What is endometriosis?

To better understand endometriosis, its symptoms, its consequences and how to diagnose and treat it, we must explain what the endometrium is, which is where this disease gets its name. The endometrium is a thin layer that coats the inside of the uterus and transforms during each menstrual cycle in order to eventually receive an embryo. At the beginning of each cycle, this layer (also known as the endometrial mucus) becomes thicker and changes so that when fertilization occurs, it can accommodate a pregnancy. These cells only exist in the female body. Men do not have endometrial cells in their bodies, since they do not have uteri and cannot become pregnant. In each cycle that does not result in a pregnancy, the feminine body releases this unused layer. As it detaches, it causes bleeding which is called menstruation. This endometrial mucus that is meant to accommodate a pregnancy should only be found in one part of the body: inside the uterus. However, 10% of women are diagnosed with having endometrial cells in other areas of their bodies. Ectopic endometrium, that is, when it is found outside of the uterus, is a condition known as "endometriosis".

Which organs are the most affected by endometriosis?

Endometriosis frequently affects organs near the uterus, such as the Fallopian tubes and ovaries. The organs in the abdomen and the internal surface of the abdominal cavity are coated with a transparent layer called the peritoneum, which is also one of the common locations for endometriosis lesions. In some cases, the disease is also found in the intestines and the bladder. Though it is rare, endometriosis can be found even further from the uterus, such as in the skin near the navel and the lungs.

What causes endometriosis?

There are many theories on why some women are affected by endometriosis and others are not. None of these have been able to clarify every case. The most commonly accepted theory is based on retrograde menstruation, in which the menstrual flow comes out through the vagina and flows back through the Fallopian tubes, implanting endometrial cells in these regions. Another proposed theory is the development of endometrial tissue outside of the uterus during embryogenesis, well before birth, when the baby's organs are forming. It has also been suggested that fragments are carried through the human body by blood or lymph vessels. Explaining and documenting the mechanism of origin for this pathology has still not been possible.

Who is affected by endometriosis?

Since endometrial cells form only in women, either in the uterus (topical) or outside the uterus (ectopic), men cannot have this disease. In the general population, 1 out of every 7 women between the ages of 15 and 45 will be affected by endometriosis. However, since this disease does not always manifest clinically, these figures cannot be confirmed. The statistics are more reliable when it comes to patients who get treatment for infertility, since this is a specific group of women who have already undergone a videolaparoscopy, a procedure done under general anesthesia that provides the most precise diagnosis for endometriosis. 10% to 20% of these patients have endometriosis.

I have endometriosis! Will I be able to get pregnant?

Being diagnosed with endometriosis does not necessarily mean you will have issues with getting pregnant. Actually, most women with endometriosis get pregnant naturally. However, 30% to 40% of patients with endometriosis have issues with getting pregnant and need special treatment.

Can endometriosis become something more serious?

Endometriosis can vary from stage I (lowest) to IV (severe) based on the classification established and revised by the American Society for Reproductive Medicine (ASRM). This type of diagnosis is only possible through a videolaparoscopy or surgery. Therefore, it is important to note that the stage of the disease is related to the extent the organs are affected, which is not necessarily related to fertility. Women with more severe stages can get pregnant naturally, and women with the lowest stage may need fertility treatment. There is no relationship between the disease and an increased risk of cancer, even in more serious cases.

What are the symptoms?

The most frequent system is progressive dysmenorrhea, a pain linked to menstruation that becomes more intense over time. Pain in your lower stomach (pelvic discomfort) is also common and often aggravated during sexual relations (pain known as dyspareunia). However, many women affected by endometriosis do not feel any pain. Often diagnoses are made when a couple is trying to figure out why they cannot get pregnant. The stage of the disease is not correlated to the patient's pain. Women with only small endometriosis lesions can have severe discomfort, while women with the severe stages can be completely asymptomatic.

How do I know if I have endometriosis?

There are non-invasive tests that can indicate the presence of endometriosis. One of the most commonly used methods is ultrasonography. It is a diagnostic method that is able to detect endometriosis cysts (endometriomas), especially when they are larger than 1.0 cm and in the ovaries. The thickness and/or invasion of affected organs such as the bladder and the intestine can also be verified. More recently, magnetic resonance imaging has been used to diagnose the stage of the disease, especially in cases of endometriosis in the rectovaginal septum (previously known as deep endometriosis). Elevated levels of the CA 125 marker in the blood can also reinforce the suspicion of a case of endometriosis. However, these levels might be altered due to other issues, which make it vague. Of the currently available ways to diagnose endometriosis, none is as precise as the videolaparoscopy. It is considered the "gold standard" for diagnosis. Videolaparoscopies (more simply known as "video") are done in a hospital under general anesthesia. They allow for detection and treatment through cauterizing lesions, resecting endometriomas or simply removing scars (lysis of adhesions). Microscopic analyses of the fragments that are biopsied or removed confirm the histopathological diagnosis.

How is endometriosis treated?

When discussing treatment for endometriosis it is important to distinguish whether the priority is to treat pain (if present) or infertility. Currently, the most popular treatment for endometriosis is: For patients who do not wish to get pregnant (who already have children or do not want any): treatment of endometriosis aiming to reduce symptoms and achieve a good quality of life (without pain). There are basically two types of treatment: medication to block hormones, or surgery to remove the affected areas. Excising endometriosis cysts from the ovaries should be avoided and only performed in specific cases. Recent research shows that resecting endometriomas often leads to a partial or total removal of a healthy ovarian parenchyma, contributing to a decrease in the ovarian reserve (loss of ova) and worsening infertility problems. During the surgery it is often technically impossible to distinguish the diseased region from the healthy parts. Thousands of ova can be accidentally harmed (removed or cauterized). The most commonly prescribed medications are birth control pills, danazol, gestrinone, medroxyprogesterone acetate, GnRH agonists, and aromatase inhibitors. For patients who wish to get pregnant: prioritize treatment/conduct aiming for a pregnancy. In this case, the main goal should be a successful pregnancy as soon as possible, especially in women over 30 years old. This must be done in order to prevent the various, long periods of endometriosis treatments from causing the physiological depletion of the ovarian reserve (loss of quality and quantity of ova over time) and consequently creating future infertility problems. A pregnancy in a woman with endometriosis contributes to lowering the intensity of the disease through a long period without menstruating that can make the regions with the disease atrophy. Assisted reproductive treatment aims to help a couple get pregnant. The most popular techniques are in vitro fertilization (IVF or a "test tube baby") and intrauterine (or artificial) insemination.