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Endometriosis

Endometriosis

The term endometriosis refers to a benign and common disease in which cells like the ones that line the inside of the womb (endometrial tissue), grows outside the uterus and attaches to other organs in the abdominal cavity such as the ovaries and fallopian tubes. These cells, like the endometrium, respond to the monthly hormonal changes. When the woman with endometriosis menstruates, the endometrium is shed in the form of a period. The endometriosis breaks down in the same way but these cells are trapped inside and cannot escape. Early implants look like small, flat dark patches or flecks of blue or black paint ( "powder-burns" ) sprinkled on the pelvic surfaces. Later, they form swellings filled with blood called endometriomas . With time, this blood darkens to a deep, reddish brown colour, giving rise to the description "chocolate cyst." These may be smaller than a pea or larger than a grapefruit . They occur most frequently in the ovary but can form anywhere in the pelvis. Endometriosis also causes an inflammation that forms scar tissue and adhesions which can block the fallopian tubes or interfere with ovulation.

No one knows for sure what causes this disease. One theory is that during menstruation some of the menstrual tissue backs up through the fallopian tubes into the abdomen, where it implants and grows. Another theory suggests that endometriosis may be genetic, or runs in families.

Endometriosis tends to occur in women who are in their 30s and early 40s, but occasionally occurs in those under 30 years of age. It is more commonly seen in patients who have not borne a child . 30-40% of women with endometriosis may have difficulties in becoming pregnant. Though endometriosis prevents conception, when treated the patient can conceive.

The disease is highly unpredictable. Some women may have just a few isolated implants that never spread or grow, while in others the disease may spread throughout the pelvis. Endometriosis is usually a progressive disease that tends to get worse over time and can reoccur after treatment. When it will recur cannot be predicted. However a full term pregnancy may prevent recurrence or delay it. Endometriosis recurs in about 20 percent of cases over 5 years in patients who have been treated for endometriosis

Some patients with endometriosis may have no symptoms. Symptoms include severe menstrual cramps, pain during intercourse, and infertility. . Occasionally, however, the disease is accompanied by vaginal bleeding at irregular intervals; or by premenstrual spotting. There is little correlation between the severity of symptoms and extent of the endometriosis.

The anatomical distortion caused by endometriosis, specially when it is moderate and severe, could explain a mechanical cause of infertility. The precise mechanism by which minimal and mild endometriosis affects fertility is not fully understood. It is possible that endometriosis adversely affects the egg development, sperm binding to the egg, fertilization, tubal function and embryo implantation.

The only means to confirm a diagnosis of endometriosis after a medical history , pelvic exam and a sonography is by laparoscopy. Laparoscopy assesses the severity of endometriosis and the condition of the Fallopian tubes.

The treatment is planned based on the stage of endometriosis ( mild to extensive), and may include medication or surgery or IVF, or a combination.

Treatment Options

Hormone medication

The goal of hormonal treatment is to simulate pregnancy ( progesterone drugs) or menopause (danazole and GnRH agonists), two natural conditions known to inhibit the disease. In each case, the normal endometrium is no longer stimulated to grow and regresses with each monthly cycle. This action prevents menstruation and causes endometrial implants to shrink. To be effective against endometriosis, the pills / injections must be taken continuously for 3 – 6 months, without pausing for withdrawal bleeding.

Gonadotropin-releasing hormone (Gn-RH) agonists. These drugs block the production of ovarian-stimulating hormones.. It can force endometriosis into remission during the time of treatment and sometimes for months or years afterward. These drugs create an artificial menopause that can sometimes lead to troublesome side effects such as hot flashes and vaginal dryness. These drugs can be given in the form of special injections called depot preparations, which release small quantities of the drug daily, allowing administration at monthly intervals.

Danazol(a testosterone derivative), may not be the first choice because it can cause unwanted side effects, such as acne and facial hair.

Progesterone drugs, given in the form of daily oral medication, are much cheaper but may not be tolerated well as its side effects include weight gain and a depressed mood.

Surgery

Hormonal therapy may be prescribed along with conservative surgery.

Medication usually controls mild or moderate pain and may eliminate small patches of the disease. But large chocolate cysts in the ovary are less likely to respond, and drugs cannot remove scar tissue. This is why surgery may be needed to improve fertility by removing adhesions, lesions, nodules or endometriomas.

Conservative surgery seeks to remove or destroy the growths, relieve pain, and allow pregnancy to occur if desired. Conservative surgery can involve laparoscopy or laparotomy. Most cases can be successfully treated through the laparoscope. Open surgery (laparotomy) is needed only very rarely and may be required with advanced disease that involves large areas of the rectum or larger lesions.

  • Simple puncture - This procedure is completed by draining the chocolate material/fluid from the endometriotic cyst. It is the procedure of choice for infertile patients who need to undergo an IVF/ICSI procedure as a laparoscopy can be avoided. GnRH agonists are given for 3 months prior to the IVF/ICSI cycle and the cyst drained under anaesthesia and ultrasound guidance after the first menstrual bleed. Fertilisation rates in some patients with endometriosis can be a little lower perhaps because of an intrinsic oocyte abnormality. ICSI is usually recommended.

  • Early Endometrial lesions or superficial implants of endometriosis can be burned away using a high-energy heat source or an electric current called diathermy during a laparoscopy.
  • Ablation - Another approach is to drain the cyst and destroy or burn its base with electrosurgery – usually done as a laparoscopic procedure.
  • Cutting away of the cyst wall - This is the procedure of choice to decrease recurrence of disease and is done laparoscopically.

Radical surgery, which may be necessary in severe cases, involves hysterectomy, removal of all growths, and removal of ovaries. For women nearing 40 and who have finished childbearing, removal of uterus and both ovaries is the only option to prevent reccurence.

Adenomyosis

With adenomyosis, the tissue that lines the uterus (endometrium) grows within the uterus' muscular outer walls. This is most likely to happen in the late childbearing years and after having had children.

Adenomyosis isn't the same as endometriosis, Although the cause of adenomyosis remains unknown, the disease typically disappears after menopause. For women who experience severe discomfort from adenomyosis, there are treatments that can help, but hysterectomy is the only cure.

Although adenomyosis can be quite painful, the condition is generally harmless.

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