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PäiviHärkki

Endometriosis

Essentials

  • Endometriosis is an oestrogen-dependent disease and is usually not encountered after menopause.
  • Endometriosis-associated pain is treated with drugs that suppress oestrogen secretion in the ovaries.
  • Hormonal products used to reduce pain also prevent pregnancy and are not recommended for infertility patients.
  • Surgery relieves pain and may improve infertility.

Epidemiology

  • Endometriosis is found in women of childbearing age: in 10% of women of reproductive age and in up to 50% of patients with fertility problems.
  • Endometrium-like tissue is found at sites outside the uterine cavity, which induces a chronic inflammatory reaction.
    • Superficial foci on the peritoneal surfaces
    • Endometriosis-induced ovarian cysts (endometrioma)
    • 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.

Diagnosis Blood Biomarkers for the Non-Invasive Diagnosis of Endometriosis, Imaging Modalities for the Non-Invasive Diagnosis of Endometriosis

  • Patient history is important.
  • 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.
  • An ultrasound examination will not reveal superficial foci, but ovarian endometrial cysts, i.e. endometriomas Imaging Modalities for the Non-Invasive Diagnosis of Endometriosis, as well as deep foci in the urinary bladder and in the bowel are readily found.
  • Diagnosis can be verified by laparoscopy but the symptoms do not always correlate with the findings.
  • If the patient has pain on urination or defecation, cystoscopy and sigmoidoscopy may be warranted.
  • Pelvic MRI scan is necessary only to diagnose deep foci preoperatively.

Differential diagnostics

Treatment

  • 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.

Treatment of pain

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.
  • Laparoscopic treatment of mild endometriosis may increase the probability of pregnancy Laparoscopic Surgery for Subfertility Associated with Endometriosis.
  • Removal of the capsule of an ovarian endometrioma (> 5-7 cm) may improve the chances of pregnancy, but surgery may also impair ovarian function Surgery Prior to Assisted Reproductive Technology for Women with Endometrioma.
  • 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

    • Dunselman GA, Vermeulen N, Becker C et al. ESHRE guideline: management of women with endometriosis. Hum Reprod 2014;29(3):400-12. [PubMed]
    • Practice Committee of the American Society for Reproductive Medicine. Endometriosis and infertility: a committee opinion. Fertil Steril 2012;98(3):591-8. [PubMed]
    • Shim JY, Laufer MR. Adolescent Endometriosis: An Update. J Pediatr Adolesc Gynecol 2020;33(2):112-119. [PubMed]
    • 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]
    • Zondervan KT, Becker CM, Missmer SA. Endometriosis. N Engl J Med 2020;382(13):1244-1256. [PubMed]
    • Taylor HS, Kotlyar AM, Flores VA. Endometriosis is a chronic systemic disease: clinical challenges and novel innovations. Lancet 2021;397(10276):839-852. [PubMed]
    • 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]
    • Chen I, Veth VB, Choudhry AJ et al. Pre- and postsurgical medical therapy for endometriosis surgery. Cochrane Database Syst Rev 2020;11:CD003678. [PubMed]