Endometriosis is a prevalent condition characterized by the growth of endometrial glands and stroma tissue outside the uterus. This misplaced tissue triggers a chronic inflammatory response that is dependent on estrogen. This tissue can be found in other organs in the pelvis, such as the ovaries, fallopian tubes, or the tissue lining the pelvis. However, this definition is overly simplistic.
Endometriosis presents a significant challenge in the field of benign gynecological disorders due to its complexity, diverse clinical manifestations, and still uncertain physio-pathological origins.
The endometrial-like tissue outside the uterus responds to menstrual cycle hormones, thickening, breaking down, and bleeding, just like the tissue inside the uterus. Endometriosis affects an estimated 1% to 5% of the population, with an incidence rate of 1.4 to 3.5 cases per thousand person-years.
What Causes Endometriosis?
The direct cause of endometriosis is unknown. Potential causes of endometriosis are possible genetic links, retrograde (reverse) menstruation, surgeries, hormonal issues, immune system disorders, and cellular metaplasia.
What Are The Symptoms Of Endometriosis?
Symptoms of endometriosis vary widely and may evolve over time. Often, endometriosis is discovered incidentally during surgeries performed for other reasons, with some patients reporting no symptoms at all. However, about 90% of symptomatic cases experience secondary dysmenorrhea (severe menstrual cramps), which is frequently their main concern and is often more intense and longer-lasting than primary dysmenorrhea, which typically responds well to anti-inflammatory medications.
Other common symptoms include:
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Deep dyspareunia: Pain felt in the upper vagina during sexual intercourse.
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Chronic pelvic pain: Persistent pain in the pelvic region.
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Infertility: Difficulty conceiving, which may accompany dysmenorrhea or appear independently.
In more severe cases, deeply infiltrating endometriosis can affect nearby organs, causing symptoms such as:
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Painful bowel movements (dyschezia), particularly during menstruation.
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Blood in stools (hematochezia).
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Painful urination (dysuria) or blood in urine (hematuria).
Who Can Get Endometriosis?
Endometriosis can affect anyone assigned female at birth who menstruates, typically during their reproductive years. It is most commonly diagnosed in individuals aged 25 to 40, though symptoms can start as early as adolescence.
Endometriosis Stages
Stage I Minimal (1–5 points):
Minimal endometriosis involves small implants, typically isolated to the pelvic area. These implants are usually superficial and may cause mild symptoms or none at all.
Stage II Mild (6–15 points):
In mild endometriosis, there are more implants and a slight increase in the involvement of pelvic organs. Small lesions may form on the ovaries, and minor adhesions (scar tissue) can appear, but they are often localized and not extensive.
Stage III Modarate (16–40 points):
Moderate endometriosis is characterized by deeper implants and more extensive adhesions. Cysts, especially endometriomas (also called “chocolate cysts”), may form on the ovaries. These cysts are often painful and can complicate fertility.
Stage IV Severe (>40):
Severe endometriosis features deep implants, large endometriomas, and significant adhesions that may bind organs together, like the ovaries, fallopian tubes. Severe endometriosis is more likely to cause infertility and severe chronic pain.
How Is Endometriosis Diagnosed?
Laparoscopy remains necessary for detecting peritoneal endometriotic lesions, as no imaging method currently matches its sensitivity and specificity. While non-invasive diagnostic methods are preferable, the limitations in sensitivity and specificity of these imaging tools make laparoscopy the most reliable method. Moreover, laparoscopy allows direct visualization and biopsy of lesions, providing a definitive diagnosis and enabling treatment in the same procedure.
Transvaginal ultrasound has shown limited sensitivity (65%; 95% CI 27% to 100%) but high specificity (95%; 95% CI 89% to 100%). In contrast, MRI demonstrates both low sensitivity (72%) and low specificity (79%) for diagnosing peritoneal endometriosis. Research is ongoing to develop more advanced imaging techniques and biomarker-based tests that may, in the future, reduce the dependency on surgical diagnosis.
How To Test For Endometriosis?
At present, surgery is the only definitive method for diagnosing endometriosis, with laparoscopy being the most commonly performed procedure.
How To Treat Endometriosis?
Currently, there is no definitive cure for endometriosis, and neither medical management nor surgical interventions offer lasting relief. A comprehensive understanding of its pathophysiology is essential to improve both diagnosis and treatment strategies.
The choice of treatment depends on the severity of symptoms, the patient’s age, fertility goals, and overall health. The common treatment options are pain management, hormonal therapy, and surgical options.
How Common Is Endometriosis?
Endometriosis impacts approximately 1% to 5% of the population, with an incidence rate ranging from 1.4 to 3.5 cases per thousand person-years.
