Endometriosis, a challenge for the XXI century

Endometriosis is a complex chronic disease that represents an important challenge for modern Gynecology and for all National Health Systems. Classically, endometriosis is defined as the presence of endometrial tissue outside the uterine cavity.

The endometrium is the tissue that lines the inside of the uterus and is responsible for the feeding of the embryo until the formation of the placenta. If there is no pregnancy, the endometrium will flake producing bleeding, known as menstruation or menstruation. In the next cycle of ovulation a new endometrium will grow while waiting for a possible gestation.

Endometriosis is the most frequent pathology of the female reproductive system, together with the presence of uterine fibroids. It is a common gynecological disease that affects approximately 3-10% of women during their reproductive age, especially in the range of between 28-35 years. In those women who suffer pain with the rule ( dysmenorrhea ) the incidence of endometriosis reaches 50%, and in those suffering from infertility its incidence as a cause reaches 25-50%. This means that about 14 million women are affected in Europe and more than 150 million in the world. Its economic impact is very important, because a cost in Europe of around 30 million euros per year is estimated.

This disease is considered one of the great enigmas of general pathology and especially of gynecological pathology. Despite constant research, with more than 5,000 registered scientific articles per year, its origin remains unknown. We can only say in a general way that it constitutes an immunological alteration with a genetic basis. The natural evolution of the disease will depend on hormonal factors (the presence of estrogens favors its development) and environmental factors little known and conclusive to date.

The most frequent location of the endometrial tumor tumor implants occurs in the uterosacral ligaments, the pelvic peritoneum and the ovaries (endometriotic cyst or endometrioma). Deep implants (> 5 mm), especially in the ligaments described, are responsible for the intense dysmenorrhea and pain in sexual intercourse ( dyspareunia ) described by those affected by the disease.

Diagnosis of endometriosis

The diagnosis of suspicion is based fundamentally on the recognition of the characteristics of the symptomatology of endometriosis by the Family Doctor or the Gynecologist. It is recognized that the average time to reach the diagnosis since the patient comes to the doctor for the first time is 8 years on average. This is due to the lack of specific symptoms or clear diagnostic forms of endometriosis.

Some key symptoms such as sterility, chronic pelvic pain, dysmenorrhea resistant to medical treatment and dyspareunia, should make us suspect endometriosis as the first differential picture. Other symptoms associated with menstruation are dyschezia (pain during defecation during menstruation), dysuria (pain during urination with menstruation) and bladder tenesmus, rectal tenesmus, clinical signs of irritable bowel syndrome or interstitial cystitis. intestinal pseudo-obstructive and renoureteral crises. This symptomatology is directly related to the depth of the implants. It can occur in the absence of ovarian endometriomas (10%) and there is no direct relationship between the magnitude of the pain and the severity of the disease.

Sterility as a symptom

Currently, from the reproductive point of view, many clinicians recommend the practice of assisted reproduction techniques (ART) in patients with infertility and suspected endometriosis without confirmation by laparoscopy. The rate of pregnancies is clearly diminished in patients with endometriosis, not only because of the local inflammatory effect, but also because of the poorer quality of oocytes, the poorer quality of the embryos obtained and a lower implantation rate. We are facing a complex problem and, in the absence of conclusive studies, there is no consensus on the best conduct to carry out.. All this leads other authors to recommend sterile patients a laparoscopic approach for the treatment of endometriosis, especially for those with suspected severe endometriosis with endometriomas of> 4 cm, in the case of several failed IVF cycles and prior to the offer of an oocyte donation. Before any surgical approach, it will always be necessary to assess the oocyte reserve of the woman and the potential advantages and disadvantages of surgical treatment on reproductive prognosis.

The pelvic examination by vaginal and rectal examination by the gynecologist should be the basis of the study of a patient with possible endometriosis, in addition to the creation of a map of points of selective pain. In the presence of large rectovaginal or lateral lesions, it should be investigated preoperatively using the different imaging techniques available ( Transvaginal Ultrasound, Transrectal Ultrasound, Pelvic Magnetic Resonance ), possible severe involvement of the bladder, the ureter and / or the distal intestinal tract for adequate preparation of the possible surgery to practice. All this will facilitate the understanding by the patient of the severity of their symptoms, of the surgical complexity and of the possible risks and sequels of this treatment.. Analytically there are no specific markers, therefore the use of CA-125 antigen as a serum marker of endometriosis has little value in diagnosis and prognosis.. It only becomes important in the postoperative follow-up.

Diagnostic laparoscopy is recognized as the "Gold standard" process to carry out the diagnosis. Only a diagnosis of certainty should be made after direct observation of the implant, generally associated with an anatomopathological confirmation.. It is advisable to perform the diagnosis and treatment in the same surgical act, prior information and consent of the patient of the processes to be performed. In the case of injuries that imply a greater surgical risk and it is not possible to perform a complete treatment, the process must be completed in the diagnosis and refer the patient to a referral center.