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What is endometriosis?

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To understand what is endometriosis, it is first necessary to know what is endometrium. Endometrium is the normal tissue that lines the uterus internally. It grows and sheds every month. Its growth starts just after menstruation and then it sheds. With each menstrual cycle, this routine is repeated. It is upon it that babies are implanted. If a woman becomes pregnant, it remains during pregnancy; otherwise, it will be eliminated in the menstrual blood. This lining, often for reasons not fully understood, can implant itself to other organs: the ovaries, fallopian tubes, intestines, bladder, peritoneum, and even within the uterus itself, within the muscle. When this happens, it is given the name of endometriosis (when lodged into the muscles of the uterus, it is called Adenomyosis), that is, the endometrium is outside its usual area. The increasing number of diagnosed cases and the seriousness of the disease symptoms are worrying experts in developed and developing countries. An estimated 10-14% of women in their reproductive years (19-44 years old) and 25-50% of infertile women are affected by this disease. It is believed that in Brazil there are 3.5 to 5 million women with endometriosis. These data are sufficient to realize the magnitude and importance of this diagnosis.

In 1921, Dr. Sampson from the Johns Hopkins Hospital, in the United States, demonstrated his theory to explain endometriosis based on menstrual blood reflux. Instead of leaving completely from the uterus during menstruation, it would do the opposite, returning to the tubes towards the abdomen. Based on this assumption, many doctors treated endometriosis by removing the uterus and ovaries. This way, there would be no hormones or menstrual endometrium responsible for the disease. Over the years, it was discovered that many of the patients who were undergoing such radical interventions, continued with the same painful symptoms. In recent years, some observations were made that put this theory into question.

These observations encouraged the search for new concepts that have led to a more accurate diagnosis and more effective treatment.

TYPES AND CLASSIFICATION

Endometriosis is an enigmatic disease that requires specialized knowledge of the professional serving the patient. It has received ratings that seek to identify the location of the lesions, the degree of injury to the organs, and the severity of the disease. Although most of the clinics use the classification of the American Fertility Society that categorizes the disease into minimal, mild, moderate, and severe, recent advances in disease research recommend a new classification into three different types:

  • Superficial or peritoneal
  • Ovarian
  • Deep Infiltrating

Superficial or peritoneal endometriosis

The lesions are scattered on the surface of the interior of the abdomen. They can spread reaching even the diaphragm. Although superficial, they are usually located on important organs, such as the intestines, bladder, and ureter. For this, surgical care must be performed in order to prevent complications. The most common symptoms are: cramps, irregular menstruation, and infertility. A clinical examination does not show significant alterations; an ultrasound does not show characteristic images; and markers that may suggest the presence of the disease, measured in the blood (CA125 and SAA), may or may not be altered. The conclusive diagnosis and treatment are done by video laparoscopy.

 

Ovarian Endometriosis

The likely origin is a superficial implant that reaches the outside surface of the ovary, causes a retraction, and forms cysts. The size of the cysts is variable and causes changes in the anatomy of these organs. The diagnosis is easily made by ultrasound. The usual treatment is surgery by video laparoscopy. The accuracy of the surgical technique is crucial in order to avoid the loss of ovarian reserve; otherwise, along with the tissue of the cyst, it can also remove the ovarian tissue with good quality oocytes which can lead to premature ovarian failure. The cyst may be associated with endometriosis in other organs forming adhesions. There are situations where the patient has no symptoms and the diagnosis can occur during a routine gynecological exam. The indication for surgery will depend on the size of the cyst and other variables.

Video:

This film was edited to reduce its running time and refers to the main stages of surgery for ovarian endometriosis. This intervention was performed by the IPGO team in order to heal and preserve fertility.

To watch the video on Ovarian Endometriosis Click here

To watch the video on Ovarian Endometriosis Click here

Deep infiltrating endometriosis

It presents the most aggressive symptoms compromising the well-being and quality of life of the patients. It can interfere with fertility even when using the techniques of assisted reproduction. Implants reach a depth greater than 0.5 cm and involve other organs like the uterosacral ligaments (which hold the uterus), urinary bladder, ureters, rectovaginal septum (area between the rectum, uterus, and vagina), and intestine. In the last mentioned organs, they form nodules that affect the rectum, sigmoid colon, genitals, vagina, and sometimes the large intestine and ileum (see figure). The most likely origin is the metaplasia (meaning the transformation of embryonic tissue into a different one).

Diagnosis: The diagnosis of deep infiltrating endometriosis should be suspected initially by clinical complaints. The most common complaints are: deep pain and discomfort during sexual intercourse, severe cramping, and especially intestinal problems. Among these are: permanent abdominal bloating, pain, and difficulty in evacuation and sometimes bleeding from the rectum at the time of menstruation.

The examining physician should notice, during the gynecological examination of the vagina and rectum, nodules in the posterior region of the uterus, thickness, and especially pain during the examination of this region. If the disease is localized in the intestine, in the upper region, the professional may not detect it. However, the exams associated with the patient’s medical history will help clarify the diagnosis. Similar to other types of endometriosis, laboratory blood tests, called “markers” should be measured in the first three days of menstruation. While not guaranteeing the diagnosis and the extent of the disease, they can help guide the examination.

Imaging techniques are crucial. Among them, the transvaginal ultrasound should be performed by an experienced professional. It’s a great exam for its precision and ease. Unfortunately, there are a few doctors with expertise to make an accurate diagnosis. This evaluation should be preceded by a bowel preparation to flush (clean) the intestine and to eliminate feces helping to visualize the images. When this exam is insufficient for a conclusive diagnosis, it is recommended to do a Pelvic MRI or Echo colonoscopy. The latter is more complex which requires sedation of the patient, but it helps to better locate the lesions and the depth in the affected organs. Colonoscopy is more simple and aims to evaluate the lesions that penetrate into the intestine.

Surgical Treatment: The treatment of deep endometriosis is always surgical. Done by video laparoscopy, it is extremely complex and requires skilled and experienced physicians in this type of intervention. It should be performed by a multidisciplinary team that has at least one gynecologist and general surgeon specialized in pelvic surgery and with knowledge of the extent and involvement of the disease with other organs. The surgery preparation should be done in advance so that the patient knows of the possible implications, such as the possibility of partial resection of the intestine (rectosigmoidectomy), if there is a compromise with several layers of the organ, and the occasional complications. Both the patient and the team should be ready for these possibilities. The preoperative bowel preparation is required in order for this intervention to be done with ease.

Video:

This film was edited to reduce its running time and refers to the main stages of surgery for ovarian endometriosis. This intervention was performed by the IPGO team in order to heal and preserve fertility.

To watch the video of Deep Endometriosis Click here

Infertility X Endometriosis

The association of endometriosis with fertility has been under discussion for many years. The debates in relation to this disease that affects a woman’s ability to have children have caused, many times, a “come and go” in the medical channel and treatments. All types and degrees of endometriosis may affect fertility; however, often the diagnosis is not so obvious and is a last option in research, among other causes of infertility. This delay in the research of the disease can be due to the mild symptoms, inconsistent clinical complaints, and lack of laboratory evidence in the blood tests and transvaginal ultrasound. Only after going through a period where treatments were performed without success, video laparoscopy is indicated, which concludes the diagnosis. The wait for that explanation delays the conception and prolongs the suffering of the couple.

Endometriosis causes infertility by the following results:

  • It influences the hormones in the process of ovulation and embryo implantation.
  • It also alters the prolactin and prostaglandin hormones that act negatively on fertility.
  • It compromises the release of the egg from the ovaries to the fallopian tubes.
  • It interferes with the travel of the ova through the fallopian tube, as much by the alteration caused by an inflammatory disease as by adhesions (the tubes “stick” to other organs and cannot move).
  • Immunological alterations – cellular alterations responsible for the body’s immune cells (NK cells, macrophages, interleukins, etc.).
  • Endometrial receptivity. The endometrial tissue located inside the uterine cavity, where the embryo is implanted, is impaired by the substances produced by endometriosis (ILH and LIF-leukemia inhibitory factor) that interfere with embryo implantation.
  • Alterations in the development of pregnancy. It may interfere with embryo development and increase the chance of abortion.

Note:
Treatment by Assisted Reproduction (in vitro fertilization) can prevent the action of most of these mechanisms that interfere with fertilization and, therefore, this can be a great outlet for resolving the problem. However, even with these techniques, endometriosis may reduce the chances of positive results and may need surgical treatment by video laparoscopy.

Is Endometriosis Curable?

This is a question that patients often ask. Perhaps the main reason for this inquiry is due to the large number of women who perform repeated surgeries and treatments for this problem.

It is impossible to say that an operation will put an end to the disease, but what we have observed is that many patients have inadequate surgical treatments done to eliminate it permanently. Perhaps, many of the interventions is incomplete due to the high degree of complexity and risk of complications. Therefore, some surgeons concerned about these risks limit the degree of invasion during the procedure and end up not removing the entire disease from the affected organs.

The most modern surgeries involve details of important anatomical knowledge and have achieved a high rate of definitive cure and restoring fertility.

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