Spotlight On Endometriosis

Progresses is being made slowly, a new drug treatment for endometriosis associated pain has recently been approved, and researchers are working on a noninvasive diagnostic blood test. A national action plan to address endometriosis has been released by the Australian Minister for Health as many “have never heard the word”.  Advocates have launched a hashtag on social media, and annually the EndoMarch is held on WorldWide Endometriosis Day to draw more attention to the problems of endometriosis.

This condition is a benign chronic inflammatory disease affecting up to 10% of women. Symptoms include but are not limited to cyclic pelvic pain, dysmenorrhea, and dyspareunia, and may significantly influence quality of life, sexual relationships, and time away from work which may contribute to healthcare expenses at a national level.

Endometriosis occurs when endometrial glands and stroma migrate to extrauterine locations. Many theories suggest fragments of endometrium are passed through the fallopian tubes into the peritoneal cavity, however this does not explain all cases, especially those in which lesions can be found in distant locations. Other theories suggest endometrial tissues travel to ectopic sites through lymphatic channels or blood in a similar manner to how cancer cells spread.

Gold standard for diagnosis is histopathic analysis of surgically removed tissue samples. Characteristic symptoms such as chronic pelvic pain, dysmenorrhea, menstrual irregularities, dyspareunia, cyclic intestinal or urinary symptoms, and infertility may suggest the presence of endometriosis, and imaging may reveal lesions. Immobility of pelvic organs, palpation or direct visualizations of lesion in the vaginal wall may also suggest endometriosis. A strong clinical suspicion supported by imaging findings is sufficient for starting therapy.

Endometriosis is estrogen dependent and is not seen before menarche, symptoms typically improve after menopause, it is known to proliferate in estrogen rich environments and to undergo atrophy when levels are low. Hormones that create progesterone dominant environments are used in the management of the condition, as such drugs that suppress ovulation or hypothalamic pituitary axis, increase progesterone availability, and nonhormonal agents that interfere with neovascularization are considered medical therapy. Oral contraceptives, progestins, GnRH agonists, and androgens have demonstrated efficacy in some cases for relief of pain. NSAIDs may also help by reducing prostaglandin levels that play roles in dysmenorrhea and chronic pelvic pain. Recently and oral GnRH antagonist called elagolix has been approved for endometriosis.

Surgical treatment is recommended when pain does not respond to medical therapy, when deep infiltrating endometriosis results in significant bowel or ureter stenosis, or as part of infertility management. Surgery may be combined with postoperative medical treatment to reduce risk of recurrence.

Endometriomas cysts can sometimes develop, asymptomatic endometriomas not displaying suspicious sonographic features are often followed with regular ultrasound, medical management rarely induces regression. Cysts that are large, appear suspiciously, grow rapidly, or cause pain may require surgical intervention, excision of cyst walls are recommended over fenestration and coagulation for best results.

For women close to menopause, or those no longer desiring fertility hysterectomy without bilateral salpingo-oophorectomy may be the definitive surgery, superior results are achieved when the ovaries are removed as well. Combined hormone replacement therapy may be needed to avoid complications of hypoestrogenism. In about half of women diagnosed with infertility endometriosis may be found.

Supplements, lifestyle and dietary changes may help to manage the chronic disease, these changes may affect the immune system and may interfere with disease progression however available data on these interventions is limited to small study sample sizes. Limited evidence supports certain supplements compared with no treatment. Consumption of certain dietary fats may impact endometriosis, long chain omega-3 fatty acids appear to lower risks as well as vitamin D. Organic fruits, vegetables, certain fats, and a gluten free diet may improve symptomatic endometriosis. Unfortunately literature on the impact of diet in endometriosis is limited, however with low risk for harm these lifestyle modifications can be discussed in addition to standard medical therapies.

Endometriosis can increase the risk for some cancers, lifetime risk for ovarian cancer is 0.5-1% and it is the 6th most common cancer in women. Those with endometriosis have about 50% increased risk for epithelial ovarian cancer, altered inflammatory response may explain the increased risk. Studies suggest a link between endometriosis and ovarian cancer, use of combined oral contraceptives may help to reduce the risk, oophorectomy has been shown to carry a protective effect.