Endometriosis and female pelvic pain in all aspects

Endometriosis should be managed by a personalized approach.

Key Points

Highlights:

• Women with endometriosis should be managed by a personalized approach due to the heterogeneous characteristics of the disease and its negative effect on the quality of life.  

Importance:

• Endometriosis is a chronic disease causing pain in many organ systems such as reproductive, gastrointestinal, and urinary tracts.
• Women with endometriosis should be evaluated in all aspects for optimal patient care.

What’s done here? 

• This review evaluates endometriosis including its definition, etiopathogenetic mechanisms, symptoms, and signs, medical and surgical treatment alternatives. Extrapelvic endometriosis is also mentioned briefly regarding its diagnosis and management options.
• Endometriosis is a disease encountered in approximately 6-10% of reproductive-aged women. The incidence is high in women with chronic pelvic pain and infertility.
• Endometriosis is considered to have a genetic predisposition although inheritance has not been still completely understood.
• Sampson’s theory is the most widely accepted theory which explains the development of endometriosis by endometrial glandular and stromal cells shedding into the peritoneal cavity through Fallopian tubes called retrograde menstruation.
• The occurrence of endometriosis in distant places outside the peritoneal cavity led to other theories such as coelomic metaplasia theory, induction theory, implantation theory, lymphatic and vascular dissemination theory
• Because endometriosis is an estrogen-dependent disease, women with prolonged exposure to estrogen with early menarche, shorter cycles, lower parity, lack of lactation periods appear to have increased risk for the development of endometriosis.
• The disease is usually manifested by dysmenorrhea, dyspareunia, chronic pelvic pain, and infertility. However, the symptoms do not correlate with the stage of endometriosis classified by the revised American Society for Reproductive Medicine (r-ASRM).
• Although imaging modalities such as ultrasound and magnetic resonance imaging are helpful, the definitive diagnosis depends on the histopathologic confirmation.
• There is no consensus about the definitive treatment of endometriomas to relieve pain, optimize fertility and delay recurrence.
• Relief of pain, amelioration of infertility, or both should be aimed in the management of endometriosis.
• Non-steroidal anti-inflammatory agents (NSAIDs) can be used as the first-line treatment for the management of pelvic pain, including endometriosis-related pain. They have the advantage of having a low side effect profile. The American College of Obstetricians and Gynecologists (ACOG) and the European Society of Human Reproduction and Embryology (ESHRE) also recommends consideration of NSAIDs or other analgesics to reduce endometriosis-associated pain.
• Combined hormonal contraceptives including estrogen- and progesterone-containing pills, transdermal patches, and vaginal rings. They act by causing decidualization and atrophy of the endometrial tissue.
• Combined oral contraceptives (COCs) which are well-tolerated and relatively inexpensive have other benefits like providing contraception and decreasing the risk of ovarian and endometrial cancers. Their long-term use also results in side effects such as nausea, bloating, breast tenderness, breakthrough bleeding, the risk of thrombosis, and interactions with other drugs used by the patient.
• Progestin monotherapy has mechanisms of action including decidualization and atrophy of endometrial tissue, inhibition of inflammatory pathways suppression of matrix metalloproteinases and inhibition of angiogenesis. They can be used at any age for a long time without increasing the risk of thrombosis. The most frequently reported adverse effects are breakthrough bleeding or spotting, weight gain, breast tenderness, and depression.
• Gonadotropin-releasing hormone agonists (GnRH-a) with less favorable tolerability and several side effects including depression, flushes, lipid profile changes, and loss of bone mineral density can be preferred as a second-line treatment option. ACOG and ESHRE recommend that hormonal add-back therapy is used to reduce or eliminate bone loss for GnRH-a use beyond 6 months.
• Elagolix as a gonadotropin-releasing hormone antagonist has been approved by the FDA in August 2018 in the treatment of endometriosis-related pelvic pain.
• Aromatase inhibitors act suppressing peripheral estrogen synthesis which is reserved for women with severe, refractory endometriosis-related pain.
• Although Danazol is effective at treating endometriosis-related pain, it is not commonly used because of androgenic side effects including acne, hirsutism, weight gain, and deepening of the voice that may be irreversible.
• Although endometriosis-associated symptoms including pelvic pain, subfertility can be managed successfully with medical treatments, surgical management remains a necessary part of the treatment algorithm.
• Excisional surgery results in a more favorable outcome than drainage and ablation regarding the recurrence of disease and symptoms, and obstetric outcomes.
• Presacral neurectomy can be beneficial in reducing pain for patients with endometriosis with midline pain with a risk of postoperative constipation and urinary dysfunction.
• Endometriosis tends to recur after the operation and repeated surgery for recurrent endometriomas is harmful to ovarian reserve. ASRM and ESHRE generally recommend postoperative medical suppression of ovulation with the use of oral contraceptives, danazol or gonadotropin-releasing hormone agonists to prevent recurrence.
• Hysterectomy with or without bilateral salpingo-oophorectomy (BSO) can be preferred in women who have completed fertility.
• In the extrapelvic endometriosis, the endometrial cells attach to any other locations of the body including abdominal wall, diaphragm, thorax, and the perineum from an obstetric laceration or episiotomy. Hormonal therapy such as progestins, danazol, contraceptive pills, gonadotropin-releasing hormone agonists provides temporary relief of pain and the other symptoms, but they usually recur in time. Thus, these hormonal treatments may be preferred for reducing the size of the lesions before the surgery.
• Further research is needed for proving whether complementary interventions, such as acupuncture, exercise, electrotherapy, yoga, and dietary modifications are beneficial in endometriosis management.

Lay Summary

Endometriosis is defined as the localization of endometrial glandular and stromal tissue outside the uterine cavity.

The prevalence of the disease ranges between 6-10% in reproductive-aged women. However, endometriosis is more frequently encountered in women with chronic pelvic pain and infertility.

The symptoms including dysmenorrhea, dyspareunia, chronic pelvic pain can be variable in patients with endometriosis. Because symptoms have a significant impact on their quality of life, early diagnosis and personalized management will be beneficial.

Kim et al, a group of scientists from the USA, published a review titled as “Endometriosis and Female Pelvic Pain” in the journal named Seminars in Reproductive Medicine.

These authors aimed to evaluate endometriosis in all aspects including its definition, etiopathogenetic mechanisms, symptoms, and signs, medical and surgical treatment alternatives. They summarized all medical and surgical treatment options with side effect profiles. They emphasized that endometriosis should be considered as a heterogeneous disease and managed in a personalized approach. they also briefly mentioned about the use of postoperative medical treatment and endometriosis located in unusual locations.

“The treatment will need to be tailored to the needs of the patient, taking into consideration the patient’s desire for fertility, side effects, symptoms, past treatment history, and patient preference,” they added.

Research Source: https://www.ncbi.nlm.nih.gov/pubmed/30566980