Endometriosis is a hormone-dependent pathological process characterized by the formation of ectopic foci of functioning endometrial tissue (glands and stroma). First of all, the pelvic organs are affected: the ovaries, fallopian tubes, recto-uterine ligaments, rectosigmoid colon and bladder. With hematogenous spread, other organs (kidneys, lungs, conjunctiva) can rarely be affected. Endometriosis is a benign disease that traditionally occurs in women of childbearing age. Frequency. In 1996, in Russia, the incidence of endometriosis was 55.6; the incidence per 100,000 female population over 18 years old is 152.0. In the structure of gynecological morbidity, endometriosis ranks 3rd after inflammatory diseases of the genital organs and uterine fibroids.
Etiology and pathogenesis
- Retrograde flow of menstrual blood – penetration of endometrial cells into the pelvic cavity, implantation in various organs
- Vascular dissemination – transfer of fragments of the endometrium through the blood or lymphatic vessels (extragenital endometriosis)
- The relative risk of endometriosis is 7% among siblings compared to 1% in the general population. In the pathogenesis of endometriosis, damage is also likely
immune system. Possible genetic predisposition – inheritance of defects in the immune system. Classification. There is no single classification.
- Genital endometriosis
- Internal Endometriosis – the process develops in the myometrium (ade-nomibs). Occurs most often
- Grade 1 – germination to a depth of 1 cm
- 2 degree – germination in the myometrium
- Grade 3 – the entire myometrium is involved in the pathological process
- Grade 4 – involvement of the parietal peritoneum and neighboring organs.
- External endometriosis – endometriosis of the ovaries (2nd place in frequency), fallopian tubes, recto-uterine and broad uterine ligaments, peritoneum of the Douglas space. Classification of external endometriosis by prevalence
- Small forms of external endometriosis: single foci on the peritoneum, single foci on the ovaries without adhesions and scars
- Moderately severe external endometriosis: lesions on the plane of one or both ovaries with the formation of small cysts, mildly pronounced periovarian or intratubular adhesive process, lesions on the peritoneum of the Douglas space with scarring and displacement of the uterus, but without involvement of the large intestine in the process
- Severe form of external endometriosis: endometriosis of one or both ovaries with the formation of cysts with a diameter of >2 cm, ovarian involvement with a pronounced periovarian and / or tubal process, damage to the fallopian tubes with deformity, scarring, impaired patency, peritoneal damage with obliteration of the Douglas space, damage to the rectum – uterine ligaments and peritoneum of the Douglas space with its obliteration, involvement of the urinary tract and / or intestines in the process.
- Extragenital endometriosis – endometriosis of the bladder, intestines, postoperative scar on the anterior abdominal wall, kidneys, lungs, conjunctiva, etc.
clinical picture. In all cases of female infertility, especially accompanied by dysmenorrhea and dyspareunia, it will be necessary to exclude endometriosis.
- Many women with endometriosis are asymptomatic.
- Pain in the lower abdomen (algomenorrhea). The pain may be diffuse or localized (often in the rectal area). There is no direct relationship between the degree of endometriosis and the severity of pain.
- Dyspareunia. Pain during intercourse can occur for the following reasons:
- Foci of endometriosis located on the recto-uterine ligaments
- Endometrioid tumor of the ovary
- Fixed posterior displacement of the uterus due to endometriosis.
- Infertility (10-30%). The reasons
- Endometriomas localized within the fallopian tubes and ovaries, secreting a significant amount of prostaglandins
- Violation of the patency of the fallopian tubes due to adhesions
- With endometriosis, the syndrome of luteinization of the unovulated follicle (the egg is not released from the follicle) does not often occur. Obviously, the reason is an early rise in LH levels: the egg does not have time to mature by this time, luteinization occurs before ovulation.
- Clinical features of endometriosis depending on the localization of the process
- Internal endometriosis – prolonged and heavy menstruation, pain in the lower abdomen shortly and in the first days of menstruation, enlargement of the uterus.
- Ovarian endometriosis may be asymptomatic. Subsequently, microperforations of the chambers occur and in the process
the surrounding tissues and the peritoneum of the pelvis are involved – there are dull pains of a aching nature in the lower abdomen and in the lower back, aggravated during menstruation or after their termination.
- Irregular menstrual cycle, cyclic pain or bleeding from the rectum with rectal endometriosis, hematuria with bladder endometriosis, hemoptysis with pulmonary endometriosis.
- Pelvic examination
- Nodularity and soreness of the recto-uterine ligaments
- Endometrioid tumors, or chocolate ovarian cysts, in the form of volumetric formations of appendages, often fixed to the lateral walls of the pelvis or behind the broad ligament of the uterus. In the early stages, endometrioid foci are located on the plane of the ovary, then gradually increase in volume with the formation of cysts 2–3 cm in diameter, merging with each other, and cavities with hemorrhagic contents appear. The endometrioid cyst forms adhesions with surrounding tissues, especially with the posterior surface of the uterus and the broad ligament of the uterus
- The uterus is often fixed posteriorly
- The CA-125 test is based on the detection of a marker specific for endometrioid cells.
- With endometriosis, the content of CA-125 in the blood serum is increased
- The titer of CA-125 correlates with the degree of the disease
- A positive test is a marker of endometriosis recurrence
- Laparoscopy – ovarian enlargement and nodules in the recto-uterine space may be due to metastatic ovarian carcinoma, bowel cancer, or calcified mesothelioma
- Pathomorphology of the ectopic focus of the endometrium. Tubular, branching, cystic enlarged glands, lined with a single-layer cylindrical epithelium. Some cells have cilia (ciliated epithelium), some have secretory granules. Synchronously with the uterine mucosa, cyclic changes appear in ectopic foci, but desquamation does not occur (there are no conditions for isolating desquamated epithelium). During pregnancy, decidual changes appear in atonic foci of the endometrium.
Differential diagnosis – acute abdomen: complications of ectopic pregnancy, urinary tract infections, irritable bowel syndrome, ulcerative colitis, Crohn’s disease, pelvic adhesions, acute salpingitis, ovarian cyst rupture and other conditions; with endometriosis of the uterus – uterine fibroids, uterine cancer.
Expectant treatment. Treatment of young women with short-term infertility is considered inappropriate. Within 1 year, pregnancy begins in 72% of patients who have not received treatment, and in 76% of women who have undergone therapy. Drug therapy is aimed at hormonal suppression of menstruation. Drugs of choice
- Gonadoliberin agonists. With long-term use, they cause medical hypophysectomy.
- Nafarelin acetate 400 mcg/day intranasally in the morning and 200 mcg in the evening. If, after 2 months of treatment, hormonal suppression of menstruation does not occur, you can increase the dose to 800 mcg / day.
- Leuprolide acetate 0.5–1.0 mg/day or 3.75–7.5 mg/month.
- Goserelin acetate in the form of depot injections 3.6 mg l / c through
28 days within 6 months
- Supportive care
- After 6-9 months of treatment, the desired pregnancy is likely to occur. In her absence
it is necessary to continue treatment with oral contraceptives with a high content of progestins continuously for 9 months. Long-term use of a combination of estrogens and progestins contributes to the development of pseudopregnancy, causing rejection, necrosis and resorption of the ectopic endometrium. Calcium (calcium products) at a dose of 1000-1500 mg / day is recommended when taking GnRH agonists to prevent hypocalcemia due to hypoestrogenemia. Alternative Products
- Danazol 400-800 mg/day for 6-9 months causes pseudomenopause, temporarily reduces the synthesis of steroids in the ovaries, resulting in endometrial tissue atrophy, including ectopic.
- Medroxyprogesterone acetate 100-200 mg/month for 6-9 months inhibits the hypothalamic-pituitary gonadotropic function, which leads to amenorrhea.
- Oral contraceptives with a high content of progestins (1-3 tablets / day) for 9 months before pregnancy planning – in mild cases of endometriosis, without pronounced violations of the anatomy of the pelvis. Long-term continuous use of products contributes to the development of pseudo-pregnancy with amenorrhea. Pseudo-pregnancy causes rejection, necrosis and resorption of the ectopic endometrium.
- NSAIDs – in the treatment of dysmenorrhea due to endometriosis.
- When using GnRH agonists due to hypoestrogenemia, an increase in the excretion of calcium ions from the body is likely
- Due to hypoestrogenemia, symptoms characteristic of menopause also appear (for example, hot flashes, decreased libido, atrophic vaginitis)
- Sexually active women in the treatment of GnRH agonists are recommended to use contraception, because. they may even ovulate after suppression of menstruation
- Side effects of danazol are due to the development of a hypoestrogenic state, as well as the androgenic properties of the product (causes weight gain, acne, greasiness of the skin, coarsening of the voice, facial hair growth).
Surgical treatment is carried out with a moderate form of the disease, pronounced tubo-ovarian adhesions or large endometrioid tumors, when hormonal therapy does not give positive results.
- Gentle surgical treatment – excision, fulguration or laser vaporization of the endometrium, excision of ovarian cysts and resection of deeply affected pelvic organs with preservation of the uterus and at least one tube and ovary
- Radical surgical treatment (extirpation of the uterus and appendages) is carried out for women of mature age, with babies, as well as for severe endometriosis, excluding any attempt at reconstructive surgery. After a less radical operation, a recurrence is possible. After radical surgical treatment of endometriosis (with removal of the ovaries), women of reproductive age need estrogen replacement therapy to prevent bone decalcification, atrophic changes in the pelvic organs, especially the vagina, and premature aging of the cardiovascular system.
- Chronic pain syndrome of the pelvic region.
- In 30-40% of women with endometriosis, infertility is recorded; in 15-20% of women with infertility, endometriosis is found using laparoscopy
- After treatment with oral contraceptives, pregnancy begins in 25-50% of women
- After surgical treatment, the conception rate is 62% in women with mild disease, 55% in moderate disease, and 50% in severe disease.
Synonym. Endometrioid heterotopia See also Acute appendicitis, Pregnancy ectopic KSD
- N80 Endometriosis
- N80.0 Endometriosis of uterus
- N80.3 Endometriosis of pelvic peritoneum