endometriosis Endometriosis is one of the most common and misunderstood gynecological diseases. This diagnosis is made by gynecologists quite often, but women, as a rule, remain in the dark - what exactly was found in them, why it should be treated, and how dangerous this condition is.

Let's figure it out!

In order to understand what endometriosis is, you need to understand how menstruation occurs and what the endometrium is.

The uterine cavity is lined from the inside with a mucous membrane called the endometrium (I will decipher the name: meter - uterus (Greek); endo - inside). This mucous membrane has a complex structure. It consists of two layers - the first is basal, the second is functional.

I explain: the functional layer is the layer of the mucous membrane that is rejected every month during menstruation (if pregnancy has occurred, then a fertilized egg is implanted in this layer). The basal layer is the layer from which a new functional layer grows every month.

This process can be compared to a lawn - you cut the grown grass, and after a while the grass grows again - the lawn is the basal layer; grown grass is functional.

Bottom line: every month, under the influence of ovarian hormones, the endometrium grows in the uterus, if pregnancy does not occur, the endometrium is rejected, accompanied by bloody discharge - this is menstruation.

What is the discharge during menstruation? It is a mixture of blood and fragments of sloughing endometrium.

In almost all women, menstrual flow not only goes out (through the vagina), but some of it also enters the abdominal cavity through the tubes. Normally, menstrual flow that has entered the abdominal cavity is quickly destroyed by special protective cells in the abdominal cavity.

However, menstrual flow is not always completely cleared from the abdominal cavity. Pieces of the torn endometrium have the ability to attach to various tissues, implant in them and take root. Again, let me give you an example with a lawn. Imagine that you took a shovel and began to dig up sections of the lawn and scatter them on the soil. Most of these scattered fragments will take root, and will grow in the form of individual grass bushes.

Thus, endometriosis is a disease when the mucous membrane of the uterine cavity (endometrium) in the form of separate foci is located outside the uterine cavity, and in different places of the body - most often on the peritoneum (what the abdominal cavity is lined with from the inside. And what the intestines are covered with). These fragments of the endometrium (also called endometrioid explants) can be found on the ovaries, tubes, uterine ligaments, intestines, and can also take root in other places outside the abdominal cavity, but more on that later.

After these fragments of the endometrium take root, they begin to exist in the same way as they did when they were in the uterine cavity - that is, under the influence of ovarian hormones, the explants (foci) increase in size, and then some of them are rejected during menstruation. That is, a woman with endometriosis has not only based menstruation, but also a lot of miniature menstruation in the foci of endometriosis.

Since these miniature menses occur in the abdominal cavity on the peritoneum, which is very well innervated, pain occurs during this process. That is why the leading symptom of endometriosis is abdominal pain.

The theory of the origin of endometriosis that I have described is called “implantation”. This is one of the oldest and most obvious theories. In addition to this theory, there are also others. These theories suggest that endometriosis foci may be formed as a result of the transformation of peritoneal cells into endometrial cells, or these foci are formed as a result of genetic predisposition, immunological disorders, or as a result of hormonal influences.

Until now, there is no single view on the problem of endometriosis, but the implantation theory is considered the most obvious.

What can contribute to the development of endometriosis?

Anything that will contribute to more frequent entry of menstrual flow into the abdominal cavity.

In particular:

  • Early onset of menses, late onset of menopause
  • Short menstrual cycle, long heavy menstruation. In women with infrequent periods or a short period of menstruation, endometriosis is less common.
  • Anything that can interfere with the outflow of menstrual flow - congenital malformations (violating the outflow of blood from the uterine cavity), the use of tampons, sports and sexual activity during menstruation
  • Late first birth - it is believed that after birth, the cervix changes and more freely allows menstrual flow to flow

Other factors include:

  • Genetic predisposition - there is evidence that if mothers, sisters and grandmothers had endometriosis, then the risk of developing endometriosis in women increases greatly
  • Tall and thin
  • red hair color
  • Alcohol and caffeine abuse

Foci of endometriosis can be found not only on the peritoneum, but also in various organs and tissues of the body (this is very rare). It is assumed that this is due to the fact that fragments of endometrial tissue can be carried throughout the body by the lymphatic or circulatory system, and also get into wounds during surgery. For example, there is endometriosis of the kidneys, ureters, bladder, lungs, intestines. Endometriosis was found in the navel, in the suture after caesarean section, and also on the skin of the perineum in the scar after skin dissection during childbirth.

What do endometriosis lesions look like?

Endometriosis lesions come in a variety of shapes, sizes, and colors. Most often, these are small seals of white, red, black, brown, yellow and other colors that are scattered throughout the peritoneum. Sometimes these foci merge and infiltrate tissues, especially often behind the uterus on its ligaments. Quite large masses of endometrioid tissue can form in this area (a condition called "retrocervical endometriosis").

If endometrial tissue enters the ovary, then endometrioid cysts can form in it, they are also called “chocolate cysts”. These are benign ovarian cysts. Their contents accumulate in the process of "miniature menstruation" of those foci of endometriosis that line the walls of the cyst.

How does endometriosis manifest itself?

Pain is the most common symptom of endometriosis. Pain syndrome is characterized by a gradual increase in pain that occurs immediately before or during menstruation, pain during intercourse and painful bowel movements. In some cases, the pain syndrome may not be designated as an acquired phenomenon, but simply a woman notes that she has always had painful menstruation, although most patients indicate increased pain in menstruation.

The pain is most often bilateral and varies in intensity from slight to extremely pronounced, often the pain is associated with a feeling of pressure in the rectal area and can radiate to the back and leg.

Constant “discomfort” throughout the entire menstrual cycle, aggravated before menstruation or during intercourse, may be the only complaint made by a patient with endometriosis.

The cause of the pain is not fully established, it is assumed that it may be associated with the phenomenon of “miniature menstruation” of endometrioid explants, which leads to irritation of the nerve endings. The disappearance of pain when menstruation is stopped in patients with endometriosis, that is, the exclusion of cyclic hormonal effects on endometrioid explants, actually proves the mechanism of the pain syndrome.

Other manifestations of endometriosis include spotting, brownish spotting before or after a period. Pain over the womb, painful urination, the appearance of blood in the urine (must be distinguished from cystitis - the latter most often occurs acutely and quickly passes in the process of proper treatment).

A separate manifestation of endometriosis is infertility. It is believed that endometriosis can lead to infertility through two mechanisms: the formation of adhesions that disrupt the patency of the fallopian tubes and due to impaired egg and sperm function.

Adhesions in endometriosis are formed due to the fact that in place of foci of endometriosis on the peritoneum, an inflammatory process actually constantly occurs, which stimulates the formation of adhesions. Adhesions disrupt the patency of the fallopian tubes, which leads to infertility.

Violation of the function of spermatozoa and the egg is due to the fact that in the presence of endometriosis in the abdominal cavity, the activity of the local immune system changes. It does not work correctly - too actively. In addition, the presence of endometriosis foci on the ovary can disrupt the process of egg maturation, the process of its release (ovulation), and it is also assumed that foci of endometriosis can change the quality of eggs, which leads to this. That the fertilization and implantation of a fertilized egg is disrupted.

Diagnosis of endometriosis

The gold standard for diagnosing endometriosis is laparoscopy. In fact, only with the help of this method it is possible to see the foci of endometriosis and take a biopsy from them to confirm the diagnosis. Endometrial cysts are visible on ultrasound, for which quite accurate characteristics are formulated, however, in some cases, such cysts can be similar to other ovarian formations, for example, to the "yellow body".

With endometriosis, the level of a special marker CA125 increases in the blood. This marker is also used to diagnose ovarian masses (often given when there are suspicious ovarian cysts). This marker is not very specific as it does not reflect the severity of endometriosis. In general, its diagnostic value has remained only for assessing the regression of endometriosis during treatment, although this is not performed as often.

Other methods have also been developed, but they have not yet been widely used.

Thus, without laparoscopy, the diagnosis of endometriosis can only be assumed (with the exception of endometriotic cysts, which are visible on ultrasound). Ultrasound cannot determine the presence of foci of endometriosis in the peritoneum. With this method, it is only possible to detect the accumulation of endometrial tissue in the retrouterine space in a condition such as retrocervical endometriosis.

It is possible to assume the presence of endometriosis on the basis of the clinical picture and gynecological examination. The doctor most often pays attention to pain, their connection with menstruation and sexual life. During the examination, the doctor can palpate in the posterior fornix of the uterus (this is deep behind the cervix) painful seals in the form of "spikes" - these are, as a rule, foci of endometriosis. Patients with such seals often complain of pain during sexual activity, especially during deep penetration of a partner or in a certain position.

Endometriosis can be assumed as one of the causes of infertility in a couple. This question is still open. There are proven facts indicating that after laparoscopic destruction of endometriosis foci, pregnancies occur that have not occurred before. There are facts of detection of endometriosis in women who became pregnant on their own.

There are many opinions and tactics - in one clinic they can tell you that almost all patients with infertility need laparoscopy to exclude or confirm endometriosis with its subsequent treatment. In another, the opinion may differ radically - laparoscopy will be left for later and will be engaged in the search and treatment of other causes of infertility. Paradoxically, both will have good results in the treatment of infertility. This is such a mysterious disease - endometriosis.

How to be? I cannot answer this question unambiguously either. I believe that each specific situation should be dealt with separately. If a couple has other causes that can lead to infertility besides endometriosis, you need to correct them and try to get a result. If it is not there, perform laparoscopy (if there were no other indications for it before). If you have passed all the examinations and everything is normal, you can exclude the role of endometriosis. So logical, in my opinion. After all, if a woman has a disturbed ovulatory function, there are problems with the endometrium and a bad spermogram in her husband, you must first correct these violations and try to get pregnant.

Classification of endometriosis

The most common and worldwide accepted classification of endometriosis is the classification proposed by the American Fertility Society (AFS). It is based on determining the type, size, and depth of penetration of endometriosis foci on the peritoneum and ovary; the presence, prevalence and type of adhesions and the degree of sealing of the retrouterine space.

This classification is based on the prevalence of endometriosis and does not take into account parameters such as pain and fertility. According to this classification, there are 4 degrees of severity of endometriosis, which are determined by the sum of points that evaluate the various manifestations of the disease.

Treatment of endometriosis

First I want to note that endometriosis completely disappears only after menopause (unless the woman receives hormone replacement therapy, against which endometriosis may persist). Until then, with the help of medical methods, we can achieve a stable remission, but it is impossible to guarantee complete elimination of endometriosis until then. As long as menstruation continues and there is sufficient hormonal activity of the ovaries or other hormone-producing tissues (subcutaneous fatty tissue).

There are two ways to treat endometriosis: removing endometriosis foci or temporarily turning off menstrual function so that the foci of endometriosis atrophy. Often these two methods are combined.

Medical treatment of endometriosis

To completely turn off the menstrual function, drugs of the GnRH agonists group are most often used (buserelin-depot, zoladex, lucrin-depot. Diferelin, etc.) Such drugs are usually prescribed for a course of 3 to 6 months (the drugs are administered intramuscularly 1 injection 1 time in 28 days). Against their background, a woman's menstruation disappears and a condition similar to menopause sets in, with all the characteristic symptoms - hot flashes, mood lability, etc. But this condition is reversible. That is, after the last injection of the drug, after 1-2 months, menstruation is restored, and the state of "menopause" disappears. During this time, foci of endometriosis, devoid of hormonal stimuli, undergo atrophy.

Sadly, after such treatment, there are quite a few relapses. Apparently, after the restoration of menstruation, the mechanism for the formation of foci of endometriosis starts up again and a relapse of the disease occurs.

Other drugs that affect the foci of endometriosis include derivatives of male sex hormones - danazol, nemestran, etc. These drugs are quite effective, they are still used. Against the background of their intake, a condition similar to menopause also develops. The negative point in their use is quite pronounced side effects (especially from danazol, nemestran is relatively well tolerated). These drugs are also prescribed for a course of 3 to 6 months, relapses also occur frequently.

Hormonal contraceptives for endometriosis

Hormonal contraceptives have a curative and preventive effect on endometriosis. Against the background of hormonal contraception, the cyclic effect of hormones on the foci of endometriosis is turned off, and they lose their activity. In addition, some contraceptives (for example, Jeanine) include a progestogen component, which can have an additional therapeutic effect due to a direct effect on endometriosis foci.

The effect of contraceptives on the foci of endometriosis is less pronounced than that of the drugs described above. Contraceptives are effective in small and medium forms of endometriosis, in addition, their intake provides prevention of this disease.

In order for contraceptives to have the most pronounced effect, they must be taken according to a new, so-called “prolonged scheme”. The essence of this scheme is as follows: contraceptives are taken not for 21 days and then a 7-day break, but for 63 days (that is, 3 packs in a row) and only after that follows a break for 7 days. Thus, a woman has one menstruation every three months. Such a prolonged regimen not only has a therapeutic and preventive effect on endometriosis, but is also better tolerated in general.

Contraceptives can also be used as a second stage after the main therapy with medications (GnRH agonists). As I noted above, after the abolition of these drugs, a relapse of the disease often occurs due to the fact that menstrual function is restored. Therefore, if, after the end of the main course, you start taking contraceptives according to a prolonged scheme, the likelihood of relapse is sharply reduced and the effect achieved by the main treatment course lasts longer.

Surgical treatment of endometriosis

Laparoscopy is used to treat endometriosis. During the operation, endometriosis foci are destroyed using various energies. Endometrial cysts are simply removed from the ovary. If endometriosis has led to the appearance of adhesions (it occurs quite often), the adhesions are destroyed, and the patency of the fallopian tubes is immediately checked.

Unfortunately, the effect of such an operation does not last long. After some time, foci of endometriosis reappear, and adhesions also develop again. In order for the effect of the operation to last longer, immediately after the operation, patients are prescribed a course of drug therapy (GnRH agonists, nemestrane).

If a woman did not plan a pregnancy, after completing the main course, she can start taking contraceptives to further prevent relapses.

If pregnancy was planned, it is necessary to make attempts to become pregnant immediately after the operation. It is important to remember that the more time has passed after the operation, the more likely it is that the effect achieved by the operation has already passed - most likely, adhesions have formed again and new foci of endometriosis have appeared.

If endometriosis-related disorders lead to the development of infertility, then surgical treatment of such conditions usually has good results. The appointment of drug therapy with GnRH agonists, danazol and gestrinone in the postoperative period is irrational, since this treatment leads to suppression of reproductive function. And the highest frequency of pregnancies after surgical treatment is observed in the first 6-12 months after surgery.

The need for surgical treatment of women suffering from infertility against the background of mild and moderate forms of endometriosis is controversial. On average, 90% of women with mild to moderate endometriosis become pregnant on their own within 5 years. This is comparable to the pregnancy rate in healthy women in the same time period (93%).

The fact that surgical treatment increases the fertility of women suffering from mild and moderate forms of endometriosis is supported by only a part of the authors, the other part refutes these data. And, although it can be assumed that surgical treatment increases the fertility index in the first 6-12 months after surgery, and also contributes to the prevention of relapses, on the other hand. Unjustified surgical activity in any case increases the likelihood of occurrence and inevitable recurrence of the adhesive process.

The long-term results of surgical treatment of pain syndrome associated with endometriosis largely depend on the individual characteristics of each particular patient, in particular, on her psychological status. Only diagnostic laparoscopy without complete removal of all foci of endometriosis (in other words, placebo-surgical treatment) can lead to the disappearance of pain in 50% of women. Laparoscopic laser destruction of endometriosis foci with moderate severity of the disease usually leads to the disappearance of pain in 74% of women. At the same time, surgical treatment of mild forms of endometriosis usually does not lead to significant pain relief.

In custody:

  • Endometriosis is a fairly common disease that is most often manifested by pain and infertility.
  • Pain associated with endometriosis occurs before and during menstruation, may increase during sexual activity and during bowel movements. Pain can also be constant.
  • The most obvious theory of the development of endometriosis suggests that this disease develops as a result of menstrual flow entering the abdominal cavity, in which conditions are created for attaching fragments of the endometrium (the lining of the uterus) to the peritoneum. These fragments begin to exist on their own, "miniature menstruation" occurs in them.
  • All factors that worsen the outflow of menstrual flow during menstruation contribute to the development of endometriosis (tampons, sexual activity, sports, etc.)
  • A good prevention of endometriosis is the use of hormonal contraceptives, especially in prolonged mode (63+7)
  • It is possible to diagnose the presence of endometriosis based on the characteristics of the patient's complaints, examination on the chair and ultrasound. The only way to accurately confirm the presence of endometriosis is through laparoscopy.
  • Most often, endometriosis is treated with the help of laparoscopy - the destruction of the foci and the removal of cysts (if any) are performed. After surgical treatment, there should be a course of drug treatment (if the woman is not planning a pregnancy), which consolidates the achieved result.
  • If endometriosis is considered as the cause of infertility - it is necessary to become pregnant as soon as possible after surgical treatment - the more time passes after the operation, the greater the risk of recurrence of the disease and the formation of adhesions
  • Endometriosis completely regresses only after menopause (hormone replacement therapy may delay the regression of endometriosis).
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