![]() Kembara Xtra - Medicine - Endometriosis Endometriosis is a prevalent estrogen-dependent gynecologic disorder that mostly affects women of reproductive age. It can be excruciatingly painful and incapacitating, and it is a condition that affects women of all ages. Symptoms and indicators typically include diminished fertility, pelvic mass, and/or pelvic pain. Pelvic pain and/or abdominal pain may also be present. As a result of implants of endometrial tissue located outside of the uterus that are dependent on estrogen. Although endometriomas have been documented in the liver, bowel, umbilicus, lung, and other tissues, the most prevalent pathologic sites for endometriomas are as follows: – Peritoneum (bladder, cul-de-sac, pelvic walls, ligaments, and fallopian tubes); – Ovaries; – Fallopian tubes; – Liver; – Peritoneum (liver, intestine, umbilicus, and lung - Rectovaginal septum The menstrual cycle is associated with the proliferation and shedding of ectopic endometrial implants. ● Stage I (minimum) to IV (severe). Although staging is helpful for treatment planning, it does not correlate with the degree to which a patient is experiencing pain. Epidemiology Prevalence Females only Affects 6–10% of fertile women Found in 20–50% of infertile women Found in 71–87% of women with chronic pelvic pain Prevalence Females only Affects 6–10% of fertile women Found in 20–50% of infertile women Prevalence Considerations Relating to Children Endometriosis is a condition that can start during adolescence because endometrial implants are influenced by hormones produced by the ovaries. This can result in chronic pelvic discomfort and severe dysmenorrhea, both of which can cause a woman to miss school as well as time with her family and other social activities. Things to Think About When Expecting In women who have endometriosis, the likelihood of conceiving a child drops from 15–20% to 2–10% per month. Endometriosis affects anywhere from 25 to 50 percent of infertile women. Nevertheless, most women see a reduction in their symptoms of pelvic endometriosis while they are pregnant. Considerations Regarding the Aged Pelvic endometriosis may continue throughout menopause and may be made worse by hormone replacement treatment (HRT), despite the fact that menopause often brings about a reduction or elimination of associated symptoms. Causes and effects: etiology and pathophysiology Not completely understood; it is believed that a number of factors play a role. These factors include immunologic alterations and genetic susceptibility in the presence of aberrant proliferating endometrial tissue implants that cause persistent peritoneal inflammation. ● Among the hypotheses are: According to the Sampson idea, retrograde menstruation leads to peritoneal implantation, which in turn leads to illness. The Halban theory proposes that hematogenous or lymphatic dissemination or metaplastic transformation are the most likely mechanisms behind the spread of disease over long distances. - Coelomic metaplasia: In this type of coelomic metaplasia, the coelomic epithelium remains undifferentiated in the peritoneal cavity and then develops to create functioning endometrium. ● The causes of infertility connected with the endometrium are multifaceted: – Inflammation of the pelvis – Disruption of the anatomy of the pelvic tissues (involvement of the fallopian tube might lead to obstruction of the isthmus of the tube) - The proliferation and activation of peritoneal macrophages (which would make them more likely to carry out gamete phagocytosis). - Alteration in eutopic endometrium Genetics There is a 7.2 times increased risk of developing symptomatic endometriosis if a first-degree relative has been diagnosed with the condition. Those who have affected first-degree relatives have a 26% risk of experiencing severe symptoms, whereas those who do not have affected first-degree relatives have a 12% chance. A history of the condition in the family, menstruation and ovulation problems, and a prolonged time between pregnancies are all risk factors. Prevention It is possible that delaying the onset of sequelae by suppressing heavy menstruation and ovulation with oral contraceptives throughout adolescence will do so. The following are examples of factors that are considered protective: – Fruits, green vegetables, n-3 long-chain fatty acids - Aerobic exercise may lessen pelvic pain. It is possible that getting treated and diagnosed early can help prevent sequelae. Conditions That Often Occur Together Cancers of the ovary, breast, and endometrial are among those that are associated with an increased risk, as is an increased risk of cutaneous melanoma, non-Hodgkin lymphoma, autoimmune illnesses, asthma, and cardiovascular disease. Associated with an increased chance of developing asthma. Dysmenorrhea, which can be caused by deep-penetrating endometrial implants, can be found in between 50 and 90 percent of cases. Dyspareunia because of lesions of the cul-de-sac, uterosacral ligaments, and posterior vaginal fornix. Dyschezia because of involvement of the rectosigmoid colon and rectovaginal regions. Chronic pelvic discomfort (6 months) that worsens with time and occurs 1 to 2 days before menstrual cycles. Dyschezia because of involvement of the rectosigmoid colon a history of pelvic discomfort, infertility, and hysterectomy in a first- or second-degree relative The Patient's Clinical Examination Endometriosis is associated with focal discomfort or tenderness on pelvic exam in 66% of people who have the condition. There is a possibility of a mass in the pelvis. Pelvic organs that are unable to move (sometimes known as a "frozen pelvis"); A rectovaginal exam that reveals uterosacral nodules, beading, or soreness. Pain that is described as being like a "barb" and stabbing in nature is felt in the region of the uterosacral ligament in extreme cases. Differential Diagnosis When attempting to diagnose pelvic pain, it is necessary to consider all possible causes of acute abdomen as well as the following: Pelvic adhesions Dysmenorrhea without a specified cause a ruptured ovarian cyst; acute salpingitis; uterine leiomyomas; adenomyosis; irritable bowel syndrome; inflammatory bowel illness; adenomyosis; adenomyosis; adenomyosis; adenomyosis; adenomyosis; adenomyosis; adenomy ● Pelvic malignancy Cystitis Depression A History of Sexual Abuse Chronic Pain Syndrome Complications of an Intrauterine or Ectopic Pregnancy Results From the Laboratory Initial Tests (lab, imaging) There is no appropriate laboratory test that can rule in endometriosis; labs are only helpful for excluding other possible diagnosis. Because of its low sensitivity, testing for CA-125 levels is not suggested. If the patient's medical history and physical examination reveal adnexal pain or tenderness with or without fullness on the pelvic exam, transvaginal ultrasound (US) and magnetic resonance imaging (MRI) are equally efficient in finding ovarian endometriomas. The sensitivity of these tests ranges from 80–90%, and the specificity ranges from 60–98%. - Customers in the United States are favored because their prices are lower. When it comes to detecting peritoneal implants and adhesions, neither modality is very effective. Diagnostic Methods and Other Considerations The microscopic properties of tissue biopsied during laparoscopy or laparotomy are the only ones that can provide a definitive diagnosis. Test Interpretation Laparoscopically observed red and blue-black lesions described as "powder-burns," adhesions, and "chocolate cysts" on the surfaces of the ovary and peritoneum; these lesions were seen as red and blue-black in color. Upon examination of biopsied lesions, endometrial glands and stroma were reported histologically as having been present. Management The management of the condition is contingent on a number of criteria, including: the patient's age and reproductive goals; the accuracy of the diagnosis; the extent to which the patient's quality of life has been diminished as a result of pain and infertility. The danger to other organ systems, including the digestive tract and the bladder Medication Medication is administered to patients in order to alleviate their symptoms, which in turn helps to enhance their quality of life, as well as to slow the advancement of the disease and reduce the risk of organ failure. Unfortuitously, very few studies of medical treatment disclose outcomes that are meaningful to patients. The medical treatments provided to many women offer only a marginal or sporadic degree of effect. First Line It's possible that women who have endometriomas discovered by accident during surgery or research don't require any treatment at all. Others who experience only little discomfort may find that nonsteroidal anti-inflammatory drugs (NSAIDs) provide sufficient relief. Others might benefit from more exercise, particularly aerobic activity. Ovulation can be prevented by using cyclic combination oral contraceptive pills (OCPs), as well as by starting NSAIDs at the beginning of or immediately before menstruation. The evidence about the effectiveness is inconclusive. Second in Rank Low-dose oral contraceptive pills or low-dose progestins, with recommendations to switch from cyclic to continuous combination contraception for three to six months if symptoms continue or if there is chronic pelvic pain that is not associated with menstruation. The evidence for combination hormonal contraception is of a poorer quality than other types of contraception. Despite not having FDA approval for this use, the intrauterine device (IUD) containing the levonorgestrel brand name Mirena has been shown to reduce the frequency of unpleasant menstrual cycles. Intramuscular injection of 150 mg of medroxyprogesterone acetate every three months. A decrease in bone mineral density, the clinical relevance of which is unknown, may result from continued use. agonists of the gonadotropin-releasing hormone (GnRH) suppress the production of pituitary gonadotropin and bring about a state of hypoestrogenism. Oral administration of norethindrone acetate 5 mg once daily, along with oral administration of conjugated equine estrogen 0.625 mg once daily Third Line If the symptoms and signs do not improve, the treating physician should have previous expertise with the application and potential adverse effects of GnRH analogues before prescribing them (symptoms can return in as many as 70 percent of patients who have been treated): 3.75 mg intramuscularly (IM) of leuprolide acetate (Lupron Depot) per month or 11.25 mg intramuscularly (IM) every three months (gluteal). Intranasal spray one dose of 200 micrograms of nafarelin (Synarel) into one nostril in the morning and the other nostril in the evening (begin treatment between days 2 and 4 of the menstrual cycle). Insert 3.6 mg of goserelin (Zoladex) subcutaneously into the upper abdomen wall every 28 days. Danazol is also effective, however it has side effects that are comparable to those of GnRH analogs. Aromatase inhibitors, such as anastrozole and letrozole, make the remission that is caused by GnRH medicines last for a longer period of time. Alert When taking GnRH agonists, it is recommended to take calcium (1,000 to 1,500 mg/day) in conjunction with vitamin D (1,000 to 2,000 IU daily) or low-dose estrogen in conjunction with progestogen (1), (6)[C] in order to prevent calcium loss. Referral It is important to refer the patient as soon as possible to a specialist who specializes in the medical and surgical treatment of endometriosis, particularly if the patient is interested in becoming pregnant in the future. ● The following are examples of conditions that call for a referral to a gynecologist who specializes in their treatment: - Need for definitive diagnosis – A lack of response to a conservative or first-line therapy – Persistent pelvic pain – A delay in the potential for pregnancy Extra Medical Interventions Therapy and exercise on a regular basis are effective pain treatment strategies. When treating chronic pain, narcotics should never be used. Surgical Methods and Operations Surgical procedures, such as laparoscopy and laparotomy, can serve both a diagnostic and therapeutic purpose (in the event that more conservative treatments are ineffective): ● Peritoneal endometriosis: laser ablation/excision/fulguration ● Ovarian endometriosis (endometriomas) >3 to 4 cm: ablation, excision, drainage a process known as lysis of adhesions (LOA) Hysterectomy in conjunction with bilateral salpingo-oophorectomy for the treatment of incapacitating symptoms that have not responded to other forms of medicinal or surgical intervention: - Relieves pain in 80–90% of patients, however pain returns in 10% of patients within 1–2 years following surgery. – Postoperative HRT should contain estrogen and progestogen or progesterone. Disruption of nerve pathways: Ablations performed laparoscopically and presacral neurectomies are effective in treating dysmenorrhea. Methods for Achieving Fertility: In order to cure infertility in stages I and II of the condition, it is recommended to either ablate or excise any lesions that are present: Before resorting to assisted reproduction methods, a year's worth of attempts at natural conception are recommended to be made first. Disease does not endanger in vitro fertilization (IVF) pregnancies. Alert In advanced cases of the disease, ovarian reserve may be reduced after surgery to treat endometriomas. Extra Medical Interventions Osteopathic manipulative therapy has been shown to increase overall quality of life. It has been demonstrated that using traditional Chinese herbal therapy after surgery is beneficial. When it comes to reducing discomfort, irregular menstruation, and perineal edema, acupuncture may be more beneficial than the drug danazol. Injections of botulinum toxin have been utilized as a method of pain management. Keep in Touch Patient monitoring for both symptomatic and asymptomatic pelvic masses (source: http://www.acog.org) is an important part of routine gynecologic care. If the disease has progressed to stage III or stage IV, the prognosis is poor for the recovery of fertility, and the symptoms and signs will improve following bilateral oophorectomy. The disease has an excellent prognosis, especially if the diagnosis and treatment plans are undertaken early in the disease course. Complications Infertility, chronic pelvic pain, decreased quality of life, the need for repeated surgical intervention, depression, adverse drug reactions, and increased prescription expenditures are some of the consequences.
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