What is endometriosis?
Endometriosis is a common but poorly understood disease of
women. The characteristic feature of endometriosis is the presence of
endometrial cells (cells that line the inner wall of the womb) in other sites.
The inner lining of the pelvis is by far the commonest site for deposits of
endometriosis but the disease has been described rarely in distant sites such
as the lungs and the eye. The other characteristic of the disease is the
inflammation that occurs in relation to these tissues, which results in pain.
Deposits also have nerve fibres that contribute to the pain.
The
simplest way to explain endometriosis is that the cells that line the cavity of
the womb (the endometrium) change during the menstrual cycle to break down at
the end to result in menses. In women with endometriosis these cells become
implanted outside the womb (‘the endometrial deposits). During the menstrual
cycle, these also respond to the hormones and tend to bleed into the pelvic
cavity. In addition to the blood the endometrial deposits also produce a
variety of noxious chemicals that produce inflammation and pain. In addition,
this process makes the structures in the pelvis stick together (‘adhesions’). For
example, the ovaries, which are normally freely mobile may become adherent to
the womb or the lateral walls of the pelvis. In other women, blood may collect
over a period of time in relation to the one or both ovaries and form cysts,
called endometriomas. Since blood has persisted in the over a long period of
time, it changes to a chocolaty color and these cysts are therefore also known
as endometriomas.
These
form the basis for the pain and other problems of endometriosis.
How common is it?
Endometriosis affects up to 6-10% of women of childbearing age – therefore it is common. The disease tends to run in families. If you are a person who has pelvic pain or infertility, the likelihood of your having the disease goes up to 25-50%. The general impression is that there is a progressive increase in the prevalence of the disease in the world.What are the features of the disease?
The preeminent features of endometriosis are pain and infertility.Pain of endometriosis is typically felt during menstruation and/or sexual intercourse. Typically, menstrual pain due to endometriosis outlasts the bleeding, meaning it begins before, lasts throughout and ends after the bleeding. Many women have menstrual pain or cramping from time they begin to have menses. This is considered normal. Pain that signifies endometriosis usually begins later in life. Menstrual pain that begins afresh or keeps getting worse with time are highly suggestive of the disease. Endometriosis is also well known to produce pelvic pain that is continuous and continuous low backache.
A
problem that is well recognized as a consequence of endometriosis is
infertility. This could be due to many causes. The distortion of pelvic
structures associated with the disease is an obvious reason. However, it is
known that the mere presence of endometrial deposits in he pelvis even without
distorting the structure of the pelvis could affect fertility. It is accepted
that treatment of these deposits could improve fertility. Another reason that
contributes to infertility is the inability to have intercourse effectively due
to pain.
Deposits in the ovaries bleed
cyclically to produce collections of blood which result in what are commonly
called ‘chocolate cysts’ (endometriomas) with the blood changing its colour to
brown with time.
 |
| Image from-Radiology Assistant.in |
How does one develop it?
Despite extensive research, the exact cause of endometriosis remains unknown. Out of many theories, retrograde menstruation hypothesis is the most widely accepted. This theory, first proposed by John A. Sampson in 1927, suggests that during a woman's menstrual flow, some of the menstrual blood flows backwards through the fallopian tubes into the pelvis and attaches itself to the peritoneal surface (the lining of the abdominal cavity). It can then proceed to invade the tissue as endometriosis.Why is it that not all women develop endometriosis
This is one of the great mysteries about this disease. Almost all women have ‘retrograde menstruation’, but only a minority develops the disease. There has been evidence that environmental pollution and immunological factors may have a role in this. This is an area where lot of research is currently taking place.Is it a cancer?
Endometriosis itself is not a cancer, but some studies have shown a risk of progression to malignancy if it persisted for a long time.Diagnosis
The gold standard for diagnosing
endometriosis is a laparoscopy. However, the presence of endometriomas (chocolate
cysts) and other signs will indicate the diagnosis on ultrasound scanning. the
‘transvaginal’ approach is the more accurate way to make diagnose. Chocolate
cysts are typical of endometriosis and detection of them almost confirms the
diagnosis. In addition, limited mobility of the ovaries is a pointer.
Treatment
Not
all endometriosis needs to be treated by surgery, however. Those who have
lesser degrees of pain may benefit from simple analgesics. Pregnancy has long
been recognized to have a positive effect on endometriosis, but one of the
problems of the disease is difficulty in conceiving. The commonly used
contraceptives, the ‘pill’ and medroxyprogesterone acetate (Depo Provera)
injections are considered first-line treatments for the condition. Prolonged
use of these mimics pregnancy and gives temporary relief.
There
are other drugs also available for treatment, but the consensus among experts
is that these do not confer additional advantages over the first-line drugs
which are considerably cheaper. Taking the ‘pill’ in a way that brings on a
withdrawal bleed once in three months will have particular advantages for women
with menstrual pain. The newer hormone-releasing intrauterine devices are a
useful addition since they suppress menses, thus reducing associated pain.
The
main disadvantage of treating endometriosis with drugs is that they necessarily
act against conception. Therefore, women with endometriosis-associated
infertility will have to undergo surgery. Treatment with drugs is not suitable
for them.
Surgery will allow the separation of ‘adhesions’ and for normal
relationships of the pelvic organs to be restored. The endometrial deposits
could also be destroyed by cauterization during surgery. In fact, studies have
shown that such destruction of the ‘deposits’ will improve fertility rates.
With
more extensive disease, where more of the lining of the pelvis (the peritoneum)
is affected, the lining needs to be stripped off to achieve a cure. These
procedures are highly specialized, since some vital structures such as the
tubes that take urine from the kidneys to the bladder (the ureters) need to be
teased out from the lining to avoid damaging them. Only a surgeon who is
experienced in such procedures should undertake them.
By Professor Hemantha Senanayake
uploaded by Dr.Wedisha Gankanda
No comments:
Post a Comment