Endometriosis

Endometriosis is the most mysterious gynecological disorders. It is the occurrence of ectopic endometrial tissues outside the cavity of the uterus. These islands of endometriosis are composed of endometrial glands surrounded by endometrial stroma, which are capable of responding to a varying degree to cyclical hormonal stimulation.¹

Aetiology

Endometriosis is a disease of the child- bearing period. Its incidence appears to be on the increase, partly due to improvement in diagnostic techniques and partly due to changing social patterns like late marriage and limitation of family size. It has been seen that it tends to occur more amongst the affluent class, and is frequently associated with infertility.¹

Below are some theories to explain endometriosis¹

1. Implantation theory
2. Coelomic metaplasia theory
3. Metastatic theory
4. Histogenesis by induction
5. Hormonal influence
6. Immunological factor
7. Other factors – genetic, vaginal or cervical atresia

Sites¹

• Ovaries
• Cul-de-sac
• Uterosacral ligaments
• Peritoneum overlying the bladder
• Sigmoid colon
• Back of the uterus
• Intestinal coils
• Appendix
• Lower pelvis
• Umbilicus

Pathology

An endometriotic area appears as a dark red, bluish or black cystic area, adherent to the site where it is lodged. Scarring around the endometriosis gives a puckered look. Lately, atypical lesions such as no pigmented areas or yellowish whit thick plaques have been noticed. Peritoneal cavity contains yellowish brown fluid in the cul-de-sac and this contains prostaglandin responsible for pain.¹

Chocolate cysts of the ovaries represent the most important manifestation of endometriosis. To the naked eye, the chocolate cyst shows obvious thickening of tunica albuginea, and vascular red adhesions are well marked on the under surface of the ovary. The inner surface of the cyst wall is vascular and contains areas of dark brown tissue.¹

There are three categories of endometriosis and each has a different mode of development¹

• Pelvic endometriosis may be localized or diffused and scattered over the pelvic peritoneum, pouch of Douglas and utero-sacral ligaments.
• Ovarian endometriosis or chocolate cyst.
• Rectovaginal endometriosis.

Classification¹

The Classification is correlated with fertility outcome rather than pain symptom

• Minimal: Small spots of endometriosis seen at laparos­copy, but no clinical symptoms.
• Mild: Scattered fresh superficial lesions. No scarring or retraction. No adnexal adhesions.
• Moderate: Ovaries are involved, with some scarring and retraction. They contain endometriomas not more than 2 cm in size. There are minimal peritubal and periovarian adhesions. Endometriotic lesions in the anterior and posterior peritoneal pouch with some scarring and retraction may be seen.
• Severe: Ovaries are involved, with the size of the endo­metriomas exceeding 2 cm. dense peritubal and per ovarian adhesions severely restrict mobility. The uterosacral ligaments are thickened and involved and lastly, there may be evidence of involvement of the bowel and urinary tract.
• Laparoscopic findings vary with the duration of the lesion, size and location. ‘Powder-burn’—puckered black spots, red vascular, bluish, blackish cysts, chocolate cysts and dense adhesions in the pelvis as well as yellow-brown peritoneal fluid are the findings.

Poor correlation between the naked eye appearance and histology is well documented. Therefore, biopsy of the suspicious areas becomes necessary to prove the presence of endometriosis.¹

Clinical Features

Endometriosis affects women in the reproductive age, around 30 years. It may occur in an adolescent if obstruc­tion in the lower genital tract causes cryptomenorrhoea and retrograde spill of menstrual fluid. A rare case of endo­metriosis has been reported in a postmenopausal woman on hormone replacement therapy (HRT).¹

Symptoms

The symptoms vary according to the site, depth of lesion and do not always correlate well with the extent of disease. The classic symptom complex includes dysmenorrhoea, dyspareunia, menorrhagia and infertility. About 30% of the patients are asymptomatic. Overlapping of symptoms is common.¹

The following are the common symptoms¹

• Dysmenorrhoea
• Abdominal pain
• Dyspareunia
• Infertility
• Menstrual symptoms
• Chronic pelvic pain (CPP)

Differential Diagnosis¹

1. Chronic pelvic inflammatory disease closely mimics endometriosis in its symptoms and signs. Both the conditions produce pelvic pain, congestive dysmenorrhoea, menorrhagia and sterility.

Endometriosis may, if there is leakage of blood contents, produce leucocytosis, raised ESR and moderate fever. Also, both have similar physical signs.  Laparoscopic visualization of the pelvis will reveal the true pathology.

2. Uterine myomas, unless degenerate, are painless and the uterus is not fixed. Ultrasound and laparoscopic visualization will differentiate on condition from the other.
3. Ovarian malignant tumor with metastatic deposits in the pouch Douglas can be mistaken for endometriosis.
4. Recto sigmoid involvement will cause rectal symptoms which resemble the symptoms of rectal carcinoma. It may be impossible to make an accurate diagnosis until sigmoidoscopy and biopsy are performed.
5. If the chocolate cyst ruptures, all possibilities of an acute abdominal catastrophe must be considered, including a ruptured tubal gestation, though the most frequent er­ror is to operate for acute appendicitis.
6. Chronic pelvic congestion syndromes due to other causes must be excluded by ultrasound, CT, MRI and laparoscopy.

Investigations¹

1. Laparoscopic Findings

• • To detect and diagnose pelvic endometriosis.
  • Locate the site of endometriosis and staging.
  • To take biopsy.

2. Ultrasound and MRI
3. Prophylaxis

Management

Minimal asymptomatic cases should be observed over 6–8 months. Infertility should be investigated and treated as necessary.¹

All symptomatic women need treatment. The treatment depends upon the age of the patient, need forpreserving reproductive functions, severity of the symptoms, extent of the disease, response to medical treatment, relief obtained with any previous conservative surgery andthe attitude of the patient towards her problem. The objective of the treatment should be to eradicate the lesion andavoid recurrence of the disease process, alleviate symptoms, facilitate childbearing and enable the patient to leada comfortable life. Therefore, the treatment should be individualized. The treatment comprises medical surgical and a combination of both.¹

There are many medicines in homeopathic literature which indicates its usage for endometriosis. A well selected homeopathic remedy and one based on pathological action of remedy can help treat this condition. Many acute medicines are available to help in pain relieving due to endometriosis which shall be supplemented by a deep acting remedy which will correct the condition. The treatment shall be individual based treatment.

Few Medicines for Endometriosis