The Gulf Today - Time Out - - HEALTH WATCH - Dr Asheesh Me­hta In­ter­nal Medicine Spe­cial­ist

Symp­toms are re­lated to the en­dome­trial tis­sue at aber­rant sites un­der­go­ing changes in re­sponse to cycli­cal hor­monal fluc­tu­a­tions which oc­cur through­out the re­pro­duc­tive life of the wo­man

En­dometrio­si­sisacom­mon and painful con­di­tion af­fect­ing women. The nor­mal lin­ing of the uterus or womb is called en­dometrium. When en­dometrium is present as im­plants or de­posits at lo­ca­tions other than the cav­ity of the uterus the con­di­tion is called en­dometrio­sis. Es­ti­mates of its preva­lence vary from about 1% to 10% of all women in their re­pro­duc­tive age. En­dometrio­sis is the cause for much pain and mis­ery with pain and in­fer­til­ity be­ing the lead­ing com­plaints. En­dometrio­sis is of­ten over­looked with an av­er­age time from ini­tial symp­toms to di­ag­no­sis of en­dometrio­sis be­ing as much as 10 years. The wide vari­ance in preva­lence re­ported in dif­fer­ent stud­ies is partly due to en­dometrio­sis be­ing over­looked as the true cause of symp­toms.

Women dur­ing their re­pro­duc­tive pe­riod of life have a men­strual pe­riod ex­cept dur­ing preg­nancy or when breast­feed­ing. This is ev­i­dent as men­strual flow for 2 to 7 days on a more or less monthly ba­sis. Men­strual flow rep­re­sents shed­ding of the su­per­fi­cial layer of the en­dometrium, the in­ter­nal lin­ing of the cav­ity of the uterus, in re­sponse to cycli­cal hor­monal changes. The uterus is a pear shaped or­gan with an up­per body and fun­dus and a lower part called the cervix which opens into the vagina. The two fal­lop­ian tubes open into the uterus on each side at the fun­dus. The fal­lop­ian tubes serve to con­vey the ovum or egg from the ovary to the body of the uterus for im­plan­ta­tion af­ter fer­til­iza­tion by sper­ma­to­zoa. In en­dometrio­sis, en­dometrium is present at sites other than the uter­ine cav­ity. This aber­rantly lo­cated en­dometrium too re­sponds to cycli­cal hor­monal changes and this is the rea­son that symp­toms too tend to be cycli­cal cor­re­spond­ing to the men­strual cy­cle. How and why en­dome­trial tis­sue man­ages to be lo­cated at these aber­rant sites is not too clear. One the­ory is that men­strual blood may flow in a ret­ro­grade man­ner through the fal­lop­ian tubes and con­tained en­dome­trial tis­sue gets im­planted at aber­rant sites. Since such ret­ro­grade men­strual flow has been noted nor­mally also, it is likely that im­mune fac­tors that al­low such im­plan­ta­tion are also in­volved. In ad­di­tion to ret­ro­grade flow through the fal­lop­ian tubes en­dome­trial tis­sue may also travel to dis­tant sites like the lung or other or­gans through lymph chan­nels or the blood stream for sub­se­quent im­plan­ta­tion. An­other the­ory is that rather than im­plan­ta­tion of en­dome­trial tis­sue, ex­ist­ing tis­sue at aber­rant sites gets con­verted to en­dome­trial tis­sue as a re­sult of cycli­cal hor­monal stim­u­la­tion or that en­dome­trial tis­sue arises due to a de­vel­op­men­tal ab­nor­mal­ity.

A num­ber of risk fac­tors for en­dometrio­sis have been iden­ti­fied. A fam­ily his­tory of en­dometrio­sis in­creases risk. Start of men­stru­a­tion at an early age is an­other risk fac­tor. Some char­ac­ter­is­tics of the men­strual cy­cle such as shorter du­ra­tion, heavy bleed­ing or longer du­ra­tion of bleed­ing dur­ing the pe­riod too are as­so­ci­ated with a higher in­ci­dence of en­dometrio­sis. Women who have had more preg­nan­cies ap­pear to be some­what pro­tected from de­vel­op­ment of en­dometrio­sis while women who have never been preg­nant or be­come preg­nant rel­a­tively late are at greater risk. De­vel­op­men­tal ab­nor­mal­i­ties re­lated to the uterus and fal­lop­ian tubes too im­part a risk for en­dometrio­sis. Low weight is also a risk fac­tor for en­dometrio­sis.

Symp­toms are re­lated to the en­dome­trial tis­sue at aber­rant sites un­der­go­ing changes in re­sponse to cycli­cal hor­monal fluc­tu­a­tions which oc­cur through­out the re­pro­duc­tive life of the wo­man. Not all women with en­dometrio­sis de­posits have symp­toms. In fact a third of them have no symp­toms. The more deeply im­pacted the de­posits, the higher the like­li­hood of pain and its sever­ity too is linked to the depth of de­posits. Like nor­mal en­dome­trial tis­sue, there is mi­nor bleed­ing in en­dometrio­sis tis­sue too. This causes an in­flam­ma­tory re­sponse which man­i­fests as pain and ten­der­ness. The in­flam­ma­tory re­sponse may also cause fi­bro­sis with dis­tor­tion of tis­sues. Symp­toms usu­ally start around the age of 25 years or later. They too oc­cur cycli­cally, start­ing a few days be­fore the men­strual pe­riod, build­ing up grad­u­ally to then sub­side in a day or two once men­strual flow starts. Site of pain de­pends mainly on the lo­ca­tion of de­posits. The pelvis is the usual lo­ca­tion for en­dometrio­sis and ar­eas close to the uterus such as the ovaries, uri­nary blad­der, ureters, the rec­tum and colon and the folds and crevices around the uterus are com­mon sites. Less com­monly, en­dometrio­sis oc­curs in the up­per ab­domen and some­times in the lungs and very rarely in to­tally un­ex­pected sites such as the brain. Com­moner symp­toms in­clude men­strual pain, back pain, painful in­ter­course, pain when pass­ing stools or urine, ab­dom­i­nal dis­com­fort and bloat­ing. The char­ac­ter­is­tic of these symp­toms is the on­set or ex­ac­er­ba­tion of symp­toms a few days be­fore the men­strual pe­riod and re­lief once it starts. Some pa­tients may com­plain of pass­ing blood in urine or in stools, again in a cycli­cal man­ner in as­so­ci­a­tion with their pe­riod. Over time re­cur­rent in­flam­ma­tion may re­sult in scar­ring and if this in­volves crit­i­cal ar­eas such as a bowel loop or the ureter, it could cause in­testi­nal ob­struc­tion or dam­age to a kid­ney from ob­struc­tion to urine flow. An­other ma­jor prob­lem with en­dometrio­sis is that about a third of af­fected women suf­fer im­paired fer­til­ity. En­dometrio­sis also in­creases risk for cancer of the ovary by a small de­gree. Since this is a rel­a­tively less com­mon cancer the im­pact is not too great.

The de­fin­i­tive di­ag­nos­tic test is vi­su­al­iza­tion of en­dometrio­sis de­posits at la­paroscopy along with biopsy. This in­volves in­tro­duc­tion of a slen­der tele­scope through a tiny in­ci­sion in the ab­domen. Sur­gi­cal in­stru­ments to ma­nip­u­late the or­gans and to carry out surgery are in­tro­duced through ad­di­tional small in­ci­sions. This form of key­hole surgery is widely prac­ticed for a va­ri­ety of gy­nae­co­log­i­cal prob­lems as well as for gen­eral sur­gi­cal pro­ce­dures for gall blad­der stones, ap­pen­dici­tis, her­nia, weight loss surgery, etc. La­paroscopy is a sur­gi­cal pro­ce­dure and like any sur­gi­cal pro­ce­dure there is a small but def­i­nite risk as­so­ci­ated with it and with the ad­min­is­tra­tion of anaes­the­sia. In well trained and ex­pe­ri­enced hands this risk is very small. Ad­van­tage of la­paroscopy is that tis­sue for histopathol­ogy con­fir­ma­tion can also be ob­tained and ther­a­peu­tic pro­ce­dure to de­stroy prob­lem­atic en­dometrio­sis le­sions can also be car­ried out at the same time. Other tests such as blood tests and imag­ing tests like ul­tra­sonog­ra­phy and MRI scan are sup­port­ive rather than di­ag­nos­tic in cases of en­dometrio­sis, the lat­ter tests be­ing par­tic­u­larly help­ful when com­pli­ca­tions of en­dometrio­sis such as bowel ob­struc­tion are sus­pected.

Re­gard­ing treat­ment, the two main is­sues are pre­vent­ing or con­trol­ling pain and im­prov­ing fer­til­ity where this is af­fected. Treat­ment can be med­i­cal or sur­gi­cal. In gen­eral, ex­cept when there are com­pli­ca­tions, the pri­mary line opted for is med­i­cal with surgery be­ing re­served for re­frac­tory cases or for spe­cific in­di­ca­tions. Med­i­cal ther­apy is tar­geted at the cycli­cal hor­monal in­flu­ences to which en­dometrium re­sponds. Med­i­cal ther­apy only sup­presses en­dometrio­sis and there is no pos­si­bil­ity of achiev­ing a cure with this line of treat­ment. Oral con­tra­cep­tives are one of the treat­ment op­tions. One type of oral con­tra­cep­tion in­volves tak­ing a pill con­tain­ing the hor­mones for 21 days fol­lowed by placebo tablets for a week while the other type in­volves tak­ing the hor­mones con­tain­ing pill daily. The con­tin­u­ous type of pill gives bet­ter re­sponse in con­trol­ling en­dometrio­sis. An al­ter­na­tive is pro­gestin ther­apy alone. This may be ad­min­is­tered as a tablet, in an in­trauter­ine de­vice con­tain­ing the hor­mone or as a de­pot in­jec­tion. The men­strual pe­riod and the en­dometrio­sis le­sions are sup­pressed by this ther­apy with re­sul­tant re­lief of symp­toms. Gon­adotrophin re­leas­ing hor­mone ther­a­pies which work at the pi­tu­itary level is an­other op­tion. They sup­press se­cre­tion of LH (leu­tiniz­ing hor­mone) and FSH (fol­li­cle stim­u­lat­ing hor­mone) which in turn causes re­duc­tion in se­cre­tion of oe­stro­gen and pro­ges­terone in the body. The re­sult is a pre­ma­ture menopause which is re­versed once these medicines are with­drawn. How­ever, this treat­ment can cause dis­com­fort­ing menopausal symp­toms such as hot flashes and also loss of bone and re­place­ment hor­monal ther­apy may have to be con­sid­ered. Dana­zol is an­other hor­monal drug fairly ef­fec­tive in en­dometrio­sis. A ma­jor draw­back is po­ten­tial for an­dro­genic ef­fects like de­vel­op­ment of acne, oily skin, hair on the face, deep­en­ing of voice, weight gain, etc.

Sur­gi­cally, the en­dome­trial de­posits maybe de­stroyed by laser or elec­tro-cautery, usu­ally dur­ing la­paroscopy. This sort of surgery does not in­ter­fere with fu­ture re­pro­duc­tion. If no fur­ther preg­nan­cies are de­sired the uterus may also be re­moved with or with­out the ovaries. In the lat­ter case hor­monal re­place­ment ther­apy may be in­di­cated de­pend­ing on the age of the wo­man. Women with fer­til­ity prob­lems who are de­sirous of fu­ture preg­nan­cies may ben­e­fit from cor­rec­tive surgery in case of fi­bro­sis or other struc­tural ab­nor­mal­i­ties re­lated to en­dometrio­sis.

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