Endometriosis, pelvic pain and infertility.

Filiberto Di Prospero, M.D.
Gynecologic Endocrinology Unit,  Maternal and Child Department, Civitanova Marche General Hospital.
62012 Civitanova Marche, Italy. PRIVATE OFFICE IN ROME, MILAN, CIVITANOVA MARCHE.

More info and contacts.

"It’s a very long time that I’m thinking about an article on endometriosis, a not well-known disease such frequent and invalidating. Unfortunately the real cause of the disease is still unknown. It’s a disease that, as you will see, very often we need to look for and that I’m convinced is necessary to know."

Key words: endometriosis, adenomiosis, cronic pelvic pain, infertility, dispareunia, dismenorrhea, algomenorrhea  

I'm grateful to Stefania Luzi MD, for the translation of this article in english.

Endometriosis is certainly one of the most important chapter of ginecology. Is estimated that worldwide almost 3-10% of the women in reproductive age are affected from this disease. This data is allarming if we think that often the disease causes cronic pelvic pain, infertility and dispareunia (pain during sexual intercourse). 25-35% of women with reproductive failure and 20-40% of those with cronic pelvic pain has evidence of endometriosis lesions. The prevalence of the disease among adolescents with severe pelvic pain is 53%. Endometriosis is furthermore the first cause of hospitalization in ginecologic units in women between 15 and 44 years. There aren’t any ethnic or geographic differences, but the disease is really rare before menarque and after menopause, with a first diagnosis frequently between 20 and 35 years.

Described for the first time in 1921 from Jhon Sampson, endometriosis is a benign disease caused by the presence of endometrium-like tissue (that normally cover uterine cavity) on ectopic sites, that means outside of the uterus. Tipically it’s located in the pelvis, where causes adherences, cysts, bleeding and various symptoms, from ndd infertility in asymptomatic healthy women to “acute abdomen” that requires surgery. Ovaries are the most frequently affected (developping cysts with ematic content, named “chocolate cyst”), then salpinges, uterus surface, gut and peritoneum (the inside covering of abdomen). Seldom the disease can affect organs outside the pelvis, such as lungs, brain or other tissues. Sometimes the endometriosic tissue can show upon surgery scars or on the cervix; it can spread and relapse and, befaore drugs were available, it required frequently surgery treatment.

But why most women are affected by endometriosis? The first and oldest ethiopathogenetic hypothesis, formulated by Sampson in an historical publication (1927) is that of retrogade menstruation: during menstrual bleeding some endometrial cells could invert their way, up through the salpinges and develop in other organs. Actually, the possibility of an inverted menstrual flux has been demonstrated (and should be frequent), but this doesn’t explain why in many women these cells don’t take and how they develop in organs outside the pelvis, such as the brain.  Some Authors have hypothized a spreading of endometrial cells by linfatic or haematic circulation. Others have identified as disease’s “primum movens”the altered immune response detected in these patients; a Natural Killer cells and T lymphocites reduced function could facilitate the taking of endometrial cells outside the uterus. It’s still not possible to clarify if these immunological changes are secondary to the disease itself. A genetic predisposition could be involved too; HLA B27 allele expression seems to be more frequent in these patients and actually familiarit has been demonstrated. Anyway, still today the real cause of the disease is unknown and further studies are mandatory.

As we’ve already discussed, symptomatology is really various. The ectopic endometrial tissue can bleed such as the endouterine endometrium during menstruation. With time, little endometriosic lesions tend to spread out and to meet, forming adherences and healing processes; sometimes, particularly on the ovaries, cysts with piceum content can develop. Symptoms, especially in the earlier stage of the disease,  can be totally absent. Unexplained sterility can be associated to endometriosis, and the ethiopathogenetic mechanisms are still unknown. Many patients complain about cronic pelvic pain and dyspareunia, worsening before menstrual cycle. An endometriosic cyst’s ropture can cause haemoperitoneum (bleeding in abdomen) and so “acute abdomen”. Except for complications, the disease, when severe, can cause intestinal and urinary symptoms.

Diagnosis is often fortuitous, during exams or surgery performed for various and differents reasons. The endometriosic lesions are easily recognized by an expert surgeon. Sometimes, is necessary to look for the disease, especially in young women with cronic pelvic pain, unexpalined sterility or abdominal mass. A good anamnesis and gynecological examination can determine the suspect of endometriosis. Useful for diagnosisare pelvic ecography, CA 125 plasmatic levels measurement, RMN and laparoscopy; the last one allows to see directly the endometriosic lesions and to take bioptic samples.

Adenomiosis can be considered a particolar form of endometriosis, but is instead an other disease. In this case, there are isolated or diffuse areas of endometrial tissue inside the uterine wall; it can be totally asimptomatic or cause abnormal bleeding, pain during menstruation (algomenorrhea), dyspareunia, cronic pelvic pain, volumetric and morphological changes of the uterus.

Endometriosis is an endocrine-dependent disease and oestrogens have out certainly an important role in developping the disease ( even if they can’t be considered the cause). The unknown origin indeed doesn’t allow today to use an aethiological therapy, ie definitive. Anyway, the endocrine evidence allows to approach in many ways different patients, according therapy to their clinical response; among the used ormonal substances we can list the contraceptive pill, the progestinic pill, the GnRH analogues that induces a temporary menopausal state, tha danazole (even vaginally), the progesterone releasing IUD. The long amenorrheic periods necessary to reduce and control the disease are actually well controlled with the “add-back therapy”; this means that, after a few months of GnRH analogues therapy, oestro-progestinic combined therapy or Tibolone are associated. This way, the patients’ discomfort side effects’ related and the bone loss are limitated.

Aim of the surgery, beyond the acute complications, is to eliminate all lesions that cause pelvic pain, such as endometriosic cysts, adherences, peritoneal and rectovaginal septum focuses. Generally is a conservative surgery; it can be preceeded (when possible and indicated) and is always followed by medical therapy. The demolitive surgery, the hysterectomy with bilateral annessiectomy (the ovaries removal) is always less frequent and can occur only in particularly severe cases.