Endometriosis: A Brief Primer

Endometriosis is the presence of endometrial tissue (which normally lines the uterine cavity) outside of the uterus. When abnormally located, this tissue can lead to inflammation, scaring, distortion of normal anatomy, as well as tissue and nerve invasion. The disease affects 2-7% of American women.

SYMPTOMS

  • Pelvic pain
  • Pain with menstruation (dysmenorrhea)
  • Pain with intercourse (dyspareunia)
  • Pain with bowel movements (dyschezia)
  • Low back pain
  • Decreased fertility

Note:  The degree of symptomatology generally correlates with the degree of the disease, but this is not always the case.

LOCATION

The most common locations of endometriosis are on the lining tissue of the pelvic cavity (peritoneum), the pelvis cul-de-sac, and ovary. Endometriosis can also occur on non-gynecological organs (colon, appendix, and bladder) and at distant sites.

CAUSES

  • The cause of Endometriosis is not definitively known.
  • Environmental factors (particularly dioxin) have been implicated as possible causes, but epidemiological and toxicological evidence fail to definitively link these factors to Endometriosis.
  • A genetic component appears to exist, but the exact basis of inheritance is unknown. To date, no differences in the immune systems of patients with endometriosis have been identified or proven. Endometriosis is not a malignant disease, but those with the disease appear to have greater risks of developing gynecological cancers later in life.

ORIGINS

  • The best explanation for the occurrence of endometriosis is the cellular transformation of primitive embryologic cells in predisposed individuals (known as the Coelomic Metaplasia Theory).
  • Sampson’s Theory is another commonly proposed theory, which points to retrograde menstruation and implantation. Although widely accepted, this theory appears to lack rigorous scientific foundation and does not fit with the natural history of the disease.

DIAGNOSIS
               
The only definitive method of diagnosis is by laparoscopy in the individual with symptoms suspicious for endometriosis.

TREATMENT

It has become increasingly evident that the best treatment for endometriosis is excision (removal) of the disease at the time of the initial laparoscopy. Excised tissue is sent to pathology for definitive diagnosis. Nothing is left for chance, guesses, or subjective observation. Excision allows one to determine the complete depth of endometriosis and removes disease in its entirety. Fertility can also best be improved by removal of the disease and assessment of anatomy in order to determine the best future course of treatment.

Excision of disease has a proven record of success, with upwards of an 80% long-term success rate in pain relief.

Surgical excision of endometriosis is the only technique documented to be efficacious in follow up of patients. The best results are obtained when the surgeon is highly experienced with the disease and utilizes advanced excisional techniques.

Other methods have also been utilized at laparoscopy, including vaporization with laser or electro surgery, heating of tissue-endocoagulation, and ultrasound energy, among others.

MEDICATION

Medication for endometriosis can be used to treat pain and the symptoms of the disease, but no medication can eliminate endometriosis. There is no medical literature demonstrating the superiority of one medication over another in treating the symptoms of endometriosis. Commonly used medications include oral contraceptive pills, various progestins, danzol and lupron. Combinations of medicines and surgery are also sometimes used.

COMPLICATIONS

Unfortunately, if the patient opts for treatment by superficial techniques, such as cauterization or laser vaporization, most of the endometriosis and symptoms recur. This can result in repeat (and equally ineffective) procedures, resulting in a laparoscopy treadmill of repeated procedures, ineffective results, and ongoing symptoms. Recurrence is usually rare with excision of disease.

SUMMARY

Endometriosis is a variable complex disease with many remaining unanswered questions. However, treatment has become increasingly successful and should be undertaken by doctors with experience in managing the disease and possessing the surgical skills needed for excisional surgery.

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