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Endometriosis is a disease characterized by the growth of uterine tissue (endometrium) outside the uterus. During every menstrual cycle, this tissue grows, swells and bleeds. The growth of this uterine tissue can be:

  • Internal - in the miometrium (also known as adenomyosis)

  • External - outside the uterus (ovary, peritoneum, rectum, bladder, liver, intestine, vagina, vulva, etc)

The real cause of endometriosis is still unknown but there are a lot of theories that try to explain the reason why endometrial tissue grows in other places. The most acceptable theories are:

  • Implantation theory - also known as retrograde menstrual flow

  • Metastatic theory - Hematogenous spread (endometrial cells enter the venous system and can be deposited anywhere in the body with the blood flow)

  • Metaplasic theory

  • Immune system disorder

  • Surgical scar implantation.

The incidence of endometriosis in the general population is 3 to 10 percent. The incidence in infertile women is significantly higher at between 25 and 40 percent.

Endometriosis affects women in the reproductive period(ages 25-40). It never appears before puberty and always ends with menopause, because of a lack of ovarian hormones (estradiol).

Factors that increase the risk of endometriosis are:

  • Never giving birth

  • Uterine abnormalities

  • A history of pelvic infections

  • A family history of endometriosis (mother, sister, aunt, etc)

Common symptoms of endometriosis are:

  • Pelvic pain - severe pain during menstruation, pain in the lower part of the abdomen

  • Dyspareunia - pain during sexual intercourse

  • Menorrhagia - occasional heavy periods

  • Menometrorrhagia - bleeding between periods

  • When the large intestine is affected, you might have painful bowel movements, diarrhea, constipation or even rectal bleeding

  • When the bladder is affected, you might have suprapubic pain, the constant urge to urinate or even blood in the urine

  • When the ovaries are affected, a cystic mass called an endometrioma can form. This cystic mass occasionally ruptures or leaks, causing acute abdominal pain and peritoneal signs.

Infertility is the biggest complication of endometriosis.

In many cases this disease is diagnosed only when women seek treatment for infertility. Endometriosis affects fertility in several ways. It destroys the anatomy of the ovaries and pelvis, alters the immune system, the quality of the eggs, and implantation, causes inflammation the tissues, changes the hormonal system and creates multiple adhesions.

The diagnosis of endometriosis consists of :

  • A pelvic examination

  • Ultrasound

  • Laparoscopy

  • Magnetic resonance imaging (MRI)

  • Tumor markers CA - 125

A bimanual examination may show normal results or your doctor may palpate an enlargement of the ovaries, thickening of the rectovaginal space, noduli in the uretrosacral ligament or even an adnexal mass. In rare cases lesions can be seen in the cervix, vagina, vulva, umbilicus, or other areas.

There is no cure for endometriosis, but it can be treated medically or surgically. First doctors recommend conservative treatment and if this doesn't help then surgical treatment is used.

Medical treatment consists of:

  • NSAID - for the pain

  • Hormonal therapy - like hormonal contraceptives and Gonadotropin-releasing hormone (Gn-RH) agonists and antagonists, Danazol.

When there are problems conceiving, assisted reproductive technologies are used.

Surgical treatment consists of:

  • Conservative surgery

  • Radical surgery - hysterectomy and the removal of both ovaries

Endometriosis comes in four stages:

Stage I - minimal, lesions are only superficial and few filmy adhesions are possible

Stage II - mild, deep lesions are present in cavum Douglasi (extension of the peritoneal cavity between posterior wall of the uterus and rectum)

Stage III - moderate, presence of endometriomas on the ovary and more adhesions

Stage IV - severe, large endometriomas, extensive adhesions

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