What is it?

The name endometriosis comes from the word endometrium, i. e. the mucous membrane that lines the uterus.

It is this same mucous membrane that thickens during the cycle at ovulation to allow receiving the egg if there is fecundation. When this phenomenon does not exist, the tissue will detach 14 days later and this will create the periods.
In some women, endometrial-like cells are found inside the abdomen. One of the hypotheses is that blood flows back into the abdomen through the fallopian tubes during menstruation. These cells are then able to expand and create new tissues. This is called Endometriosis.
Endometriosis can occur throughout the abdominal cavity: on the peritoneum (the membrane that surrounds the abdominal cavity), the bladder, fallopian tubes, uterosacral ligaments (located behind the uterus), the digestive tube… There are even exceptional types of remote lesions as far as in the lung.

Who is affected?

The diagnosis of endometriosis can be suspected in any woman having her period. It is estimated that 10% of the general female population is affected by Endometriosis. But Endometriosis is observed in 40% of women with chronic pelvic pain.

There is no identified family form.
Nevertheless, several genes are studied by comparing populations of women with endometriosis with women who are not ill. Some initial results are promising and could in the distant future serve as a diagnostic or prognostic tool.

How does it work?

In case of Endometriosis, endometrium-like tissue develops inside the abdomen. With each cycle, these cells become saturated with blood and cause a surrounding inflammatory reaction.
This ground is then ideal for the evolution of the endometriosis tissue, i. e. for the growth of the tissue. Through this mechanism endometriosis can unfortunately reach several organs such as the intestines and bladder, for example.
But this inflammatory reaction will generate the creation of scar tissue. It’s fibrosis.
This scar can create nodules and adhesions between organs. The mobility loss between organs can be painful for women.
As a result, the symptoms of endometriosis will evolve over the course of a person’s life.
They stabilize at the time of menopause. The discomfort that exists during menstruation will disappear. But all the endometriosis symptoms caused by “fibrosis” will persist.

Is it serious?

Endometriosis affects many people.
Inserm refers to Endometriosis as benign metastases. But there is no malignant transformation comparable to cancers. Nevertheless, some damages can be severe.

Symptoms

Endometriosis can be found anywhere inside the abdomen. Its progression (location and rapidity) is unpredictable. The inflammatory phase related to the cycle can result in symptoms that are very different from the fibrosis phase. Thus, a patient with endometriosis may have differing symptoms over the cycles.

Very often women talk about painful menstruations (Dysmenorrhoea).The other most common symptoms are pain in other parts of the abdomen, urinary pain, constipation or diarrhea.

But there may be symptoms that occur apart from menstruation:pain during sexual intercourse (dyspareunia), abdominal pain, back pain (lumbago), pain underneath the ribs….
The disease sometimes develops like a tumor and affects organs: the rectum and generates bleeding in the stool (rectorragies); the bladder and causes bleeding when urinating (hematuria), ureters with an impact on the kidneys and pain in the lumbar fossa (ureterohydronephrosis).
The discomfort experienced is not proportional to the damage. A woman may have no pain despite a very severe endometriosis and, on the other hand, a woman may have a small nodule of endometriosis and be in great pain.
To conclude, it is important to remember that women with endometriosis may have no symptoms at all.

Diagnostics

As we have already said, endometriosis can be found everywhere inside the abdominal area. In addition, endometriosis does not follow a linear progression. The inflammatory phase related to the cycle can result in symptoms that are very different from the fibrosis phase. Thus, a patient with endometriosis may experience different symptoms over the cycles.

Very often women talk about painful, abundant periods. There may be different forms of discomfort in endometriosis: abdominal pain in different parts of the body, urinary pain, constipation or diarrhea.
But endometriosis creates scars inside the abdomen that can cause pain outside the menstrual period because of fibrosis. The most frequently reported symptoms are pains during sexual intercourse (dyspareunia), abdominal pain, back pain ( lumbago), pain underneath the ribs….
In the end, endometriosis disease sometimes develops like a tumor and affects organs: the rectum and generates bleeding in the stool (rectorragies); the bladder and causes bleeding when urinating (hematuria); ureters with an impact on the kidneys and pain in the lumbar fossa (ureterohydronephrosis).
It is impossible to make an exhaustive list of symptoms because the effects of endometriosis are very diverse.
Furthermore, the discomfort experienced is not proportional to the damage. A woman may have no pain despite a very severe endometriosis and, on the other hand, a woman may have a small nodule of endometriosis and be in great pain.
To conclude, it is important to remember that women with endometriosis may have no symptoms at all.

Treatments

There is no such thing as “an” endometriosis disease because the conditions and symptoms are very diverse.

An action on the hormonal cycle is essential in order to interrupt the evolution mechanism of Endometriosis.For this purpose, medical treatments are used. The objective is to completely stop the periods.

There may be pains for which physiotherapy and osteopathy no longer have to prove their effectiveness.
Sophrology and psychology also have a very important part in helping women with endometriosis as a chronic disease that requires learning to live with and handle pain.

Good physical condition and in some cases changes in diet dramatically improve the well-being of women suffering from Endometriosis. In a similar manner, homeopathy is sometimes beneficial.
The support of a sexologist can be very useful for both the patient and her partner.
Finally, surgery also has its place in the therapeutic options in three situations: when certain organs are affected, in second-line treatment when medical care is not sufficient to relieve the patient and finally in assisted reproduction.

Medical treatment

Obviously, among the options are the analgesic drugs we will not discuss here.
The purpose of the treatment is to stop the periods. There are several ways to achieve this and it may sometimes require several attempts to find the right treatment for a patient. In 2017, new recommendations were published to guide the practitioner along the way.
Many therapeutic groups are available: single-phase estrogen-progestins sometimes used in continuous-flow therapy, micro-progestins or progestins, LHRH analogues.
There are currently no studies on the usage of Ulipristal so we will not discuss it here.

Surgical treatment

Surgery will most often be carried out by video-surgery, whether by conventional laparoscopy or by video robot-assisted surgery.
Endometriosis surgery is performed when non-invasive treatments are not sufficient to relieve a woman suffering from endometriosis.
The resulting surgery will be performed that will attempt to completely eliminate the disease. All affected organs shall be treated. Therefore, this procedure may involve major surgery such as resection of a part of the large intestine which may require an artificial intestinal outlet for a few months (stoma), resection of a part of the bladder with a urinary catheter for a while, resection of a part of the ureter, i.e. the tube between the kidney and the bladder…

Surgery is never offered as a first-line option except in cases of organ damage or for the management of fertility disorders It will always be preceded by a clear discussion with the surgeon who will detail to each patient the specificity of her case and the estimated risks incurred.

Classification

The most commonly used classification is the American Fertility Society classification, abbreviated as AFS.

It ranges from stage I to IV, stage IV being the most severe. It is defined by a score that can only be assessed by laparoscopy. Nevertheless, some typical lesions can be used to define a woman suffering from stage IV endometriosis.
This classification can be used to substantiate a case to obtain an LDD (Long Duration Disease).

Fertility

Endometriosis is one of the main causes of female infertility. It is sometimes ignored for a long time. Some consider that 1/3 of endometriosis patients will experience fertility problems.

As part of the care of this infertility, several check-ups are offered to the patient. Whether or not endometriosis is known, laparoscopy (i.e. video surgery) can be used to both confirm the diagnosis and treat endometriosis. In the process, the surgeon will evaluate the tubes visually but also functionally through the so-called blue test.The procedure involves introducing a blue liquid into the uterine cavity as part of the process. This dye must come out through the orifice of the tube to ensure its permeability, an essential step for natural fertilization.
Generally speaking, the fertility of women with endometriosis is slightly reduced. For instance, we find that there are 10% more miscarriages.
It is likely that there would be biological and physiological differences that may lead to changes in endometrial or ovarian response.

Nevertheless, thanks to medical care, women with endometriosis can in the vast majority of cases have children and normal pregnancies.

Healing

Endometriosis is a multifaceted disease.
The medical care of a woman with endometriosis is a comprehensive care, including psychological support. A woman cannot be guaranteed that the disease has been completely eradicated, even after surgery. Nevertheless, surgery remains nowadays the only way to “cure” endometriosis, i.e. to eliminate the lesions.
As such many women are “cured” of their endometriosis.

Sexuality

One of the most common symptoms of endometriosis is pain during sexual intercourse. Simply, abdominal pains do not encourage people to have a sexual life.
Unfortunately, it is a subject that is seldom discussed in consultation, although it is one of the most frequent problems.

Anatomically, damage to an area called the pouch of Douglas is most often responsible for symptoms during sexual intercourse, but it can also be caused by a pre-existing lesion between the bladder and the uterus.
But sex life cannot be reduced to an anatomical lesion. Especially since the discomfort caused can be a severe pain that will gradually wither away the couple’s life.

It is essential that a woman with endometriosis do not ignore these symptoms called dyspareunia and discuss them with her doctor, even if she feels uncomfortable doing so. The intensity of her pain, physical or psychological, will be essential in the therapeutic orientation she will be offered. Simultaneously, support by a sexologist can help preserve sexuality within the couple through romantic games and thus not affect the relationship.

Couple

Endometriosis is a chronic disease as well as cyclical.

Each month, a woman with endometriosis will experience an upsurge in her symptoms. In addition, this woman may experience severe pain during sexual intercourse, which can gradually cloud her sex life until it disappears.
As a result, her intimate relationship can be destabilized.
Endometriosis is a little-known disease. Explaining it to a spouse is not always easy. And get him to come to a gynecological consultation even less….
The help of a sexologist can be salutary.

Depression

Endometriosis and doctor

LLD/Therapeutic part-time

Long-Duration Diseases (LDD) are pathologies that are 100% reimbursed by the French social security system. They are defined by Article L-324.
In some cases, a woman with endometriosis may benefit from this coverage. The request must be made by the medical consultant as “Off-list exonerator”, i.e. “a serious disease of disabling or progressive form that involves long-term treatment lasting more than 6 months and costly therapy”.
This approach can facilitate access to therapeutic half-time, for example.

The medical consultant updates the protocol with the French social security system so that the LDD coverage can be renewed. The request must be made three months before the expiration date.

HFIU

There are many types of endometriosis disease. In many cases, there is a lesion between the vagina and rectum.
This lesion may be a smaller or larger nodule. Even small, given this sensitive location, it may require treatment.

Modern medicine seeks to limit surgical indications as much as possible and tries to develop new techniques.

One of them called HIFU looks promising. This means “High Intensity Focused Ultrasound”. It is currently under evaluation in Lyon by Professor Dubernard. This involves using very high frequency ultrasound to treat a posterior nodule.
As we speak, it is the princeps study, but the very first results seem encouraging. However, it is premature to recommend it.

Reference centers

This is a fairly recent concept, formalized in the recommendations for professional practice, drafted by the “collège national des gynécologues et obstétriciens de France” in a recent text presented in December 2017.The reference center brings together various professionals which are both interested and used to treat women with endometriosis. Thus, treatment can be coordinated and multidisciplinary.

Tumeur

Les ultrasons à l'essai pour traiter les tumeurs bénignes du sein.

Opération

Aliquam erat volutpat. Morbi nibh ex, tempus id ipsum id, dictum venenatis.