وصف
Endometriosis is a prevalent illness that can negatively impact quality of life, involve several organ systems, and cause pelvic pain and infertility.There is presently no cure for endometriosis, and its etiology is not entirely understood. While a clear histological diagnosis can be obtained through surgery, the majority of worldwide recommendations currently suggest a nonsurgical diagnosis based on physical examination findings, imaging results, and symptoms in order to minimize therapeutic delays. In order to treat persistent pain resulting from central sensitization and nociplastic pain processes, a multidisciplinary approach may be necessary in addition to hormone suppression, surgery, or a combination of the two.
ملخص
- Endometriosis is defined by the presence of endometrial tissue outside the uterus, affecting 6-10% of women of reproductive age. A significant diagnostic delay, averaging over 10 years in some European countries, is often attributed to factors like intermittent contraceptive use masking symptoms, misdiagnosis, and the normalization of menstrual pain. Common implantation sites include pelvic organs and peritoneum, while extra-pelvic sites may involve intestines, lungs, and urinary tract.
- Endometriosis presents in various forms, including vesicular, polypoid, fibrillar, and cystic types. The pathophysiology is explained by theories like transplantation, coelomic metaplasia, and genetic/immunological factors, with inflammation and estrogen dependence playing crucial roles. Symptoms range from gynecological (dysmenorrhea, pelvic pain, infertility) to non-gynecological (dyschezia, dysuria, shoulder pain).
- ASHRE guidelines recommend considering endometriosis diagnosis in individuals presenting cyclic and non-cyclic symptoms. Diagnostic approaches include clinical examination, imaging (TVUS, MRI), and, in select cases, laparoscopy with histological confirmation. However, negative imaging doesn't exclude the condition, especially superficial peritoneal disease. Measurement of biomarkers in endometrial tissue, blood, menstrual, or uterine fluids is not recommended for diagnosis.
- Medical management includes NSAIDs, COCs, progestins, and GnRH agonists/antagonists. ASHRE emphasizes shared decision-making, considering individual preferences, side effects, cost, and availability. Surgical procedures like excision of endometriomas and endometriosis have strong evidence. However, surgical treatment of endometriomas can reduce ovarian reserve, impacting fertility. Danazol, anti-progestogens, laparoscopic uterosacral nerve ablation, and anti-adhesion agents are not included in current recommendations.
- Infertility associated with endometriosis can arise from mechanical causes, altered peritoneal fluid, hormonal factors, and immune responses. ASHRE guidelines advise against ovarian suppression for fertility improvement. Operative laparoscopy may be offered for ASRM stage I/II endometriosis. Decisions regarding surgery should be guided by pain symptoms, patient age, preferences, and other infertility factors. Extended administration of GnRH agonists or routine surgery for ovarian endometriomas prior to ART is not recommended.
- Deep infiltrating endometriosis (DIE) management involves excision of nodules for pain relief, although its impact on fertility is controversial. Hysterectomy with excision of endometriotic lesions is considered a last resort for women with completed family planning. Adhesiolysis for endometriosis-associated pain is noted, but Cocrhane reviews report no evidence of available agents improving the outcome.
- Recurrence is defined as lesion recurrence on reoperation or imaging after previous complete excision of the disease, there are four subtypes that include the symptoms, imaging, laparoscopically, and histologically prove the recurrence. After surgical management, LNB IUS or CHC is recommended for at least 18-24 months. ART does not increase endometriosis recurrence, and extended hormonal treatments are recommended for long-term management and to inform adolescence about the potential negative effect on ovarian reserve.
- For adolescents, careful history-taking to identify risk factors and symptomatic assessment is crucial. Serum biomarkers are not recommended for diagnosing or ruling out endometriosis in adolescents. First-line hormonal therapy includes hormonal contraceptives or progestins. Surgical treatment should be performed laparoscopically. If extensive ovarian endometriosis is discovered, clinicians should discuss fertility preservation.
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