Endometriosis: the Incidence is Increasing Surprisingly

title with picture showing sites of endometriosis

The inner wall of the uterus (the womb) is called the endometrium. When these endometrial tissues are found in sites other than the womb then it is called endometriosis. 

Endometriosis is a disease of reproductive life of females i.e. the problem develops after puberty and may persist up to menopause. But the most common age group is 30- 45years.

The prevalence of endometriosis has been increasing for the last few decades and the incidence is higher among infertile women, which is about 40-60%.

Types of Endometriosis:

Endometriosis is subdivided into endometriosis externa and endometriosis interna.
When the endometrial tissues are found in sites other than the uterus, then it is called endometriosis externa. But in endometriosis interna, the endometrial tissues are found within the myometrium (i.e. the middle coat of the uterus). It is known as adenomyosis.
In general, endometriosis indicates the endometriosis externa.

Common Sites of Endometriosis:

Endometriosis is called the disease of contrast. Because it is benign but locally invasive and widely disseminates. Although in a few cases, there is a chance to transform into malignancy.
However, the common sites of endometriosis are-
  • Ovaries
  • Pelvis
  • The pouch of Douglas (an extension of the peritoneal cavity between the rectum and uterus).
  • Uterosacral ligament.
  • Different parts of the large gut.
  • Appendix.
  • Fallopian tube.
  • Abdominal scar of previous surgery.
  • Umbilicus
Endometriosis can also be found in other sites but their incidence is rare.

Why Endometriosis is Increasing Surprisingly in the Last Few Decades:

  • Late marriage.
  • First child at a late age.
  • A family history of endometriosis.
  • Genital tract (outflow) obstruction.
  • Early age of first menstruation.
  • Frequent and prolong menstruation.
  • Nulliparity i.e. women who have never conceived.
  • Some environmental factors (pollutants, dioxins) also have influences on endometriosis.

How the disease develops:

The actual pathogenesis is unclear but multiple theories are suggested. The principal theories are as follows:
  • Retrograde menstruation theory (Sampson's theory) for pelvic endometriosis.
  • Coelomic metaplasia (Meyer & Ivanoff) theory for pelvic peritoneum, abdominal organ, and umbilicus.
  • Direct implantation theory for endometriosis of the abdominal scar, vagina, and cervix.
  • Lymphatic spread for the lymph nodes.
However, the theories are, the main mechanism of the disease is-
Proliferative changes in the ectopic endometrial tissues by the influences of hormone results in cyclical shedding and bleeding.

Clinical Features of Endometriosis:

Patient Profile:

Age: Reproductive age but more common at 30-45years. Higher social status is often related due to late marriage and late childbearing. About 40-60% of cases are infertile women, although endometriosis causes infertility or infertility causes endometriosis is not clear.

Symptoms of the Patient:

About 25% of cases patient may remain asymptomatic, even when the endometriosis is widespread and diagnosed accidentally during the diagnosis of other diseases.
However, symptomatic patients often complaints with-
    a lady with abdominal pain
  • Painful menstruation (Dysmenorrhoea).
  • Abnormal menstruations like menorrhagia (excessive menstruation in duration or amount or both).
  • Polymenorrhoea (i.e. increase frequency) may be seen if ovaries are involved.
  • Painful sexual intercourse (Dyspareunia): commonly seen in endometriosis of rectovaginal septum or pouch of Douglas.
  • Lower abdominal pain or a backache may be due to peritoneal inflammation, tissue damage nerve irritation or release of inflammatory mediators.
  • Urinary frequency, painful urination, painful defecation, diarrhoea, constipation, and rectal bleeding may also be found.

Investigations of Endometriosis:

  • Diagnostic laparoscopy (gold standard).
  • Serum tumour marker: CA125.
  • Ultrasonography.
  • MRI.
  • CT scan.
  • Colonoscopy, rectosigmoidoscopy and cystoscopy are performed when symptoms suggest the involvement of the respective organs.

Why Laparoscopy is called Gold Standard for diagnosis of Endometriosis:

By laparoscopy, the actual site, size and extent of endometriosis can be assessed. The staging of endometriosis is done on the basis of laparoscopic findings.
A biopsy can be collected during laparoscopy, for confirmation of cancer.

Staging of Endometriosis:

Staging is done based on findings of laparoscopy to predict the prognosis and evaluate the treatment protocol.
The stages are as follows-
  • Stage I: Minimal.
  • Stage II: Mild.
  • Stage III: Moderate.
  • Stage IV: Severe.

Treatment of Endometriosis:

  1. No treatment, only observation: painkiller to relieve pain. Married women are advised to become pregnant.
  2. Medical treatment: consists of Hormonal treatment and symptomatic treatment.
  3. Surgical treatment: conservative (i.e. with preserving the ovaries and uterus) and definitive surgery (i.e. without preserving the ovaries and uterus).
  4. Combined therapy: both medical and hormonal treatment.
These options are selected based on some factors. They are-
  • Patient's age.
  • Size and extent of the lesions.
  • The desire for children.
  • Results of previous therapy.

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