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Endometriosis- diagnosis and treatment

With the start of the new year we also begin a new collection of articles. This month, we will focus on endometriosis. Endometriosis, such an enigmatic disease that affects up to 15% of women of reproductive age yet there is no cure for it currently. Only a treatment to alleviate the symptoms exists. Endometriosis has significant effects on the social, occupational, psychological, and physiological life of women.

Last week we looked into what exactly endometriosis is and what the symptoms are.

But how can it be diagnosed and the symptoms treated? Let’s find out!

How is endometriosis diagnosed?

Unfortunately, as endometriosis is usually diagnosed later, the difference of time between the first symptoms and the actual diagnosis can range from 4 to 11 years. Factors that lead to such a late diagnosis can be the “normalization” of the symptoms or misdiagnosing. Interestingly enough, the delay in diagnosis is a global phenomenon, without any connection to the medical standard of one’s country. This just proves how endometriosis still is not fully elucidated and why it affects so many women. As an outcome of this delay in diagnosing, endometriosis can evolve and spread to other organs and can compromise fertility.

These are some of the current diagnosis methods

1. Ultrasonography

  • It is considered to be the first line tool for detection

  • It improves accuracy of a diagnosis when combined with symptoms overview, patient history and physical examination.

  • It can detect ovarian endometriosis and deep endometriosis with high accuracy

2. Laparoscopy

  • It is the gold standard for diagnosis as it provides a direct visualization of lesions (wounds)

  • Laparoscopy is a type of surgery performed in the abdomen or pelvis. It uses small cuts through which a small camera can be inserted for diagnosis or treatment purposes.

3. Clinical diagnosis

  • diagnosing without any surgical method sometimes even decreases the time between the first consultation and the diagnosis.

  • This method requires specific clinical methods that can accurately diagnose endometriosis

  • Such methods include: family history, the existence of previous pelvic surgery, a history of benign ovarian cysts and/or ovarian pain, menstrual cycle characteristics (heavy menstrual bleeding, excessive/irregular bleeding, irregular menstrual periods, passing clots, premenstrual clotting) and physical examination (pelvic examination)

In case of an endometriosis spreading deep into other organs, other investigations, such as colonoscopy, rectal ultrasonography and MRI can be performed. Studies suggest that the likelihood of endometriosis increases with the number of symptoms presented. Several studies used this approach to develop models that predict endometriosis.

How can endometriosis be treated?

There is no cure for endometriosis but a treatment for symptoms only. The treatment needs to have as least side effects as possible as it needs to be maintained until the age of menopause or desire of pregnancy. Endometriosis should be treated only when symptoms such as pain or infertility are present.

The aim of endometriosis treatment is to relieve pain, avoid rupture and prevent symptomatic or spreading endometriosis.

Currently, treatment used for endometriosis is based on suppressing estrogen production and induction of amenorrhea (lack of menstruation), therefore it is a contraceptive treatment in nature. This approach creates an environment with less estrogen, preventing ectopic endometrial growth and disease progression. Unfortunately, this treatment is currently not very successful as it has several limitations.

Hence, this treatment is suppressive but not curative. Once the treatment is discontinued the symptoms appear again. Endometriosis related pain can continue even after medical treatment or conservative surgery. Side effects of medical treatment can be: mood changes, breast tenderness, bloating, vaginal bleeding between menstruations. The treatment is usually decided based on the side effect profile, costs and personal preferences.

Some of the currently available treatments for endometriosis are the following:

1. Hormonal therapy. It inhibits the growth of endometriotic cells by suppressing the production of estrogen

  • Combined oral contraceptives. The use of contraceptives that contain a combination of estrogen and progestin is the first-line treatment for pain due to endometriosis

  • Oral progestin therapy. The use of stand alone progestin is used as well in alleviating the pain in patients with endometriosis

  • IUS (intrauterine system) with progestin. The use of IUS that releases progestin has been proven to be effective for treating endometriosis. It induces amenorrhea (lack of menstruation) without inhibiting ovulation (in up to 60% of patients), and it reduces dyspareunia (pain during intercourse) and dyschezia (difficulty in defecation) as well

  • GnRH antagonists (gonadotropin releasing hormone antagonists). GnRH suppresses estrogen release only partially, making it a very tolerable and preferable treatment for patients with less side effects. It can treat mild to severe forms of endometriosis and it is recommended to patients that do not respond to oral progestin therapy

2. Pain killers

  • Medicine such as NSAIDS (non-steroidal anti-inflammatory steroids, for ex: ibuprofen) or even opioids can help with alleviating the pain due to endometriosis

  • The only medical option for women that desire a pregnancy

3. Surgery. It is recommended only for:

  • Patients with pelvic pain that do not respond or have contraindications to medical therapy

  • Endometriosis that has spread to other organs such as the bowel, bladder, ureters or pelvic nerves

  • Patients that are suspected with endometriosis spread in the ovaries (ovarian endometrioma)

  • Patients diagnosed with infertility

Surgery can be classified into conservative surgery and definitive surgery:

  1. Conservatory surgery aims to restore the normal anatomy of the reproductive system while alleviating pain. This approach is recommended to women in reproductive age that wish to conceive or want to avoid having an early menopause. It implies removing affected tissue or organs while maintaining their functions.

  2. Definitive surgery involves a bilateral oophorectomy (removal of ovaries) in order to induce menopause. Sometimes it can even include the removal of the uterus, the fallopian tubes and any other affected tissue. It is recommended to women that have significant pain and other treatments are not effective, that do not want future pregnancies or have other severe conditions such as menorrhagia (heavy menstrual bleeding) or fibroids (benign tumor that usually grow in the wall of the uterus).

Laparoscopy is the preferred way for performing this kind of surgery. Laparoscopic surgery is a surgical technique through which small cuts are made into the abdomen or pelvis that allow inserting narrow utensils that can manipulate, cut and sew tissue. Unfortunately, surgery is not always effective. Up to 40 % of women may not show an improvement upon surgery and the recurrence of endometriosis is up to 50% after 5 years.

Future treatment aims to cure endometriosis rather than suppress it. It should effectively treat, be safe and affordable. Moreover, the treatment should not be contraceptive and not intervene in the ovulation process and in a woman’s choice of having a pregnancy.

Researchers are currently working on developing several biomarkers (a biomarker is a biological indicator that can measure the severity or presence of a specific disease) that would specifically target endometriotic cells and help with a faster and more conclusive diagnosis. These types of biomarkers would reduce the costs of surgery necessary for diagnosing and provide an early diagnosis. This ultimately could improve the clinical management of endometriosis.

We are looking forward to a cure for endometriosis and support and admire the researchers that are continuously working on it.

Be smart. Be (c)LIT. Fly with us!🌺🐝


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