Endometriosis

What is it?

Endometriosis is defined as the presence of endometrial tissue outside the uterine cavity, predomi-nantly, but not exclusively, in the pelvic compartment. It is an estrogen-dependent chronic inflammatory con¬dition that affects ~5% women in their reproductive period with a prevalence peak between 25 years and 35 years of age. The presence of endometrium outside the uterine cavity causes pain and infertility, which are the main burdens of endometriosis disease.
Endometriosis can be localized in the ovary (ovarian endometriosis cysts also called endometrioma, OMA), superficially in the pelvic cavity (superficial endometriosis, SPE) or deep in the layers of pelvic organs such as the rectum (posterior deep endometriosis, posterior DIE) or the bladder (anterior deep endometriosis, anterior DIE).

Which are the symptoms?

The two most frequent pain symptoms are dysmenorrhea (pain during menstrual bleeding) and deep dyspareunia (pain during sexual intercourse). Other symptoms include dyschezia (pain during defecation), dysuria (pain during peeing) and inter-menstrual pelvic pain.
Endometriosis (especially the ovarian localization of the disease) is also associated with infertility and can sometimes be discovered during the diagnostic work-up of an infertile couple wishing to conceive.

  • Dysmenorrhea
  • Dyspareunia
  • Chronic pelvic pain
  • Dyschezia
  • Dysuria
  • Infertility

How is it diagnosed?

Since the histological diagnosis of endometriosis can be obtained only with surgery (diagnostic laparoscopy), it remains the diagnostic gold standard according with the majority of international guidelines.
Moreover, some experts believe that endometriosis can be suspected and should be diagnosed even in the absence of a histological confirmation throughout the combination of symptoms, signs and ultrasonographic findings.
As a matter of fact, ovarian endometriomas and deep invasive nodules can be reliably identified with the use of noninvasive diagnostic tools. Gynecologic bimanual examination and transvaginal ultrasonography are highly accurate in diagnosing ovarian endometriomas, deep nodules and bladder lesions. Recto sigmoidoscopy, barium enema, MRI and urinary apparatus imaging may be of help in selected circumstances. The role of serum CA 125 levels assessment in primary diagnosis is still undefined.
In conclusion, the combination of symptoms, signs and ultrasonographic findings is generally reliable in the nonsurgical diagnosis of endometriosis.

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How is it treated?

In endometriosis-associated pelvic pain, medical or surgical approaches can be adopted. The choice between the two alternatives is influenced by several factors, which need an expert evaluation by a specialized gynecologic team.  The most frequent medical treatments used to treat pain in endometriosis includes oral contraceptives and pro¬gestins. In more severe form of endometriosis gonadotropin-releasing hormone agonists (GnRHa) can be used.
Medical therapy in endometriosis is symptomatic and do not destroy already formed lesions. They should be conceived as long-term treatments; symptom recurrence at drug discontinuation is expected and does not constitute demonstration of inefficacy of treatments. 
In clinical practice, symptoms refractory to medical therapies usually need a surgical approach either by laparoscopy (more often) or laparotomy.
Also endometriosis-related infertility may be theoretically treated either by surgery or by medically assisted reproductive techniques. Although lesion eradication is considered a fertility-enhancing procedure, assisted reproductive technologies constitute a valid alternative.
Given the lack of robust data, the decision between surgery and IVF must be discussed and shared with the patient. Women should receive comprehen¬sive information illustrating the potential benefits and risks of both approaches. 

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