometriosis and Other Pelvic Pain

Staging of Endometriosis:

 

There have been numerous classifications to describe the severity of the condition. The American Society for Reproductive Medicine revised the classification in 1997 to take account of the latest observations. A score is obtained according to the number of sites and the size of each deposit. Assessment of the severity of endometriosis using the revised American Fertility Society classification allows a degree of comparison although a study of the laparoscopic videotapes of 20 patients with endometriosis showed considerable variation of scoring between observers and also by the same observer on re-evaluation of the same patient.

 

When there is severe endometriosis, there can be little doubt that there is a disease process. The relevance of minimal and mild endometriosis is more often a matter of debate. Some suggest that endometriosis is so commonly found in association with pelvic pain that the possibility of its presence should always be considered. Others are more sceptical as to its significance. At a meeting of the European Society of Human Reproduction and Embryology in 1991, a group of experts concluded that 'Endometriosis does not exist; all women have endometriosis.'

There is no way of looking at endometriosis and deciding whether or not it is the cause of symptoms. Ultimately a trial of therapy may seem appropriate. If symptoms respond our goal has been achieved. If symptoms do not respond the assumption must be that cause and effect have been refuted and a different causation must be sought (Q4. 3). Even when symptoms respond to treatment, this does not necessarily confirm that the endometriosis has been causative; suppression of the menstrual cycle could not only affect the endometriosis but also other conditions that are cyclically related including bowel disturbance as in the irritable bowel syndrome (Q 23.39). The failure of symptoms to respond should be recognised as evidence that the endometriosis is probably not a factor in the pain.  

Related Medical Abstracts - Click on the paper title:-

How prevalent is endometriosis?

Endometriosis is a frequent finding. An incidence of 10-25 % of all women having endometriosis is commonly quoted but if the pelvis is carefully scrutinised, the incidence is probably much higher. When there is pelvic pain or infertility an incidence of more than 60% is quoted. Recent observations, however, suggest that endometriosis is present in most if not all women at some stage. Minimal endometriosis is probably a natural process and not a disease. Endometriosis is often found coincidentally in women without symptoms. 


Related Medical Abstracts - Click on the paper title.

What causes endometriosis?

Sex hormones must play a significant role in endometriosis as the condition is not found before the onset of menstruation and is rare after the menopause. Removing the ovaries usually cures endometriosis.

The origin of endometriosis remains an area of debate. No single theory explains all aspects of endometriosis so there is presumably more than one cause. The implantation theory remains the most likely explanation for the majority of occurrences. During a period, although most of the blood is passed out through the vagina, some passes in a retrograde fashion up through the Fallopian tubes and into the peritoneal cavity (Figure 23.2). Some of this blood will contain live endometrial cells, which can implant on to structures around the pelvis. This would explain why the most common sites of endometriosis are the ovaries and the pouch behind the uterus where the fluid will collect as a result of gravity. As a result of effective contraception and reduction of breast feeding, women today experience a ten-fold increase in the number of periods they experience compared to their great-grandmothers. This may explain the increased incidence of endometriosis.

Other theories include:-

Coelomic metaplasia and changes in the immune system. "metaplasia" refers to the transformation of one kind of tissue into another. Coelomic metaplasia refers to cells that transform into endometrial cells, perhaps as a result of chronic inflammation or irritation from retrograde menstrual blood. There may be a genetic predisposition.

The transplantation theory - That Endometriosis spreads via the circulatory and lymphatic system.

Latrogenic transplantation - Endometriosis is accidentally transported during surgery. Endometriosis occasionally occurs in wounds following caesarean section or hysterectomy

Coelomic metaplasia - This theory holds that certain cells, when stimulated, can transform themselves into a different kind of cells.

The hereditary theory - Women with family members who have Endometriosis are more likely, or are susceptible to developing the disease. Studies of twins have shown that there is a genetic predisposition to endometriosis. At one time it was thought that Caucasian women were more susceptible than others but the latest data shows that the only group with a genuine increased incidence is the Japanese. African women seem to be at lower risk.

Auto-immune disorder - Of all the theories being postulated for the cause of Endometriosis, the idea that this disease is an autoimmune disease seems the very likely, credible and feasible. Autoimmune diseases are now widely believed to occur based on genetic predisposition that may be triggered by environmental and other external factors.

Thin women seem to be more at risk. Endometriosis is more common in those who have not been pregnant.

If deposition of live endometrial cells in the peritoneal cavity is a common, monthly occurrence, why do the majority of women have just a few tiny spots of endometriosis at most, whilst others have severe disease? It is likely that there are a variety of mechanisms which can facilitate the development of endometriosis and others that remove endometriotic deposits. The effectiveness of these mechanisms must vary between individuals. It would seem that there is a normal dynamic process so that small endometriotic deposits develop and are then removed by natural processes. The tiny spots of endometriosis so frequently seen at laparoscopy may be a normal event that nature will usually remove without intervention. Some experts now question whether minimal endometriosis is a disease or just a normal biological process.

Related Medical Abstracts - Click on the paper title:-

How can endometriosis be treated?

Medical treatment takes account of the dependence of endometriosis on sex hormones by reducing oestrogen levels or by creating a largely progestogenic or androgenic (Q 2.9) environment. It is not yet clear whether treatments designed to reduce menstrual flow exert their benefit by reducing the activity of the endometriotic deposits or by suppressing retrograde menstruation (Q 23. 6) and hence deposition of endometrial cells.

  • Reducing menstrual flow by the combined oral contraceptive pill or with the LNG-IUS (Mirena) for example may be beneficial.
  • Progestogens (Q33.10) or danazol (Q33.13) can be prescribed daily for several months to suppress the menstrual cycle.
  • The LNG-IUS (Mirena) is effective in the treatment of chronic pelvic pain (CPP) associated endometriosis, although no differences were observed between it and GnRH. Among the additional advantages of the LNG-IUS is the fact that it does not provoke hypoestrogenism and that it requires only one medical intervention for its introduction every 5 years. This device could therefore become the treatment of choice for CPP-associated endometriosis in women who do not wish to conceive.0502 Insertion of an Lng-IUD after laparoscopic surgery for symptomatic endometriosis significantly reduced the medium-term risk of recurrence of moderate or severe dysmenorrhea.0301