Endometriosis is a disease in which tissue grows beyond the limits of the uterine cavity, with properties similar to that of the uterus. The incidence varies from 7 to 50% in women of childbearing age.
A special case of the disease – adenomyosis (location of the endometrial tissue in the thickness of the muscle layer)
The main symptoms include
- complaints of pain, feeling of heaviness in the lower abdomen;
- intermenstrual discharge often brown, spotting;
- long-term endometriosis may be accompanied by manifestations of the central nervous system, for example, decreased performance, drowsiness, deterioration of attention, irritability.
Endometrial cells extend beyond the uterus, where they can settle and germinate on the peritoneum, fallopian tubes, in the ovaries and on neighboring organs: the rectum, bladder, intestines, and other organs. Extremely rarely (when released into the bloodstream), these cells settle in the lungs, larynx, kidneys and other organs distant from the uterus.
A feature of endometriosis is that, regardless of where the endometrial cells have settled, they function like they are in the uterus, that is, every month according to the phases of the menstrual cycle, they expand, loosen, and bleed during menstruation (for example, with endometriosis of the urinary system, bloody urinary excretion, with rectal endometriosis – discharge of blood from the anus, etc.).
Every month, a few days before and during the menstruation period, the woman develops abdominal pain of varying severity – from discomfort to the need to lie down, take painkillers, and even to complete disability. These pains can spread to the rectum, sacrum, buttocks, legs, back, etc.
In the latter case, the pain during sexual intercourse is often noted up to their complete impossibility. Depending on the location and extent of spread, endometriosis can be accompanied by headaches and dizziness.
There are cases of asymptomatic flow. even with a pronounced lesion of an organ.
If any link of the reproductive system is affected by endometriosis (uterus, fallopian tubes, ovaries, pelvic peritoneum), sterility may occur.
For diagnosis, a number of procedures.
The doctor may suspect the disease on the basis of the patient’s listing of her complaints and symptoms.
Indicate endometriosis will
- menstrual disorders (painful and heavy menstruation, chocolate-colored discharge before menstruation),
- pain, increasing before menstruation,
- as well as the presence of infertility
- involvement in the process of internal organs located near the uterus and ovaries (bladder, rectum).
- Patients with a rectum affected by endometriosis often notice that pains before menstruation are given to the sacrum, anus, accompanied by constipation, blood in the stool, and painful bowel movements. During sexual contact in such patients, pain and irradiation of pain in the rectal area are also noted. If endometriosis infiltrates the wall of the bladder, then the patients talk about painful urination, and in the analysis of urine traces of blood are detected periodically (a small amount of protein and blood cells).
When compulsory vaginal examination by a gynecologist with endometriosis are determined by the characteristic features:
- globular uterus,
- enlarged ovaries due to endometrioid cysts,
- limited mobility of the uterus and appendages with severe adhesions,
- seals behind the uterus in the form of spikes, painful on palpation – this is a sign of damage to the sacro-uterine ligaments by endometriosis.
A colposcopy, or examination of the cervix with a microscope, allows you to see the presence of foci of endometriosis on the cervix.
Ultrasound examination of the pelvic organs
Ultrasound is a mandatory and most accessible method for diagnosing a disease. Using it, it is possible to detect both internal endometriosis of the uterus ( adenomyosis ) and external endometriosis (outside the uterus).
The following lesions of the uterus are characteristic of the ultrasound picture of internal endometriosis:
- pathological growth of the uterine layer of the endometrium and its germination in the thickness of the uterus,
- uneven thickening of the uterus, increasing its size,
- the presence of areas of heterogeneous density in the muscle of the uterus with the formation of nodes without clear contours,
- the presence of microscopic cysts in the endometrium and the thickness of the uterine wall.
In case of external genital endometriosis, ultrasound helps to detect:
- endometrioid ovarian cysts,
- indirect signs of the formation of nodes behind the uterus (in the thickness of the sacro-uterine ligaments),
- indirect signs of adhesions in the pelvis.
In addition, using ultrasound is the differential diagnosis of endometriosis with uterine myoma , malignant disease.
The gynecologist will send the patient to the ultrasound immediately after the first examination.
For more informativeness, the study is recommended to be carried out in the second half of the menstrual cycle (on days 16-19 of the cycle) and with the use of a transvaginal ultrasound probe.
Magnetic resonance imaging (MRI) and computed tomography ( CT )
MRI and CT are radiological methods.
They are more clearly than ultrasound, secrete healthy tissues of the body and affected by endometriosis. With CT and MRI, a differential diagnosis can be made between uterine myoma, a malignant tumor and a nodal or infiltrative form of endometriosis, as well as to assess the degree of involvement in the process of the bladder, sacro-uterine ligaments behind the uterus and rectum.
The sensitivity and accuracy of MRI diagnostics is 95% , so this method should always be prescribed for diagnosis in unclear cases.
When hysteroscopy examines the uterus from the inside using a microscopic camera, usually performed under intravenous anesthesia in the hospital.
The doctor prescribes hysteroscopy usually in cases where there are irregularities in the menstrual cycle and the endometrial pathology is described by ultrasound – the growth of the endometrium, the presence of polyps, nodes that deform the uterus, the suspicion of a malignant disease. In these cases, the diagnosis is clarified by visual inspection of the uterus and endometrium, and as a result of a histological examination of the endometrial biopsy, a malignant disease can be excluded from the uterus.
Hysteroscopy to clarify endometrial pathology is also shown to all patients with infertility.
* Hysterosalpingography (an x-ray of the uterus and fallopian tubes with contrast inserted into the uterus cavity) is not currently used to diagnose endometriosis. At the same time, patients with infertility, who take such a picture to clarify the patency of the tubes and the absence of uterine development abnormalities, often reveal signs of endometriotic lesions of the uterus wall as a finding: this is the “isotment” of the uterus contours, the deformity in the form of spikes in the inner surface of the uterus.
Cystoscopy (examination of the endoscopic chamber of the bladder) and examination of the urologist, as well as studies of the intestine ( irrigoscopy ) will clarify the degree of involvement in the process of organs adjacent to the uterus and determine the further treatment tactics.
This is the most accurate method for making a diagnosis of endometriosis and clarifying the stage and extent of the process.
Laparoscopy involves puncture of the abdominal wall in order to introduce a special instrument equipped with a video camera – a laparoscope. You can examine the uterus, ovaries, ligamentous apparatus of the uterus, the bladder with the rectum, assess the severity of adhesions, conduct a study of patency of the fallopian tubes. When the diagnosis of external genital endometriosis is confirmed, diagnostic laparoscopy enters the therapeutic stage (surgical treatment of endometriosis).
Laboratory diagnosis of endometriosis: it has been established that the concentration of tumor markers increases in the blood of patients with endometriosis
- CA-125, REA (cancer embryonic antigen)
The growth of CEA in the blood is observed with endometriosis, as well as with malignant tumors of the uterus, ovaries, vulva.
CA-125 is specific for ovarian adenocarcinoma; with endometriosis, its specificity is 97%, sensitivity – only 27%.
In a nutshell, it is worth deciphering “specificity” and “sensitivity.” That is, in simple terms, only in 27 patients out of 100 this tumor marker in the blood will be recorded above normal. The remaining 73 patients will not feel the method. But on the other hand, those who have a tumor marker will be elevated, in 97% (almost 100%!), The presence of a specific disease is confirmed.
Important! Due to the low sensitivity of markers, the determination of tumor markers of blood is only an auxiliary method for the diagnosis of endometriosis.
Endometriosis is a chronic disease and prone to recurrence, therefore, patients with an established diagnosis of endometriosis should be followed by a gynecologist for life. The priority is the complex treatment of the disease: removal of foci of endometriosis by surgery, followed by drug therapy and prevention of repeated surgical procedures.
involves the use of nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce the intensity of pain. They are recommended to use no more than 3 months. due to the large number of side effects on the stomach and intestines. It is assumed that the doctor prescribes NSAIDs temporarily, for the period of exacerbation, or until the main drug or surgical treatment begins to work.
Many patients are afraid of the principle of hormone intake. Women are worried about the fears of weight gain and facial hair growth, which was typical for the use of the first invented hormonal drugs decades ago. Now most drugs are devoid of these side effects. Others remained: fluid retention in the body, engorgement of the mammary glands, decreased libido, acne, increased thrombotic activity of the blood, depressed and changeable mood, headaches, intermenstrual bleeding, dry vagina, vaginitis, etc.
Meanwhile, hormonal therapy for endometriosis plays a key role and cannot be done without it, because endometriosis initially develops because of hormonal imbalance. In heterotopic areas, endometriotic tissue grows under the influence of an excess amount of estrogen and a decrease in the sensitivity of the focus cells to gestagens. Treatment of endometriosis can be carried out with the help of various groups of drugs with a similar mechanism of action: they all reduce the amount of estrogen in the blood of patients, and some of them increase the sensitivity of endometrial cells to gestogens. The following groups are used in treatment:
- progestins as a first line drug . This is a large group of drugs (4 generations), whose action is aimed at suppressing the growth of the endometrium. Drugs are available in different forms – for oral administration (for example, Vizanna, Norcolut, Duphaston), in the form of injections (Depo-Prover), in the form of an intrauterine device with the release of a hormone (Miren).
- combined (estrogen + progestogen containing) oral contraceptives (for example, Silhouette, Janine, Kleira), also inhibit the growth of the endometrium,
- Gonadotropin-releasing hormone agonists (GnRH) – act on hormones at the level of the brain, pituitary, and hypothalamus. Examples are Buserelin, Lukrin Depot, Zoladex,
- androgenic antigonadotropins – Danazole, Gestrinone,
- group of aromatase inhibitors (inhibitors of estrogen synthesis in peripheral tissues) – Anastrozole, Letrozole,
- combination of drugs among themselves and with surgical treatment.
Surgical treatment can be radical (implying the removal of the uterus and appendages) only in case of severe disease and in the case when the woman has already finished the reproductive age and is not interested in pregnancy. In all other cases, surgical treatment will, if possible, organ-preserving.
According to the surgical approach, surgical treatment is divided into laparoscopic and abdominal (abdominal).
Laparoscopy is the preferred surgical approach (“gold standard”) in the treatment of endometriosis of any severity. Benefits of laparoscopic access:
- minimal tissue trauma,
- the period of postoperative rehabilitation is reduced,
- lower percentage of postoperative adhesions,
- better visualization of the affected tissues due to the optical magnification of the endoscope camera, therefore – more laborious and skillful work of the surgeon.
When performing laparoscopy, you can remove endometrioid cysts and nodes, cauterize or excise the foci of endometriosis on the pelvic peritoneum, separate adhesions, restore the patency of the fallopian tubes and normal pelvic anatomy, introduce an anti-adhesion gel barrier. Even removal of the uterus and appendages is possible by the method of operating laparoscopy with appropriate qualifications of surgeons.
Abdominal access with a cut of all layers of the abdominal wall is still necessary in cases of extensive organ damage and the need for excision of endometriosis nodes from the walls of the rectum and bladder. Here, the surgery by the abdominal method is safer for the patient and the doctor.
In patients with severe pain, disorders of the menstrual function, in the absence of the effect of laparoscopic organ-sparing surgery, but the desire to preserve the uterus, the use of ablation of the sacro-uterine nerve (LUNA operation) is also used. At the same time, the effect of reducing pain syndrome from denervation is described as insignificant .
Surgical treatment is indicated for patients with identified cystic forms of endometriosis, with the syndrome of not relieving chronic pelvic pain, with infertility, with nodal forms of the disease, with the involvement of adjacent pelvic organs in the process with a violation of their function and pain.
The goal of surgical treatment is to remove all foci of endometriosis, while respecting the principle of organ preservation, whenever possible. Removal of foci of the disease is a major factor in the reduction of pain in the postoperative period in patients. Also during the operation, the adhesions are separated and the normal anatomy of the pelvic organs is restored.
After the operative stage, drug treatment should be individualized depending on the severity of endometriosis, the patient’s age, interest in the occurrence of pregnancy, the presence of concomitant diseases, etc.
If the patient had no complaints, and only on a planned operation for the removal of an ovarian cyst its endometrial nature was detected, then in the postoperative period it will be sufficient to prescribe a COC of a certain composition (containing a dienogest) with subsequent observation by a gynecologist in dynamics.
If the patient in the clinic has a pronounced pain syndrome, bleeding, and the operation has revealed a severe degree of the disease, then the gynecologist will prescribe her hormonal therapy for a long time and with the use of one or several drugs. So, the combination of gonadotropin-releasing hormone agonists with gestagens, or the pure use of gestagens will be reasonable.
Important! All drugs must be prescribed by the doctor individually for each specific patient! For a woman who is not interested in becoming pregnant, the doctor will advise, as a drug containing progestogen, to choose, for example, the intrauterine hormonal coil. The patient planning to enter into the IVF program after the end of treatment is a completely different drug.
What is taken into account when choosing a hormonal drug:
- stage and prevalence of endometriosis,
- the age of the patient
- plans for the implementation of the fertile function,
- hormonal drug tolerance,
- presence of concomitant diseases
- budget options of the patient.
Hormone treatment is usually prescribed for 3 months, then its effectiveness is assessed. With a satisfactory result, treatment continues up to 6-9 months, followed by observation by a doctor and prescription of supportive and prophylactic therapy. With the ineffectiveness of treatment, either its scheme is changed, or surgical treatment is prescribed, if it has not been applied before.
In the postoperative and rehabilitation period, patients may benefit from physiotherapy treatment methods – low-frequency magnetic and electromagnetic fields, balneotherapy, hydrotherapy (conifers, common radon and iodine-bromine baths). Conversely, one should be aware of the factors that adversely affect the body and cause the progression of the disease. Contraindicated for use in patients with endometriosis:
- healing mud,
- paraffin, heated sand,
- bath and sauna,
- hydrogen sulfide, turpentine, sodium chloride, sulphide baths,
- It is not recommended to sunbathe excessively.
Surgery can be avoided if the patient has no cystic and severe common forms of endometriosis.
For example, a patient was referred to a doctor with menstrual dysfunction at the age of 50 years; during the examination, a slight increase and heterogeneity of the uterine walls was revealed; no deviations were described from the appendages and the small pelvis. The patient underwent a hysteroscopy with an endometrial biopsy, a malignant disease of the uterus was ruled out, and the uterine wall and the endometrium were visually inspected with a hysteroscope camera. Internal endometriosis of the uterus (adenomyosis) has been established. The patient is prescribed hormone therapy for 6 months with a drug from the group of progestogens with an assessment of the effect after 3 and 6 months.
Another example: a 35-year-old patient interested in pregnancy asked a doctor. Three years ago, she had already undergone laparoscopy for endometrioid cysts of both ovaries and resection of the ovaries. Now, according to an ultrasound, a picture of adenomyosis and small cystic inclusions on the operated ovary (no more than 2 cm), presumably endometrioid, are described. With regard to infertility, the patient is observed at a fertility specialist and is preparing for an IVF protocol. Now, before IVF, she needs to have an endometrial biopsy. Reproductive specialist is not recommended re-excision of the ovarian tissue, in order to avoid preserving the supply of eggs. Before IVF to suppress the activity of endometriosis, together with a reproduction specialist, treatment was prescribed using gonadotropin agonist group drugs without reoperation.
Endometriosis is a recurrent disease, the process is not resumed only in patients undergoing radical surgery with removal of the uterus and appendages. A more favorable prognosis for women who received treatment at the age before menopause: after hormonal therapy, a smooth transition to menopause usually occurs, the level of estrogen continues to decline physiologically and there is no recurrence.
At the reproductive young age, the recurrence rate is up to 20% per year, and after 5 years – up to 74%. Therefore, it is important to be monitored by a gynecologist without interruption and to complete courses of hormonal therapy. It is also important to choose a competent attending physician, who takes into account the characteristics of the patient’s case and sees with it the goals of treatment:
- removal of foci of endometriosis,
- the fight against infertility,
- reducing the risk of reoperation and recurrence of the disease,
- prevention of disease progression and spread to neighboring organs,
- reducing pain and improving quality of life.