Endometriosis Diagnosis and Treatment
The New England Journal of Medicine (NEJM):
Endometriosis is defined as the presence of endometrium-like tissue outside the uterus.
Figure 1. Endometriosis across the Life Course.
Endometriosis is primarily diagnosed through surgical visualization — ideally, laparoscopy. Treatment consists of surgical removal of lesions and hormonal medication, often with side effects and variable efficacy.
Epidemiology
Prevalence
Endometriosis is estimated to affect 10% of reproductive-age women.
Presentation, Risk Factors, and Coexisting Conditions
Figure 2. Multisystemic Endometriosis Phenome.
Presentations of endometriosis (Figure 2) range from superficial peritoneal lesions of varying color, to cysts in the ovaries (endometrioma), to nodules with a depth of penetration exceeding 5 mm (deep endometriosis, often accompanied by scarring [fibrosis] and adhesions), to extrapelvic lesions (Figure 3).
Chronic pelvic pain that is unresponsive to conventional treatments develops in approximately 30% of patients with endometriosis. About one third of affected women have infertility (approximately twice the rate among women without endometriosis).
The few robust risk-factor associations that are emerging suggest critical windows of exposure. For example, diethylstilbestrol exposure, low birth weight, and an early age at menarche have been associated with a greater risk of endometriosis. Risk factors from adolescence into adulthood include a short menstrual cycle, low body-mass index, low waist-to-hip ratio, and low parity.
Diagnosis
Endometriosis remains difficult to diagnose. No biomarkers to detect or rule out endometriosis are available. The predominantly intraabdominal location of the lesions, plus their small size, means that laparoscopic visualization (ideally with histologic verification) remains the standard for diagnosis of the disease.
Imaging is of little use for identifying the most prevalent of the three macropresentations described above: superficial peritoneal lesions.
However, endometriomas can be identified reliably by transvaginal ultrasonography or magnetic resonance imaging (MRI), with more than 90% sensitivity and specificity.
A skilled specialist can identify deep endometriosis and adhesions involving pelvic organs with transvaginal ultrasonography. MRI has 94% sensitivity for detecting deep endometriosis, but the specificity is only 79%.
Doctors Liked to Read More
In choosing treatment for endometriosis, it is crucial to consider the patient’s predominant symptoms and preferences, side-effect profile, and age, as well as the extent and location of disease, previous treatment, and costs.
Management of endometriosis (particularly disease involving the bowel, bladder, ureters, or extrapelvic structures and cases with overlapping pain conditions) requires multidisciplinary expertise.
Approximately 50% of women with endometriosis have recurrent symptoms over a period of 5 years, irrespective of the treatment approach.
Medical Treatment
Current hormonal treatment for endometriosis-associated pain focuses on systemic or local estrogen suppression, inhibition of tissue proliferation and inflammation, or both.
The oral contraceptive pill, both combined or progestin only, is widely used as the first-line treatment for dysmenorrhea or chronic pelvic pain with or without presumed endometriosis, particularly in primary care.
Daily or depot progestins have been effective in some women.
Gonadotropin-releasing hormone (GnRH) agonists are second-line treatments that substantially suppress systemic estrogen levels. Menopause-like side effects, including bone loss, can be decreased by adding low-dose estrogen-replacement therapy.
Analgesia for endometriosis-associated pain consists of a combination of acetaminophen and nonsteroidal antiinflammatory drugs. The International Association for the Study of Pain recommends opioids for severe, short-lived pain during acute events but not for chronic pain conditions, stating, “Chronic pain treatment strategies that focus on improving the quality of life, especially those integrating behavioral and physical treatments, are preferred.”
Complementary Treatment
Current therapeutic options range from pharmacologic treatment, including analgesic, anxiolytic, and antidepressant agents and membrane stabilizers, to pelvic physical therapy and cognitive behavioral therapy.
Surgical Treatment
In women with hormone-resistant pain associated with endometriosis, surgical treatment should be considered. Surgery has been shown to decrease pain in some but not all women.The aim is complete destruction or removal of endometriotic tissue and adhesions.
Hysterectomy is common; endometriosis-associated pain is the leading indication for hysterectomy among women 30 to 34 years of age.
Comments
You must login to write comment