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Endometriosis

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Title: Endometriosis  
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Subject: Endometriosis of ovary, Combined oral contraceptive pill, Hematosalpinx, Atrophic vaginitis, Adhesion (medicine)
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Endometriosis

Endometriosis
Classification and external resources
ICD-10 N80
ICD-9 617.0
OMIM 131200
DiseasesDB 4269
MedlinePlus 000915
eMedicine med/3419 ped/677 emerg/165
MeSH D004715

Endometriosis is a hormonal and immune system disease in which cells similar to that which line the uterus (endometrium) grow outside the uterine cavity, most commonly on the membrane which lines the abdominal cavity, the peritoneum. The uterine cavity is lined with endometrial cells, which are under the influence of female hormones. Endometrial cells in areas outside the uterus are also influenced by hormonal changes and respond in a way that is similar to the cells found inside the uterus. Common symptoms of endometriosis are pain and infertility. The pain often is worse with the menstrual cycle and is the most common cause of secondary dysmenorrhea.

Endometriosis is typically diagnosed during the reproductive years, but has been diagnosed in girls as young as 8 and has been found to continue past menopause; it has been estimated that endometriosis occurs in roughly 4–10% of women.[1] Symptoms may depend on the site of active endometriosis. Its main but not universal symptom is pelvic pain in various manifestations. There is an established association between endometriosis and infertility.[1] Endometriosis has a significant social and psychological impact.[2]

There is no cure for endometriosis, but it can be treated in a variety of ways, including pain medication, hormonal treatments, and surgery.[3]

Contents

  • Signs and symptoms 1
    • Pelvic pain 1.1
    • Infertility 1.2
    • Other 1.3
    • Complications 1.4
  • Risk factors 2
    • Genetics 2.1
    • Environmental toxins 2.2
    • Aging 2.3
  • Pathophysiology 3
    • Formation 3.1
      • Retrograde menstruation 3.1.1
      • Other theories 3.1.2
    • Localization 3.2
  • Diagnosis 4
    • Staging 4.1
    • Markers 4.2
    • Histopathology 4.3
  • Prevention 5
  • Management 6
    • Surgery 6.1
    • Hormones 6.2
    • Other medication 6.3
    • Manual physical therapy 6.4
    • Nutritional therapy 6.5
    • Comparison of interventions 6.6
    • Treatment of infertility 6.7
  • Prognosis 7
  • Epidemiology 8
  • History 9
  • Society and culture 10
  • References 11
  • External links 12

Signs and symptoms

Illustration depicting Endometriosis.

Pelvic pain

A major symptom of endometriosis is recurring pelvic pain. The pain can range from mild to severe cramping or stabbing pain 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 (1 through 4) of endometriosis, with some women having little or no pain despite having extensive endometriosis or endometriosis with scarring, while other women may have severe pain even though they have only a few small areas of endometriosis.[4] Symptoms of endometriosis-related pain may include:[5]

  • dysmenorrhea – painful, sometimes disabling cramps during the menstrual period; pain may get worse 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
  • dysuria – urinary urgency, frequency, and sometimes painful voiding

Throbbing, gnawing, and dragging pain to the legs are reported more commonly by women with endometriosis.[6] 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.[6] Individual pain areas and pain intensity appears to be unrelated to the surgical diagnosis, and the area of pain unrelated to area of endometriosis.[6]

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

  • Endometriosis at DMOZ
  • Endometriosis fact sheet from womenshealth.gov

External links

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  2. ^ Culley L, Law C, Hudson N, Denny E, Mitchell H, Baumgarten M, Raine-Fenning N (2013). "The social and psychological impact of endometriosis on women's lives: A critical narrative review". Human Reproduction Update 19 (6): 625–639.  
  3. ^ "Endometriosis fact sheet". NIH. Retrieved Feb 12, 2013. 
  4. ^ a b Stratton P, Berkley KJ (2011). "Chronic pelvic pain and endometriosis: translational evidence of the relationship and implications". Hum. Reprod. Update 17 (3): 327–46.  
  5. ^ Endometriosis;NIH Pub. No. 02-2413; September 2002
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  7. ^ Murray, Michael T.; Pizzorno, Joseph (2012). The Encyclopedia of Natural Medicine (3rd ed.). New York, NY: Simon and Schuster. 
  8. ^ Endometriosis: Does It Cause Infertility?, from American Society for Reproductive Medicine. Revised 2012
  9. ^ Women with Endometriosis Have Higher Rates of Some Diseases; NIH News Release; 26 September 2002; http://www.nih.gov/news/pr/sep2002/nichd-26.htm
  10. ^ Arbique, D., Carter, S., & van Sell, S. (2008). Endometriosis can evade diagnosis: being alert to signs of endometriosis can arrest the disease before it takes over a patient's life. Rn, 71(9), 28-32.
  11. ^ Colette S, Donnez J (July 2011). "Are aromatase inhibitors effective in endometriosis treatment?". Expert Opin Investig Drugs 20 (7): 917–31.  
  12. ^ Pearce CL, Templeman C, Rossing MA, Lee A, Near AM, Webb PM, Nagle CM, Doherty JA, Cushing-Haugen KL, Wicklund KG, Chang-Claude J, Hein R, Lurie G, Wilkens LR, Carney ME, Goodman MT, Moysich K, Kjaer SK, Hogdall E, Jensen A, Goode EL, Fridley BL, Larson MC, Schildkraut JM, Palmieri RT, Cramer DW, Terry KL, Vitonis AF, Titus LJ, Ziogas A, Brewster W, Anton-Culver H, Gentry-Maharaj A, Ramus SJ, Anderson AR, Brueggmann D, Fasching PA, Gayther SA, Huntsman DG, Menon U, Ness RB, Pike MC, Risch H, Wu AH, Berchuck A (2012). "Association between endometriosis and risk of histological subtypes of ovarian cancer: a pooled analysis of case-control studies". Lancet Oncol. 13 (4): 385–94.  
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References

In terms of societal effects, the economic effects associated with endometriosis are substantial and are similar to that of other chronic diseases such as Crohn’s disease, diabetes, or rheumatoid arthritis.[96] This economic burden is attributed mostly to the inability to consistently work and predicted by decreased quality of life.[96]

Historical review found that Hippocratic doctors believed that delaying childbearing could trigger diseases of the uterus, which caused endometriosis-like symptoms. Women with dysmenorrhea were encouraged to marry and have children at a young age.[93] The fact that Hippocratics were recommending changes in marriage practices due to an endometriosis-like illness implies that this disease was likely common, with rates higher than the 5-15% prevalence that is often cited today.[93] If indeed this disorder was so common historically, this may point away from modern theories that suggest links between endometriosis and dioxins, PCBs, and chemicals.[93]

Historically, the symptoms of inexplicable chronic pelvic pain have often been attributed to imagined madness, female weakness, promiscuity, or hysteria.[93] As recently as 1995, reports found that over 50% of women with chronic pelvic pain had no “organic” cause, with women still often being considered mentally unstable.[94] Due to century-old attitudes linking mental illness to pelvic pain, there is often a delay in the correct diagnosis - on average, it takes 6 to 7 years for a woman to receive the diagnosis of endometriosis.[95]

Society and culture

Endometriosis was first discovered microscopically by Karl von Rokitansky in 1860.[92] However, this disease has likely affected women for thousands of years, with documentation in medical texts more than 4,000 years ago.[93] The Hippocratic Corpus outlines several symptoms very similar to endometriosis, including uterine ulcers, adhesions, and infertility.[93] A medical review of the history of endometriosis found that women with these symptoms were treated with leeches, straight-jackets, bloodletting, chemical douches, genital mutilation, pregnancy (as a form of treatment), hanging upside down, surgical intervention, and even killing due to suspicion of demonic possession.[93] 2,500 years ago, Hippocratic doctors recognized and treated chronic pelvic pain as a true organic disorder; however, during the Middle Ages, there was a shift into believing that women with pelvic pain were mad, immoral, imagining the pain, or simply misbehaving.[93] There is evidence to suggest that the old diagnosis of hysteria, which was thought to be a psychological disease, may have indeed been endometriosis.[93] This idea that chronic pelvic pain was related to mental illness influenced more recent attitudes regarding women with endometriosis, leading to delays in correct diagnosis and indifference to the patients’ true pain during the 20th century.[93]

History

As an estrogen-dependent process, it can persist beyond menopause and persists in up to 40% of women following hysterectomy.[91]

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.[90] Its prevalence varies, but 6–10% is a reasonable number, more common in women with infertility and chronic pelvic pain (35–50%).[1]

Epidemiology

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.[89]

The underlying process that causes endometriosis may not cease after surgical or medical intervention. Studies have shown that endometriosis recurs at a rate of 20 to 40 percent within five years following conservative surgery,[88] unless hysterectomy is performed or menopause reached. Monitoring of women consists of periodic clinical examinations and sonography.

Proper counseling of women with endometriosis requires attention to several aspects of the disorder. Of primary importance is the initial operative staging of the disease to obtain adequate information on which to base future decisions about therapy. The woman's symptoms and desire for childbearing dictate appropriate therapy. Not all therapy works for all women. Some women have recurrences after surgery or pseudo-menopause. In most cases, treatment will give women significant relief from pelvic pain and assist them in achieving pregnancy.[87]

Prognosis

In case of infertility in a woman with endometriosis, surgery is more effective than medicinal intervention.[65] For this purpose, surgery attempts to remove endometrial tissue and preserving the ovaries without damaging normal tissue.[65] In addition, in-vitro fertilization (IVF) procedures are effective in improving fertility in many women with endometriosis.

Treatment of infertility

The advantages of physical therapy techniques are decreased cost, absence of major side-effects, it does not interfere with fertility, and near-universal increase of sexual function.[84] Disadvantages are that there are no large or long-term studies of its use for treating pain or infertility related to endometriosis.[84]

The advantages of surgery are demonstrated efficacy for pain control,[85] it is more effective for infertility than medicinal intervention,[65] it provides a definitive diagnosis,[65] and surgery can often be performed as a minimally invasive (laparoscopic) procedure to reduce morbidity and minimize the risk of post-operative adhesions.[86] Efforts to develop effective strategies to reduce or prevent adhesions have been undertaken, but their formation remain a frequent side effect of abdominal surgery.[68]

The advantages of medicinal intervention are decreased initial cost, therapy can be modified as needed, and effective pain control. Its disadvantages are common adverse effects, unlikely improvement in fertility, and limitations on the length of time some can be used. Evidence on how effective medication is for relieving pain associated with endometriosis is limited.[63]

Efficacy studies show that both medicinal and surgical interventions produce roughly equivalent pain-relief benefits. Recurrence of pain was found to be 44 and 53 percent with medicinal and surgical interventions, respectively.[22] Each approach has advantages and disadvantages.[44] Manual therapy showed a decrease in pain for 84 percent of study participants, and a 93 percent improvement in sexual function.[84]

Comparison of interventions

There is no evidence to support the notion that nutritional therapy is effective in the management of endometriosis.

Nutritional therapy

The overall effectiveness of manual physical therapy to treat endometriosis has not yet been identified.[83]

Manual physical therapy

  • 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.
  • Opioids: 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.
  • Following laparoscopic surgery women who were given Chinese herbs were reported to have comparable benefits to women with conventional drug treatments, though the journal article that reviewed this study also noted that "the two trials included in this review are of poor methodological quality so these findings must be interpreted cautiously. Better quality randomised controlled trials are needed to investigate a possible role for CHM [Chinese Herbal Medicine] in the treatment of endometriosis.",[77]
  • Pentoxifylline, an immunomodulating agent, has been theorized to improve pain as well as improve pregnancy rates in women with endometriosis. A 2012 Cochrane review; however, enough evidence to support either of these uses.[78] Current American Congress of Obstetricians and Gynecologists (ACOG) guidelines do not include immune-modulators, such as pentoxifylline, in standard treatment protocols.[79]
  • Angiogenesis inhibitors lack clinical evidence of efficacy in endometriosis therapy.[80] Under experimental in vitro and in vivo conditions, compounds that have been shown to exert inhibitory effects on endometriotic lesions include growth factor inhibitors, endogenous angiogenesis inhibitors, fumagillin analogues, statins, cyclo-oxygenase-2 inhibitors, phytochemical compounds, immunomodulators, dopamine agonists, peroxisome proliferator-activated receptor agonists, progestins, danazol and gonadotropin-releasing hormone agonists.[80] However, many of these agents are associated with undesirable side effects and more research is necessary. An ideal therapy would diminish inflammation and underlying symptoms without being contraceptive.[81][82]

Other 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. An example of a Progestin is Dienogest (Visanne).
  • 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.[74] They may function by reducing or eliminating menstrual flow and providing estrogen support. Typically, it is a long-term approach. Recently Seasonale was FDA approved to reduce periods to 4 per year. Other OCPs have however been used like this off label for years. Continuous hormonal contraception consists of the use of combined oral contraceptive pills without the use of placebo pills, or the use of NuvaRing or the contraceptive patch without the break week. This eliminates monthly bleeding episodes.
  • Danazol (Danocrine) and gestrinone are suppressive steroids with some androgenic activity.[65] Both agents inhibit the growth of endometriosis but their use remains limited as they may cause hirsutism and voice changes.
  • Gonadotropin Releasing Hormone (GnRH) agonist:[65] These agents work by increasing the levels of GnRH. Consistent stimulation of the GnRH receptors results in downregulation, inducing a profound hypoestrogenism by decreasing FSH and LH levels. While effective in some people, 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 2 different doses: a 3-month-dose injections (11.25 mg); or a 6 month course of monthly injections, each with the dosage of 3.75 mg.[75] Note that the symptoms will mostly come back after completing the Lupron courses. Long-term use of Lupron (over 5–6 months) is associated with severe side effects, and should not be offered to the women. Thus, Lupron is not considered a treatment option for endometriosis. Instead, it is widely used in the United States as the non-invasive method for the diagnosis of endometriosis.
  • Aromatase inhibitors are medications that block the formation of estrogen and have become of interest for researchers who are treating endometriosis.[76]

Hormones

For women with extreme pain, a presacral neurectomy may be very rarely performed where the nerves to the uterus are cut. However, this technique is almost never used due to the high incidence of associated complications including presacral haematoma and irreversible problems with urination and constipation.[73]

A hysterectomy (removal of the uterus) can be used to treat endometriosis in women who do not wish to conceive. However, this should only be done when combined with removal of the endometriosis by excision, as if endometriosis is not also removed at the time of hysterectomy, pain may still persist.[73]

Endometriosis recurrence following conservative surgery is estimated as 21.5% at 2 years and 40-50% at 5 years.[72]

Conservative treatment involves excision of endometriosis while preserving the ovaries and uterus, very important for women wishing to conceive, but may increase the risk of recurrence.[71]

Conservative treatment consists of the excision (called cystectomy) of the endometrium, adhesions, resection of endometriomas, and restoration of normal pelvic anatomy as much as is possible.[66] Laparoscopy, besides being used for diagnosis, can also be used to perform surgery. It's considered a "minimally invasive" surgery because the surgeon makes very small openings (incisions) at (or around) the belly button and lower portion of the belly. A thin telescope-like instrument (the laparoscope) is placed into one incision, which allows the doctor to look for endometriosis using a small camera attached to the laparoscope. Small instruments are inserted through the incisions to remove the endometriosis tissue and adhesions. Because the incisions are very small, there will only be small scars on the skin after the procedure, and all endometriosis can be removed, and women recover from surgery quicker and have a lower risk of adhesions.[67] 55% to 100% of women develop adhesions following pelvic surgery,[68] which can result in infertility, chronic abdominal and pelvic pain, and difficult reoperative surgery. Trehan's temporary ovarian suspension, a technique in which the ovaries are suspended for a week after surgery may be used to reduce the incidence of adhesions after endometriosis surgery.[69][70]

Surgery

In general, the diagnosis of endometriosis is confirmed during surgery, at which time ablative steps can be taken. Further steps depend on circumstances: a woman without infertility can be managed with hormonal medication that suppress the natural cycle and pain medication, while an infertile woman may be treated expectantly after surgery, with fertility medication, or with IVF. As to the surgical procedure, ablation (or fulguration) of endometriosis (burning and vaporizing the lesions with a pointy electric device) has shown high rate of short-term recurrence after the procedure. The best surgical procedure with much less rate of short-term recurrence is to excise (cut and remove) the lesions completely.

While there is no cure for endometriosis, there are two types of interventions; treatment of pain and treatment of endometriosis-associated infertility.[63] In many women menopause (natural or surgical) will abate the process.[64] In women in the reproductive years, endometriosis is merely managed: 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.[65]

Management

Limited evidence indicates that the use of combined oral contraceptives is associated with a reduced risk of endometriosis.[62]

Prevention

Immunohistochemistry has been found to be useful in diagnosing endometriosis as stromal cells have a peculiar surface antigen, CD10, thus allowing the pathologist go straight to a staining area and hence confirm the presence of stromal cells and sometimes glandular tissue is thus identified that was missed on routine H&E staining.[61]

Typical endometriotic lesions show histopathologic features similar to endometrium, namely endometrial stroma, endometrial epithelium, and glands that respond to hormonal stimuli. Older lesions may display no glands but hemosiderindeposits (see photomicrograph on right) as residual.

Micrograph of the wall of an endometrioma. All features of endometriosis are present (endometrial glands, endometrial stroma and hemosiderin-laden macrophages). H&E stain.

Histopathology

It has been postulated a future diagnostic tool for endometriosis will consist of a panel of several specific and sensitive biomarkers, including both substance concentrations and genetic predisposition.[59]

The one biomarker that has been used in clinical practice over the last 20 years is CA-125.[59] However, its performance in diagnosing endometriosis is low, even though it shows some promise in detecting more severe disease.[59] CA-125 levels appear to fall during endometriosis treatment, but has not shown a correlation with disease response.[59]

A systematic review in 2010 of essentially all proposed biomarkers for endometriosis in serum, plasma and urine came to the conclusion that none of them have been clearly shown to be of clinical use, although some appear to be promising.[59] Another review in 2011 identified several putative biomarkers upon biopsy, including findings of small sensory nerve fibers or defectively expressed β3 integrin subunit.[60]

An area of research is the search for endometriosis markers.[59]

Markers

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.

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.

Surgically, endometriosis can be staged I–IV (Revised Classification of the American Society of Reproductive Medicine).[58] 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 person with Stage I endometriosis may have little disease and severe pain, while a person with Stage IV endometriosis may have severe disease and no pain or vice versa. In principle the various stages show these findings:

Staging

Frequently during diagnostic laparoscopy, no lesions are found in women with chronic pelvic pain, a symptom common to other disorders including adenomyosis, pelvic adhesions, pelvic inflammatory disease, congenital anomalies of the reproductive tract, and ovarian or tubal masses.[56] In order to avoid invasive diagnosis and potentially life-threatening complications of laparoscopy, the response to hormonal agonists such as Lupron has been advocated as a possible method for diagnosing endometriosis, under the premise that if the chronic pelvic pain was reduced or relieved with Lupron, the diagnosis would be established.[56] However, a randomized controlled trial investigating pain relief in response to Lupron administration found that pain relief was not significantly different in women who did or did not have endometriosis as detected by laparoscopy.[57] Thus, response to Lupron is currently not an accurate diagnostic method for detecting endometriosis, and the only definitive measure for diagnosis is laparoscopy.

Although doctors can often feel the endometrial growths during a pelvic exam, and these symptoms may be signs of endometriosis, diagnosis cannot be confirmed by exam only. To the eye, lesions can appear dark blue, powder-burn black, red, white, yellow, brown or non-pigmented. Lesions vary in size. Some within the pelvis walls may not be visible, as normal-appearing peritoneum of infertile women reveals endometriosis on biopsy in 6–13% of cases.[55] Early endometriosis typically 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.

Laparoscopic image of endometriotic lesions in the Pouch of Douglas and on the right sacrouterine ligament.

Laparoscopy, a surgical procedure where a camera is used to look inside the abdominal cavity, is the only way to officially diagnose endometriosis as it permits lesion visualization, unless the lesion is visible externally, e.g. an endometriotic nodule in the vagina. If the growths are not visible, a biopsy may be taken to determine the diagnosis.[54] Surgery for diagnoses also allows for surgical treatment of endometriosis at the same time.

A health history and a physical examination can lead the health care practitioner to suspect endometriosis. Use of pelvic ultrasound may identify large endometriotic cysts (such as endometrioma). However, smaller endometriosis implants cannot be visualized with ultrasound technique.

Micrograph showing endometriosis (right) and ovarian stroma (left). H&E stain.
Endometriosis, abdominal wall

Diagnosis

Less commonly lesions can be found on the diaphragm. Diaphragmatic endometriosis is rare, almost always on the right hemidiaphragm, and may inflict cyclic pain of the right shoulder just before and during a menstrual period. Rarely, endometriosis can be extraperitoneal and is found in the lungs and CNS.[53]

Endometriosis may also present with skin lesions in cutaneous endometriosis.

Endometriosis may spread to the cervix and vagina or to sites of a surgical abdominal incision, known as "scar endometriosis."[49] Risk factors for scar endometriosis include previous abdominal surgeries, such as a hysterotomy or cesarean section, or ectopic pregnancies, salpingostomy puerperal sterilization, laparoscopy, amniocentesis, appendectomy, episiotomy, vaginal hysterectomies, and hernia repair.[50][51][52]

Rectovaginal or bowel endometriosis affects approximately 5-12% of women with endometriosis, and can cause severe pain with bowel movements.[48]

Most endometriosis is found on these structures in the pelvic cavity: [47]

possible locations of endometriosis

Localization

  • Müllerianosis: A competing theory states that cells with the potential to become endometrial are laid down in tracts during embryonic development and stem cells. This theory is supported by foetal autopsy.[43]
  • Coelomic metaplasia: This theory is based on the fact that coelomic epithelium is the 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.[44]
  • Vasculogenesis: Up to 37% of the microvascular endothelium of ectopic endometrial tissue originates from endothelial progenitor cells, which result in de novo formation of microvessels by the process of vasculogenesis rather than the conventional process of angiogenesis.[45]
  • Neural growth: An increased expression of new nerve fibres is found in endometriosis, but does not fully explain the formation of ectopic endometrial tissue, and is not definitely correlated with the amount of perceived pain.[46]

Other theories

The theory of retrograde menstruation as a cause of endometriosis was first proposed by John A. Sampson.

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 woman 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.

In addition, at least one study found that endometriotic lesions are biochemically very different from artificially transplanted ectopic tissue.[42] The latter finding, however, can in turn be explained by that the cells that establish endometrial lesions are not of the main cell type in ordinary endometrium, but rather of a side population cell type, as supported by exhibitition of a side population phenotype upon staining with Hoechst dye and by flow cytometry.[21] Similarly, there are changes in for example the mesothelium of the peritoneum in women with endometriosis, such as loss of tight junctions, but it is unknown if these are causes or effects of the disorder.[41]

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. In this context there is interest in studying the relationship of endometriosis to autoimmune disease, allergic reactions, and the impact of toxins.[39][40] It is still unclear what, if any, causal relationship exists between toxins, autoimmune disease, and endometriosis. There are immune system changes in women with endometriosis, such as an increase macrophage-derived secretion products, but it is unknown if these are contributing to the disorder or are reactions from it.[41]

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. However, in some women, endometrial tissue transplanted by retrograde menstruation may be able to implant and establish itself as endometriosis. 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, e.g., hereditary factors, toxins, or a compromised immune system. It can be argued that the uninterrupted occurrence of regular menstruation month after month for decades is a modern phenomenon, as in the past women had more frequent menstrual rest due to pregnancy and lactation.

The theory of retrograde menstruation (also called the implantation theory or transplantation theory)[38] is the most widely accepted theory for the formation of ectopic endometrium in endometriosis.[21] 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.[21]

Retrograde menstruation

The main theories for the formation of ectopic endometrium are retrograde menstruation, müllerianosis, coelomic metaplasia and transplantation, each further described below.

Formation

Broadly, the aspects of the pathophysiology can basically be classified as underlying predisposing factors, inflammation, 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 and inflammatory changes and so on, or if metabolic and inflammatory 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.[21] Inflammation is a central part of the aetiopathology and causes pain.[37] Also, pathogenic mechanisms appear to differ in the formation of distinct types of endometriotic lesion, such as peritoneal, ovarian and rectovaginal lesions.[21]

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 an interplay between several factors.[21]

Laparoscopic image of endometriotic lesions at the peritoneum of the pelvic wall.

Pathophysiology

Incidences of endometriosis have occurred in postmenopausal women,[34] and in less common cases, girls may have endometriosis symptoms before they even reach menarche.[35][36]

Aging brings with it many effects that may reduce fertility. Depletion over time 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 affects carrying 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).

Aging

Several studies have investigated the potential link between exposure to dioxins and endometriosis, but the evidence is equivocal and potential mechanisms are poorly understood.[27] In the early 1990s, Sherry Rier and colleagues found that 79% of a group of monkeys developed endometriosis ten years after exposure to dioxin. The severity of endometriosis found in the monkeys was directly related to the amount of TCDD (2,3,7,8-Tetrachlorodibenzodioxin – the most toxic dioxin) to which they had been exposed . Monkeys that were fed dioxin in amounts as small as five parts per trillion developed endometriosis. In addition, the dioxin-exposed monkeys showed immune abnormalities similar to those observed in women with endometriosis.[28] A similar follow up study in 2000 observed similar findings.[29] In 1994, Drs. Frederick Yves Bois and Brenda Eskenazi wrote in the Environmental Health Perspectives journal titled Possible Risk of Endometriosis for Seveso, Italy Residents: An Assessment of Exposure to Dioxin stating that women who are sensitive to exposure may have a greater risk of having this condition.[30] However, a 2004 review of studies of dioxin and endometriosis concluded that "the human data supporting the dioxin-endometriosis association are scanty and conflicting,"[31] and a 2009 follow-up review also found that there was "insufficient evidence at this moment" in support of a link between dioxin exposure and women developing endometriosis.[32] A 2008 review by Rier concluded that more work was needed, stating that "although preliminary work suggests a potential involvement of exposure to dioxins in the pathogenesis of endometriosis, much work remains to clearly define cause and effect and to understand the potential mechanism of toxicity."[33]

Environmental toxins

In addition, there are many findings of altered gene expression and epigenetics, but both of these can also be a secondary result of, for example, environmental factors and altered metabolism. Examples of altered gene expression include that of miRNAs.[21]

In addition, there is a weaker association with changes in the fibronectin gene as well as in the 2p14 region of chromosome 2.[24]

Individual genomic changes (found by genotyping including genome-wide association studies) that have been associated with endometriosis include:

It has been proposed that endometriosis results from a series of multiple hits within target genes, in a mechanism similar to the development of cancer.[21] In this case, the initial mutation may be either somatic or heritable.[21]

Genetic predisposition plays a role in endometriosis.[21] Daughters or sisters of women with endometriosis are at higher risk of developing endometriosis themselves; low progesterone levels may be genetic, and may contribute to a hormone imbalance.[22] There is an about 6-fold increased incidence in women with an affected first-degree relative.[23]

Genetics

Risk factors

Pleural implantations are associated with recurrent right pneumothoraces at times of a menstrual period, termed catamenial pneumothorax.[20]

Ovarian endometriosis may complicate pregnancy by decidualization, abscess and/or rupture.[19]

Complications of endometriosis include internal scarring, adhesions, pelvic cysts, chocolate cyst of ovaries, ruptured cysts, and bowel and ureteral obstruction resulting from pelvic adhesions.[18] Endometriosis-associated infertility can be related to scar formation and anatomical distortions due to the endometriosis.

Complications

Endometriosis often also coexists with leiomyoma or adenomyosis, but studies that look into similarities and differences between endometriosis and adenomyosis have conflicting results.[16] 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.[17]

Current research has demonstrated an association between endometriosis and certain types of cancers, notably some types of ovarian cancer,[12][13] non-Hodgkin's lymphoma and brain cancer.[14] Despite similarities in their name and location, endometriosis bears no relationship to endometrial cancer.[15]

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 a menstrual period, during and even a week after a menstrual period, or it can be constant. The pain can be debilitating and the emotional stress can take a toll.[11]

Other symptoms include diarrhea or constipation,[6] chronic fatigue,[9] nausea and vomiting, headaches, low-grade fevers, heavy and/or irregular periods, and hypoglycemia.[10]

Other

Many women with infertility may have endometriosis. Among women with endometriosis, up to 30% to 50% may experience infertility.[8]

Infertility

Also, endometriotic 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.[4]

[7]

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