REVIEW ARTICLES Endometriosis - An Update LP BANUa, S TASNIMb Summary: relevant information. The study results showed that both Endometriosis is a common and important health problem medical and surgical treatments are almost equally effective of women. The prevalence of endometriosis is difficult to in pain management there is no evidence that medical determine. Diagnosis is often difficult and delayed due to treatment improves fertility. Surgical treatment is associated close similarity of symptoms of endometriosis with other with small but significant improvement in live birth rate. gynecological disorder. Optimum treatment involves a Newer non hormonal drugs are more selective with less combination of medical and surgical treatments tailored to metabolic side effects. Surgical treatment is invasive the patient’s needs and response. procedure and repeated surgery is associated with major complication. The objective of the study is to discuss the current updates Medical treatment is considered more effective in the long on diagnosis, treatment and the optimal role of different term management of endometriosis. options in the treatment of endometriosis. The article reviews different medical journals, medline and internet to get the (J Banagladesh Coll Phys Surg 2013; 31: 144-149) Introduction: Endometriosis run in families. The mode of inheritance Endometriosis is a chronic and recurrent disease is probably polygenic and multi factorial. Chromosome characterized by the presence and proliferation of no 10 q26 5, 6 is thought to carry the involved gene. functional endometrial glands and stroma outside the There is some defect in immune response to tissue injury uterine cavity. Around 10% of women of reproductive in women with endometriosis that fail to remove age are affected by endometriosis, suffer from chronic refluxed menstrual debris from the extra uterine site. pelvic pain and contribute to infertility 1. Endometriosis The scavenger activity of peritoneal macrophages is 7 8, not only lowers the quality of life of the affected women; reduced with abnormal T-cell-mediated cytotoxcity, 9 10 it jeopardizes her conjugal life, hamper wellbeing of natural-killer-cell activity, B-cell functions and other members of the family and ultimately the society complement deposition. They suffer from different autoimmune diseases, allergic reactions and certain toxins is also affected. The original three theories of 11.12. Growth factors may also have some role.13, 14. histogenesis of endometriosis fail to explain all the Another area of research is the search for endometriosis criteria of histogenesis. According to serosal cell markers. CA 125 is elevated in patient with metaplasia theory endometriosis should occur in men endometriosis.15 also. Few rare case of endometriosis in male has been reported 2, 3. The recent molecular explanation for Clinical findings: Sampson’s theory states that aberrant production of Endometriosis is associated with a wide variety of aromatase converts the precursor of steroids to estrogen symptoms ranging from mild dysmenorrheal to in endometriotic tissue that plays a key role in the path incapacitating pain. Pelvic pain is usually cyclical and physiology of endometriosis4. become severe as the disease advances. 16 Pain of endometriosis has a diverse presentation causing a. Dr. Laila Parveen Banu, FCPS (O&G) Asso Prof, Department dysmenorrhea, deep dyspareunia, constant pelvic pain of Obs and Gynae, MAG Osmani Medical College Sylhet. or a low sacral backache. One of the characteristics of b. Prof Saria Tasnim, FCPS (O&G), Department of Obs and the disease is that the symptoms do not correlate with Gynae, Institute of Child and Mother Health, Matuail Dhaka. the amount of the disease. There are women with Address of Correspondence: Dr. Laila Parveen Banu, FCPS (O&G0) Asso Prof, Department of Obs and Gynae, MAG Osmani minimal disease but with lot of symptoms. On the other Medical College. E-mail: [email protected] hand there are women who have lot of disease with 17 Received: 28 October, 2009 Accepted: 16 May, 2013 minimal symptoms. Journal of Bangladesh College of Physicians and Surgeons Vol. 31, No. 3, July 2013 Infertility is another common association of the disease. well with the chance of conception following therapy. It’s incidence among infertile women according to one This poor predictive ability is related to the arbitrary study is 14%18. There is evidence of impaired oocye assignment of point scores for the observed pathology development, embryogenesis or implantation in mild and the arbitrary cut-off points chosen to establish the degree endometriosis19. Many cases of endometriosis stage of disease. The description of the morphologic suffer from dysfunctional uterine type of bleeding20. subtype of disease or other biological markers may be 23 Endometriosis is often confused with pelvic included with The ASRM 1996 classification system. inflammatory disease, irritable bowel syndrome and A better understanding of the patho-physiology of pelvic tumor which often causes delayed diagnosis and endometriosis-associated infertility may help to develop require surgical evaluation. a more accurate staging system. Diagnosis AMD Staging Treatment options: In current clinical practice, laparoscopy is required for Medical treatment is usually considered as the first line a definitive diagnosis of endometriosis. Histological of treatment. Treatment is often individualized and is evaluation is essential when the diagnosis is not obvious tailored depending on patient’s age, desire for future fertility, severity of symptoms and the stage of disease. on visual inspection at surgery. When addressing Endometriosis is a disease of pain. Empirical treatment whether or not to perform a laparoscopy on a women of pain is offered to suspected cases of endometriosis presenting on a complain of infertility, one should without a definitive diagnosis. Ti includes counseling, consider both the likelihood of diagnosis of adequate analgesia, progestogens, the combined oral endometriosis as well as potential benefit of treatment. contraceptives (COC), gonadotropin releasing hormone A history and physical examination can yield a number (GNRH) agonists and antagonists, danazol, nutritional of significant findings suggestive of endometriosis therapy and most recently aromatase inhibitors. All of including: cyclic or chronic pelvic pain dysmenorrheal, them are appropriate for pain management and where dyspareunia, a fixed retroverted uterus, an adnexal mass, there is no desire for immediate fertility24. and uterosacral ligament nodularity, thickening or tenderness .Pelvic ultra sound can help the clinician to The Hormones can effectively control pain and reduces establish a presumptive diagnosis of an endometrioma anatomical extent of the disease. Only they differ in side but cannot detect peritoneal implants of disease. effect and cost profile. Symptoms recur after discontinuing therapy. There is no improvement in A laparoscopic diagnosis of asymptomatic endometriosis infertility by medical management. can sometimes be made. However, laparoscopic Oral contraceptive pills (OCPs): OCPs are considered confirmation of asymptomatic endometriosis is almost as number one choice for patients having minimal or always limited to minimal or mild disease. The therapeutic mild symptoms. It can be given cyclically and benefit of laparoscopy to increase fecundity in a woman continuously for 2 years25. with mild disease is minimal. The combination of these factors renders laparoscopy of asymptomatic women with Progestin alone or combined with estrogen are used infertility, simply to rule out or confirm disease, frequently for long term management of endometriosis 26 unwarranted20,21. associated pain . Progestins inhibit angiogenesis which is required for maintenance of endometriotic implants27. Endometriosis is a heterogeneous disease with typical They are available in multiple delivery forms, and atypical peritoneal lesions ranging from a single convenient in dose and have less impact on bone mineral 1mm peritoneal implant to less than or equal to 10 cm density (BMD). endometriosis with cul-de-sac obliterated. Thus a staging system has been proposed for better understanding the Medroxy progesterone acetate is the most popularly extent of disease and standardization and comparisons prescribed progesterone that causes relief of pain of outcomes for clinical trials. The American society of ranging from 70% to100%. It is as effective as danazol 27 Reproductive Medicine classification system for and is better than placebo . endometriosis (ASRM 1996) is the most widely The levonotgestrel intra-uterine system (LNG IUS): it accepted staging system22. No staging system correlates is a newer non daily hormonal preparation28. It is 145 Endometriosis - An Update LP Banu & S Tasnim convenient in symptom control for over 3 years. It may vitamin D for six months caused marked reduction of have the potential to be a long term treatment option laparoscopic visible lesion and significant reduction of for endometriosis. pelvic pain with no changes in BMD34. Danazol is 19 nor testosterone derivative. Numerous Anti-estrogens: Non- steroidal anti-estrogen can act as clinical trials have proved that danazol is effective in either estrogen agonist or antagonists. It acts by binding regressing endometriosis implants with relief of pain with estrogen receptors (ERs) and depending on the 29. Women with all stages of disease showed no target tissue, they are known