Deep (> 5 mm) foci in the area between the vagina and the rectum (rectovaginal endometriosis), in the urinary bladder or in the bowel, more seldom in other organs
Pathogenesis remains unclear. Endometrial tissue may migrate through the Fallopian tubes into the peritoneal cavity, or peritoneal cells may transform to be similar to endometrial tissue.
Endometriosis is oestrogen-dependent, and symptoms are usually not seen after menopause.
In addition to oestrogen produced by the ovaries, the endometriotic foci themselves synthesize both oestrogen and prostaglandins, which maintains the condition.
In the affected individuals, the normal immune system is disturbed making it possible for endometriosis to develop.
The risk of endometriosis is 7-fold if a relative has the condition.
Signs and symptoms
The most common symptom is dysmenorrhoea that starts several days before the onset of menstrual bleeding.
Dyspareunia or pain induced by jumping or running
Pain on urination or defecation, blood in urine or stools
Abnormal vaginal bleeding, tiredness
Infertility
Lower abdominal mass
Symptoms are often cyclic; in the severe form of the disease the pain is continuous.
Gynaecological examination may show normal findings in a mild disease.
In the gynaecological examination, tenderness is found in the posterior ligaments and laterally to the uterus, the uterus is tender when moved, and in some cases, bluish endometriosis is seen in the vagina.
In endometriosis, either the pain or infertility is treated; treating both simultaneously may be difficult.
Symptomless endometriosis needs no treatment.
No curative treatment exists.
Pharmacotherapy aims to prevent the action of oestrogen on the endometrial tissue and to induce a state where there is no menstrual bleeding, and thus to decrease the size of the endometriotic foci. Symptoms will return in half of the patients when treatment is withdrawn.
Pharmacotherapy may be commenced on symptoms basis before the diagnosis has been confirmed by laparoscopy.
Surgical treatment aims to remove any ectopic endometrium completely and to restore normal anatomy.
All the above-mentioned hormonal therapies are equally effective in reducing pain. The treatment is chosen on an individual basis and avoiding adverse effects.
Aromatase inhibitors prevent extra-ovarian oestrogen synthesis and may be used in young patients combined with an oral contraceptive/progestin/GnRH agonist, and after radical surgery or menopause also as the sole medication.
Surgical treatment is not helpful in 20% of the patients, and the disease recurs in 20-30% of the patients in five years.
In very severe endometriosis, hysterectomy and ovariectomy, and if necessary, also resection of the urinary bladder or the bowel are considered.
Treatment of endometriosis in a patient with infertility
Hormonal medication used to manage pain will prevent a woman from conceiving and are thus not recommended for patients with infertility problems unless it is used to suppress the disease during an infertility treatment pause.
Treating the disease with hormones before a pregnancy wish suppresses endometriosis, and the prognosis of pregnancy may be better than in the active form of the disease.
Laparoscopy is indicated if endometriosis is suspected in a patient with fertility problems and pain.
Surgical treatment of severe endometriosis may improve the chances of pregnancy Infertility.
If infertility is prolonged, or the disease is advanced, in vitro fertilization is recommended.
Pregnancy will lessen symptoms and in some cases the symptoms may even disappear altogether after delivery.
References
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Agarwal SK, Chapron C, Giudice LC et al. Clinical diagnosis of endometriosis: a call to action. Am J Obstet Gynecol 2019;220(4):354.e1-354.e12. [PubMed]
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Working group of ESGE, ESHRE and WES, Saridogan E, Becker CM et al. Recommendations for the Surgical Treatment of Endometriosis. Part 1: Ovarian Endometrioma. Hum Reprod Open 2017;2017(4):hox016. [PubMed]
Working group of ESGE, ESHRE, and WES, Keckstein J, Becker CM et al. Recommendations for the surgical treatment of endometriosis. Part 2: deep endometriosis. Hum Reprod Open 2020;2020(1):hoaa002. [PubMed]
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