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The Endometriosis Coping ZoneClinical and therapeutic aspects of endometriosis to bear in mindPart 2 of 3 The way to unveil the most hidden of gynaecological
pathologies It is a puzzling disease whose causes
are still unclear, but it is widespread and it affects over 10% of women.
Nevertheless, too often it is not recognised in time, causing a delay before
proper therapies are commenced. by Elena Mattioli [Translated from the Italian. The original article can be viewed by clicking here.]
Pictured above:
Paolo Vercellini, associate professor at Milan University.
On the left a CAT scan shows an endoluminal paramediane
lesion originated from the back wall of the bladder (B) (E=endometrial
nodule). Below, at sonography, a hypoecogen median formation inside the
bladder back wall. 
Symptoms and signs The following symptoms, associated in different ways, may suggest the presence of endometriosis. Each patient may have one or several, depending on the localisation of ectopic implants and on the stage of the disease. Period pain Pain during or after sexual intercourse Infertility Pain during ovulation Chronic pelvic pain Pain when urinating Pain when defecating Sciatic nerve pain/lumbar pain Persistent low fever Blood in urine (micro and macro) Blood in faeces Endometriosis affects over 10% of fertile women and is characterised by the presence of ectopic endometrium in areas such as the ovaries, tubes, peritoneum, bladder, recto-vaginal septum, which grows and exfoliates following the stimulation of oestrogen.
Localisation of
lesions Uterosacral ligament 60% Ovary 52% Peritoneum – Douglas 28% Large ligament 16% Bladder 15% Rectum 12% Mesosalpinx 10% Intestine 7% Round ligament 5% Tube 4% Appendix 2%
Pregnancy is not a cure for endometriosis. Even if it is true that many women’s symptoms decrease or disappear during pregnancy, after delivery, ectopic implants that had remained silent start being active again.
Anamnesis and
useful diagnostic techniques Accurate anamnesis Gynaecological visit Transvaginal sonography NMR CA125 Intestine radiological exams Sonography of upper and lower abdomen Urography Cistoscopy (pyelography) Laparoscopy and histological exam (gold standard)
Hysterectomy does not prevent any residual ectopic implant
to maintain activity following hormonal stimulation. Even the removal of ovaries
at the same time does not always guarantee the total absence of oestrogen.
Finally, HRT following a radical surgery can cause recurrence of the disease.
Drugs prescribed NSAIDs: such as sodium naproxene, nimesulid, diclofenac, piroxicam… Central analgesic: tramadol Oestro-progestagen contraceptive pill: monophasic pill with low oestrogen content, vaginal ring, slow release patch Progestogens: ciproteron acetate, noretisteron acetate, medroxiprogesterone acetate, desogestrel, slow release levonorgestrel spiral Anti-hormones: various (androgens), danazol, gestrinone GnRH agonists: leuprorelin, triptorelin, goserelin, buserelin
Examples of therapeutic options Desogestrel 0.15 mg and ethinyl oestradiol 0.02 mg, once a day Gestoden 0.075 mg and ethinyl oestradiol 0.03 mg, once a day Ciproteron acetate 12.5 mg, once a day Ethinyl estradiol 0.01 mg + ciproteron acetate 2 or 3 mg once a day Danazol, 200 mg once a day or personalised minimum dose to stop ovulation, once a day
The link between endometriosis and infertility, which may affect up to 40% of patients, is not clear. In some cases there is a mechanic obstacle due to distortion of the organs of the reproductive system, in other cases there can be a scarce ovarian response, a worse quality of the egg cell or of its crown, a defect of catching by the fallopian tube, etc.
Blue peritoneum nodules Nodules and cysts visible with laparoscopy Bilateral ovarian cysts of endometriosis
Levonorgestrel-releasing Intrauterine System (IUS) (it lasts for 5 years) (already in use for endometriosis) Intra-vaginal ring system* releasing a combination of progestagen and oestrogen (etonogestrel and ethinyl estradiol 0,120 mg e 0,015 mg, respectively). It lasts for 3 weeks and must then be substituted. Slow releasing norelgestromin and ethinyl estradiol patch* (it lasts for one week and must then be substituted). * The therapeutic experience with these devices is not sufficient to provide data, but at least on a theoretical basis they will be useful in treating this pathology.
Today’s tendency in the case of infertility is to start right away with assisted reproductive techniques (IVF or ICSI) in order not to waste precious years and to avoid an overload of hormones.
Management suggested for symptomatic endometriosis (see original article). Evaluation and management of women with endometriosis. Click here to continue to Part 3 of this article
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