en dome trios is morong report

8/3/2019 En Dome Trios Is Morong Report

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Endometriosis

Endometriosis (from Greek - endon, "within", and - mtra, "womb") is

a gynecological medical condition in which cells from the lining of theuterus (endometrium) appear and flourish outside the uterine cavity, most commonly on

the ovaries. The uterine cavity is lined by endometrial cells, which are under the influence

of female hormones. These endometrial-like cells in areas outside the uterus

(endometriosis) are influenced by hormonal changes and respond in a way that is similar

to the cells found inside the uterus. Symptoms often worsen with the menstrual cycle.

Endometriosis is typically seen during the reproductive years; it has been estimated that

endometriosis occurs in roughly 510% of women. Symptoms may depend on the site of

active endometriosis. Its main but not universal symptom is pelvic pain in variousmanifestations. Endometriosis is a common finding in women with infertility.

SIGNS & SYMPTOMS

1.)Pelvic pain

A major symptom of endometriosis is recurring pelvic pain. The pain can be mild to severe

cramping that occurs on both sides of the pelvis, in the lower back and rectal area, and even

down the legs. The amount of pain a woman feels correlates poorly with the extent or stage


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(1 through 4) of endometriosis, with some women having little or no pain despite having

extensive endometriosis or endometriosis with scarring, while, on the other hand, other

women may have severe pain even though they have only a few small areas of

endometriosis.

Symptoms of endometriosis-related pain may include:

Dysmenorrhea painful, sometimes disabling cramps during menses; pain may getworse over time (progressive pain), also lower back pains linked to the pelvis

Chronic pelvic pain typically accompanied by lower back pain or abdominal pain Dyspareunia painful sex, or painful intercourse. Dysuria urinary urgency, frequency, and sometimes painful voiding.

Throbbing, gnawing, and dragging pain to the legs are reported more commonly by women

with endometriosis. Compared with women with superficial endometriosis, those with

deep disease appear to be more likely to report shooting rectal pain and a sense of their

insides being pulled down. Individual pain areas and pain intensity appears to be unrelatedto the surgical diagnosis, and the area of pain unrelated to area of endometriosis.

2.) Fertility

Many women with infertility may have endometriosis. As endometriosis can lead to

anatomical distortions and adhesions (the fibrous bands that form between tissues and

organs following recovery from an injury), the causality may be easy to understand;

however, the link between infertility and endometriosis remains enigmatic when the extent

of endometriosis is limited. It has been suggested that endometriosis lesions release factors

which are detrimental to gametes or embryos, or, alternatively, endometriosis may more

likely develop in women who fail to conceive for other reasons and thus be a secondary

phenomenon; for this reason it is preferable to speak ofendometriosis-associated

infertility in such cases. In some cases it can take a woman with endometriosis 710 years

to conceive her first child, to most couples this can be stressful and daunting.

Other

Other symptoms may be present, including:

Constipation Chronic fatigue

In addition to pain during menstruation, the pain of endometriosis can occur at other times

of the month. There can be pain with ovulation , pain associated with adhesions, pain

caused by inflammation in the pelvic cavity, pain during bowel movements and urination,

during general bodily movement like exercise, pain from standing or walking, and pain

with intercourse. But the most desperate pain is usually with menstruation and many

women dread having their periods. Pain can also start a week before menses , during and


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even a week after menses, or it can be constant. There is no known cure for

endometriosis. Endometriosis bears no relationship to endometrial cancer. Current

research has demonstrated an association between endometriosis and certain types of

cancers, notably ovarian cancer, non-Hodgkin's lymphoma and brain cancer. Endometriosis

often also coexists with leiomyoma or adenomyosis, as well as autoimmune disorders. A

1988 survey conducted in the US found significantly more

Hypothyroidism, fibromyalgia, chronic fatigue syndrome, autoimmune

diseases, allergies and asthma in women with endometriosis compared to the general

population.

Complications

Endoscopic image of a ruptured chocolate cystin left ovary.

Complications of endometriosis include:

Internal scarring Adhesions Pelvic cysts Chocolate cyst of ovaries Ruptured cyst Bowel obstruction

Infertility can be related to scar formation and anatomical distortions due to theendometriosis; however, endometriosis may also interfere in more subtle ways: cytokines

and other chemical agents may be released that interfere with reproduction.

Other complications of endometriosis include bowel and ureteral obstruction resulting

from pelvic adhesions. Also, peritonitis from bowel perforation can occur.

Ovarian endometriosis may complicate pregnancy by decasualization, abscess and/or

rupture. It is the most common adnexal mass detected during pregnancy , being present in


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0.52% of deliveries as studied in the period 2002 to 2007. Still , ovarian endometriosis

during pregnancy can be safely observed conservatively.

Pleural implantations are associated with recurrent right pneumothoraxes at times of

menses, termed cat menial pneumothorax.

RISKFACTORS

Genetics

Genetic predisposition plays a role in endometriosis. It is well recognized that daughters or

sisters of patients with endometriosis are at higher risk of developing endometriosis

themselves. One study found that in female siblings of patients with endometriosis

the relative risk of endometriosis is 5.7:1 versus a control population.

Environmental

There is a growing suspicion that environmental factors may cause endometriosis ,specifically some plastics and cooking with certain types of plastic containers

with microwave ovens. Dioxin exposure has been found a very likely cause of

endometriosis in one well known study by The Endometriosis association that found that

79% of monkeys developed Endometriosis after receiving doses of dioxin. Other sources

suggest that pesticides and hormones in our food cause a hormone imbalance.

y Tobacco smoking: The risk of endometriosis has been reported to be reduced insmokers. Smoking causes decreased estrogens with increased breakthrough

bleeding and shortened luteal phases. Smokers have an earlier than normal (by

about 1.53 years) menopause which suggests that there is some toxic effect of

smoking on the follicles directly.

y Aging: Aging brings with it many effects that may reduce fertility. Depletion overtime of ovarian follicles affects menstrual regularity. Endometriosis has more time

to produce scarring of the ovary and tubes so they cannot move freely or it can even

replace ovarian follicular tissue if ovarian endometriosis persists and grows.

Leiomyomata (fibroids) can slowly grow and start causing endometrial bleeding

that disrupts implantation sites or distorts the endometrial cavity which affectscarrying a pregnancy in the very early stages. Abdominal adhesions from other

intraabdominal surgery, or ruptured ovarian cysts can also affect tubal motility

needed to sweep the ovary and gather an ovulated follicle (egg).

Endometriosis in postmenopausal women does occur and has been described as an

aggressive form of this disease characterized by complete progesterone resistance and

extraordinarily high levels of aromatase expression. In less common cases , girls may have

endometriosis symptoms before they even reach menarche.


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Pathophysiology

While the exact cause of endometriosis remains unknown, many theories have been

presented to better understand and explain its development. These concepts do not

necessarily exclude each other. The pathophysiology of endometriosis is likely to be

multifactorial and to involve interplay between several factors.

Broadly, the aspects of the pathophysiology can basically be classified as underlying

predisposing factors, metabolic changes, formation of ectopic endometrium, and

generation of pain and other effects. It is not certain, however, to what degree predisposing

factors lead to metabolic changes and so on, or if metabolic changes or formation of ectopic

endometrium is the primary cause. Also, there are several theories within each category,

but the uncertainty over what is a cause versus what is an effect when considered in

relation to other aspects is as true for any individual entry in the pathophysiology of

endometriosis.[16]

Also, pathogenic mechanisms appear to differ in the formation of distinct types of

endometriosis lesion, such as peritoneal, ovarian and rectovaginal lesions.

Metabolic changes

Endoscopic image of endometriosis lesions at the peritoneum of the pelvic wall.

Endometriosis correlates with abnormal amounts of multiple substances, possibly

indicating a causative link in its pathogenesis, although correlation does not imply

causation:

y Endometrial cells in women with endometriosis demonstrate increased adherenceto peritoneal cells and increased expression of splice variants of CD44, a cell-surface

protein involved in cell adhesions.

y The matrix metalloproteinase MMP-1 and MMP-2 are also increased, and appear tobe major factors involved in the invasion of endometrium into the peritoneum and

in vascularization of endometriosis.


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y Endometriosis patients also have elevated levels of vascular endothelial growthfactor A (VEGF-A), soluble vascular endothelial growth factor receptors-1 and -2

(sVEGFR-1 and -2) and angiopoietin-2 (Ang-2). IL-4 may induce angiogenesis in

endometriosis by inducing expression of exotoxin.

y Increased oxidative stress is also implicated in the pathophysiology ofendometriosis, as well as 8-iso-PGF2 and ox sterols, being potential causative links

in this oxidative stress.

Endometriosis is a condition that is estrogen-dependent and thus seen primarily during the

reproductive years. In experimental models, estrogen is necessary to induce or maintain

endometriosis. Medical therapy is often aimed at lowering estrogen levels to control the

disease. Additionally, the current research into aromatase, an estrogen-synthesizing enzyme,

has provided evidence as to why and how the disease persists after menopause and

hysterectomy.

Formation of ectopic endometrium

The main theories for the formation of ectopic endometrium are retrograde menstruation,

mllerianosis, coelomic metaplasia and transplantation, each further described below.

Retrograde menstruation

The theory of retrograde menstruation is the most widely accepted theory for the

formation of ectopic endometrium in endometriosis. It suggests that during a woman's

menstrual flow, some of the endometrial debris exits the uterus through the fallopian tubes

and attaches itself to the peritoneal surface (the lining of the abdominal cavity) where it

can proceed to invade the tissue as endometriosis.

While most women may have some retrograde menstrual flow , typically their immune

system is able to clear the debris and prevent implantation and growth of cells from this

occurrence.

Factors that might cause the tissue to grow in some women but not in others need to be

studied, and some of the possible causes below may provide some explanation.

y hereditary factorsy toxinsy acompromised immune system.

Retrograde menstruation alone is not able to explain all instances of endometriosis, and it

needs additional factors such as genetic or immune differences to account for the fact that

many women with retrograde menstruation do not have endometriosis. Research is

focusing on the possibility that the immune system may not be able to cope with the cyclic

onslaught of retrograde menstrual fluid. It is still unclear what, if any, causal relationship

exists between toxins, autoimmune disease, and endometriosis


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In rare cases where imperforate hymen does not resolve itself prior to the first menstrual

cycle and goes undetected, blood and endometrium are trapped within the uterus of the

patient until such time as the problem is resolved by surgical incision. Many health care

practitioners never encounter this defect, and due to the flu-like symptoms it is often

misdiagnosed or overlooked until multiple menstrual cycles have passed. By the time a

correct diagnosis has been made, endometrium and other fluids have filled the uterus and

fallopian tubes with results similar to retrograde menstruation resulting in endometriosis.

The initial stage of endometriosis may vary based on the time elapsed between onset and

surgical procedure.

John A. Sampson- was proposed the theory of menstruation as a cause of endometriosis.

Other theories of endometrial formation

y Mllerianosis: A competing theory states that cells with the potential to becomeendometrial are laid down in tracts during embryonic development

and organogenesis. These tracts follow the female reproductive (Mullerian) tract as

it migrates caudally (downward) at 810 weeks of embryonic life. Primitive

endometrial cells become dislocated from the migrating uterus and act like seeds

or stem cells. This theory is supported by foetal autopsy.

y Coelomic metaplasia: This theory is based on the fact that coelomic epithelium isthe common ancestor of endometrial and peritoneal cells and hypothesizes that

later metaplasia (transformation) from one type of cell to the other is possible,

perhaps triggered by inflammation. This theory is further supported by laboratory

observation of this transformation.

y Transplantation: It is accepted that in specific patients endometriosis can spreaddirectly. Thus endometriosis has been found in abdominal incisional scars after

surgery for endometriosis. It can also grow invasively into different tissue layers,i.e.,

from the cul-de-sac into the vagina. On rare occasions endometriosis may be

transplanted by blood or by the lymphatic system into peripheral organs such as

the lungs and brain.

Generation of pain

The way endometriosis causes pain is the subject of much research. Because many women

with endometriosis feel pain during or around their periods and may spill further

menstrual flow into the pelvis with each menstruation, some researchers are trying to

reduce menstrual events in patients with endometriosis.

Endometriosis lesions react to hormonal stimulation and may "bleed" at the time of

menstruation. The blood accumulates locally, causes swelling, and triggers inflammatory

responses with the activation of cytokines. It is thought that this process may cause pain.


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Pain can also occur from adhesions (internal scar tissue) binding internal organs to each

other, causing organ dislocation. Fallopian tubes, ovaries, the uterus, the bowels, and the

bladder can be bound together in ways that are painful on a daily basis , not just during

menstrual periods.

Also, endometriosis lesions can develop their own nerve supply, thereby creating a direct

and two-way interaction between lesions and the central nervous system, potentially

producing a variety of individual differences in pain that can, in some women, become

independent of the disease itself.

Localization

Most endometriosis is found on these structures in the pelvic cavity:

Ovaries (the most common site) Fallopian tubes The back of the uterus and the posterior cul-de-sac The front of the uterus and the anterior cul-de-sac Uterine ligaments such as the broad or round ligament of the uterus Pelvic and back wall Intestines, most commonly the recto sigmoid Urinary bladder and ureters

Bowel- endometriosis affects approximately 10% of women with endometriosis, and can

cause severe pain with bowel movements.

Endometriosis may spread to the cervix and vagina or to sites of a surgicalabdominal incision.

Endometriosis may also present with skin lesions in cutaneous endometriosis.Diagnosis

Endometriosis, abdominal wall


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occurs on the surfaces of organs in the pelvic and intra-abdominal areas. Health care

providers may call areas of endometriosis by different names, such as implants, lesions, or

nodules. Larger lesions may be seen within the ovaries as ovarian endometriomas or

"chocolate cysts", "chocolate" because they contain a thick brownish fluid, mostly old

blood.

Often the symptoms of ovarian cancer are identical to those of endometriosis. If a

misdiagnosis of endometriosis occurs due to failure to confirm diagnosis through

laparoscopy, early diagnosis of ovarian cancer, which is crucial for successful treatment,

may have been missed.

If surgery is not performed, then a diagnosis of exclusion process is used. This means that

all of the other plausible causes of pelvic pain are ruled out.

Staging

Possible locations of endometriosis

Surgically, endometriosis can be staged IIV (Revised Classification of the American Society

ofReproductive Medicine). The process is a complex point system that assesses lesions and

adhesions in the pelvic organs, but it is important to note staging assesses physical disease

only, not the level of pain or infertility. A patient with Stage I endometriosis may have little

disease and severe pain, while a patient with Stage IV endometriosis may have severe

disease and no pain or vice versa. In principle the various stages show these findings:

Stage I (Minimal)

Findings restricted to only superficial lesions and possibly a few filmy adhesions

Stage II (Mild)

In addition, some deep lesions are present in the cul-de-sac

Stage III (Moderate)

As above, plus presence of endometriomas on the ovary and more adhesions.

Stage IV(Severe)

As above, plus large endometriomas, extensive adhesions.


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Endometrioma on the ovary of any significant size (Approx. 2 cm +) must be removed

surgically because hormonal treatment alone will not remove the full endometrioma cyst,

which can progress to acute pain from the rupturing of the cyst and internal bleeding.

Endometrioma is sometimes misdiagnosed as ovarian cysts.

PreventionUse of combined oral contraceptives is associated with a reduced risk of endometriosis ,

apparently giving a relative risk of endometriosis of 0.63 during active use, yet with limited

quality of evidence according to a systematic review.

Management

While there is no cure for endometriosis, in many peoplemenopause (natural or surgical)

will abate the process. In patients in the reproductive years, endometriosis is merelymanaged: the goal is to provide pain relief, to restrict progression of the process, and to

restore or preserve fertility where needed. In younger women with unfulfilled

reproductive potential, surgical treatment attempts to remove endometrial tissue and

preserving the ovaries without damaging normal tissue.

In general, the diagnosis of endometriosis is confirmed during surgery, at which time

ablative steps can be taken. Further steps depend on circumstances: patients without

infertility can be managed with hormonal medication that suppress the natural cycle and

pain medication,

while infertile patients may be treated expectantly after surgery,

withfertility medication, or with IVF.

Sonography is a method to monitor recurrence of endometriomas during treatments.

Treatments for endometriosis in women who do not wish to become pregnant include:

HORMONAL MEDICATION

*Progesterone or Progestins: Progesterone counteracts estrogen and inhibits the growth

of the endometrium. Such therapy can reduce or eliminate menstruation in a controlled

and reversible fashion. Progestins are chemical variants of natural progesterone.

*Avoiding products with xenoestrogens, which have a similar effect to naturally produced

estrogen and can increase growth of the endometrium.

*Hormone contraception therapy: Oral contraceptives reduce the menstrual pain

associated with endometriosis. They may function by reducing or eliminating menstrual

flow and providing estrogen support. Typically, it is a long-term approach. Continuous

hormonal contraception consists of the use of combined oral contraceptive pills without


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the use of placebo pills, or the use of Nuva Ring or the contraceptive patch without the

break week. This eliminates monthly bleeding episodes.

*Danazol (Danocrine) and gestrinone are suppressive steroids with some androgenic

activity. Both agents inhibit the growth of endometriosis but their use remains limited as

they may causehirsutism and voice changes.

*Gonadotropin Releasing Hormone (GnRH) agonist: These agents work by increasing

the levels of GnRH. Consistent stimulation of the GnRH receptors results in down

regulation, inducing a profound hypo estrogenism by decreasing FSH and LH levels. While

effective in some patients, they induce unpleasant menopausal symptoms, and over time

may lead to osteoporosis. To counteract such side effects some estrogen may have to be

given back (add-back therapy). These drugs can only be used for six months at a time.

*Lupron depo shot is a GnRH agonist and is used to lower the hormone levels in the

woman's body to prevent or reduce growth of endometriosis. The injection is given in 2different doses: a 3 month course of monthly injections, each with the dosage of

(11.25 mg); or a 6 month course of monthly injections, each with the dosage of (3.75 mg).

*Aromatase inhibitors are medications that block the formation of estrogen and have

become of interest for researchers who are treating endometriosis.

Other medication

NSAIDs:Anti-inflammatory. They are commonly used in conjunction with other therapy.

For more severe cases narcotic prescription drugs may be used. NSAID injections can be

helpful for severe pain or if stomach pain prevents oral NSAID use.

MST: Morphine sulphate tablets and other opioid painkillers work by mimicking the action

of naturally occurring pain-reducing chemicals called "endorphins". There are different

long acting and short acting medications that can be used alone or in combination to

provide appropriate pain control.

Pentoxifylline, an immuno-modulatory agent

SURGERY

Procedures are classified as:

conservative when reproductive organs are retained, semi-conservative when ovarian function is allowed to continue,

Conservative therapy consists of the excision (called cystectomy) of

the endometrium, adhesions, resection of endometriomas, and restoration of normal pelvic

anatomy as much as is possible. There are combinations as well, notably one consisting of


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cystectomy followed by ablative surgery (removal of endometrium) using a CO2 laser to

vaporize the remaining 1020% of the endometrioma wall close to the hilus.

Semi-conservative therapy preserves a healthy appearing ovary, but also increases the

risk of recurrence.

Comparison of medicinal and surgical interventions

Efficacy studies show that both medicinal and surgical interventions produce roughlyequivalent pain-relief benefits. Recurrence of pain was found to be 44 and 53 percent withmedicinal and surgical interventions, respectively. However, each approach has its ownadvantages and disadvantages.

Advantages of medicinal interventions

Decrease initial costEmpirical therapy (i.e. can be easily modified as needed)Effective for pain controlDisadvantages of medicinal interventions

Adverse effects are common

Not likely to improve fertilitySome can only be used for limited periods of time

Advantages of surgery

1. Has significant efficacy for pain control.2. Has increased efficacy over medicinal intervention for infertility treatment3. Combined with biopsy, it is the only way to achieve a definitive diagnosis4. Can often be carried out as a minimally invasive (laparoscopic) procedure to reduce

morbidity and minimize the risk of post-operative adhesions.

Treatment of infertility

While roughly similar to medicinal interventions in treating pain , the efficacy of surgery is

especially significant in treating infertility. One study has shown that surgical treatment of

endometriosis approximately doubles the fecundity (pregnancy rate). The use of medical

suppression after surgery for minimal/mild endometriosis has not shown benefits for

patients with infertility. Use of fertility medication that stimulates ovulation (clomiphene

citrate, gonadotropins) combined with intrauterine insemination (IUI) enhances fertility in

these patients.

In-vitro fertilization (IVF) procedures are effective in improving fertility in many women

with endometriosis. IVF makes it possible to combine sperm and eggs in a laboratory and

then place the resulting embryos into the woman's uterus. The decision when to apply IVF

in endometriosis-associated infertility takes into account the age of the patient, the severity

of the endometriosis, the presence of other infertility factors, and the results and duration

of past treatments.


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Other treatments

One theory above suggests that endometriosis is an auto-immune condition and if theimmune system is compromised with a food intolerance, then removing that food from the

diet can, in some people, have an effect. Various dietary recommendations are made in

popular media. Eating foods high in indole-3-carbinol, such as cruciferous vegetables

appears to be helpful in balancing hormones and managing pain. Physical therapy for pain management in endometriosis has been investigated in a pilot

study suggesting possible benefit. Physical exertion such as lifting, prolonged standing or

running does exacerbate pelvic pain. Use of heating pads on the lower back area , may

provide some temporary relief.

Laboratory studies indicate that heparin may alleviate endometriosis-associated fibrosis.Prognosis

Proper counseling of patients with endometriosis requires attention to several aspects of

the disorder. Of primary importance is the initial operative staging of the disease to obtainadequate information on which to base future decisions about therapy. The patient's

symptoms and desire for childbearing dictate appropriate therapy. Not all therapy works

for all patients. Some patients have recurrences after surgery or pseudo-menopause. In

most cases, treatment will give patients significant relief from pelvic pain and assist them

in achieving pregnancy. It is important for patients to be continually in contact with their

physician and keep an open dialog throughout treatment. This is a disease without a cure

but with the proper communication, a woman with endometriosis can attempt to live a

normal, functioning life. Using cystectomy and ablative surgery, pregnancy rates are

approximately 40%.

Recurrence

The underlying process that causes endometriosis may not cease after surgical or medical

intervention. The most recent studies have shown that endometriosis recurs at a rate of 20

to 40 percent within five years following conservative surgery, unless hysterectomy is

performed or menopause reached. Monitoring of patients consists of periodic clinical

examinations and sonography. Also, the CA 125 serum antigen levels have been used to

follow patients with endometriosis. With combined cystectomy and ablative surgery,

onestudy showed recurrence of a small endometrioma in only one case among fifty-two

women (2%) at a mean follow-up of 8.3 months.

Vaginal childbirth decreases recurrence of endometriosis. In contrast, endometriosis

recurrence rates have been shown to be higher in women who have not given birth

vaginally, such as in Cesarean section.


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EPIDEMIOLOGY

Endometriosis can affect any female, from premenarche to postmenopause, regardless of

race or ethnicity or whether or not they have had children. It is primarily a disease of the

reproductive years. Estimates about its prevalence vary, but 510% is a reasonable

number, more common in women with infertility (2050%) and women with chronicpelvic pain (about 80%). As an estrogen-dependent process, it can persist beyond

menopause and persists in up to 40% of patients following hysterectomy. In some cases, it

may also begin beyond menopause and it has also been described in men taking high-dose

estrogen therapy.

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