Definition of 1

8/9/2019 Definition of 1

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Definition of Endometrioma

Endometrioma: Part of the condition known as endometriosis. Endometrioma is a type of cyst

formed when endometrial tissue (the mucous membrane that makes up the inner layer of the

uterine wall) grows in the ovaries. It affects women during the reproductive years and may causechronic pelvic pain associated with menstruation.

Endometriosis is the presence of endometrial glands and tissue outside the uterus.

Women with endometriosis may have problems with fertility.

Endometrioid cysts, often filled with dark, reddish-brown blood, may range in size from 0.75-8inches.

Endometrioma is also referred to as an endometrioid cyst.

Endometriosis

From Wikipedia, the free encyclopedia

Endometriosis

Classification and external resources


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Endometriosis (from endo, "inside", and metra, "womb") is a medical condition in females in

which endometrial like cells appear and flourish in areas outside the uterine cavity, mostcommonly on the ovaries. The uterine cavity is lined by endometrial cells, which are under the

influence of female hormones. These endometrial-like cells in areas outside the uterus(endometriosis) are influenced by hormonal changes and respond similarly as do those cells

found inside the uterus. Symptoms often worsen in time with the menstrual cycle.

Endometriosis is typically seen during the reproductive years; it has been estimated that it occurs

in roughly 5% to 10% of women.[1]

Symptoms may depend on the site of active endometriosis.Its main but not universal symptom ispelvic pain in various manifestations. Endometriosis is a

common finding in women with infertility.

Contents

y 1 Symptomso 1.1 Pelvic paino 1.2 Infertilityo 1.3 Other

y 2 Epidemiologyo 2.1 Endometriosis and Smokingo 2.2 Endometriosis and Pregnancyo 2.3 Co-morbidity

y 3 Pathology and locationso 3.1 Complications

y 4 Diagnosiso 4.1 Stagingo 4.2 Markers

y 5 Potential causeso 5.1 Cause of pain

y 6 Treatmentso 6.1 Hormonal medicationo 6.2 Other medicationo 6.3 Surgeryo 6.4 Comparison of medicinal and surgical interventions


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6.4.1 Advantages of medicinal interventions 6.4.2 Disadvantages of medicinal interventions 6.4.3 Advantages of surgery 6.4.4 Disadvantages of surgery

o 6.5 Treatment of infertilityo 6.6 Other treatments

y 7 Prognosiso 7.1 Recurrence

y 8 Endometriosis in the male

Symptoms

Pelvic pain

A major symptom of endometriosis is recurringpelvic pain. The pain can be mild to severecramping that occurs on both sides of the pelvis, to the lower back and rectal area and even down

the legs. The amount of pain a woman feels is not necessarily related to the extent or stage (1through 4) of endometriosis. Some women will have little or no pain despite having extensive

endometriosis affecting large areas or having endometriosis with scarring. On the other hand,women may have severe pain even though they have only a few small areas of endometriosis.

However, pain does typically worsen with severity. Symptoms of endometriosic-related painmay include

[2]:

y dysmenorrhea painful, sometimes disabling cramps; pain may get worse over time(progressive pain), also lower back pains linked to the pelvis

y chronic pelvic pain typically accompanied by lower back pain or abdominal painy dyspareunia painful sexy dyschezia painful bowel movementsy dysuria urinary urgency, frequency, and sometimes painful voiding

Infertility

Many women with infertility have endometriosis. As endometriosis can lead to anatomicaldistorsions and adhesions (the fibrous bands that form between tissues and organs following

recovery from an injury), the causality may be easy to understand; however, the link between

infertility and endometriosis remains enigmatic when the extent of endometriosis is limited.

[3]

Ithas been suggested that endometriotic lesions release factors which are detrimental to gametes orembryos, or, alternatively, endometriosis may more likely develop in women who fail to

conceive for other reasons and thus be a secondary phenomenon; for this reason it is preferableto speak ofendometriosis-associated infertility

[4]in such cases.


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Other

Other symptoms may be present, including:

y nausea, vomiting, fainting, dizzy spells, vertigo[citation needed] or diarrheaparticularly justprior to or during the period or after

y frequent or constant menses flow[citation needed]y chronic fatigue[citation needed]y heavy or long uncontrollable menstrual periods with small or large blood clotsy some women may also suffer mood swings[citation needed]y extreme pain in legs and thighsy back painy mild to extreme pain during intercoursey extreme pain from frequent[citation needed] ovarian cystsy pain from adhesions which may bind an ovary to the side of the pelvic wall, or they mayextend between the bladder and the bowel,uterus, etcy extreme pain with or without the presence of mensesy mild to severe constipation [5]y premenstrual spottingy mild to severe fever

In addition, women who are diagnosed with endometriosis may have gastrointestinal symptomsthat mimic irritable bowel syndrome

Patients who rupture an endometriotic cyst may present with an acute abdomen as a medical

emergency.

Occasionally pain may also occur in other regions. Cysts can occur in the bladder (although rare)and cause pain and even bleeding during urination. Endometriosis can invade the intestine[citation

needed]and cause painful bowel movements or diarrhea.

In addition to pain during menstruation, the pain of endometriosis can occur at other times of the

month and doesn't have to be just on the date on menses. There can be pain with ovulation, painassociated with adhesions, pain caused by inflammation in the pelvic cavity, pain during bowel

movements and urination, during general bodily movement i.e. exercise, pain from standing orwalking, and pain with intercourse. But the most desperate pain is usually with menstruation and

many women dread having their periods. Also the pain can start a week before menses, duringand even a week after menses, or it can be constant. There is no known cure for

endometriosis.[citation needed]

Epidemiology

Endometriosis can affect any female, frompremenarche topostmenopause, regardless of race or

ethnicity or whether or not they have had children. It is primarily a disease of the reproductive


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years. Estimates about its prevalence vary, but 510% is a reasonable number, more common inwomen with infertility (2050%) and women with chronic pelvic pain (about 80%).

[6]As an

estrogen-dependent process, it can persist beyond menopause and persists in up to 40% ofpatients following hysterectomy.[7]

Endometriosis and Smoking

This condition is associated with tobacco smoking in women. The risk of a cyst turning to be

ovarian cancer is extremely high in such conditions especially in women in their 30's. Ovariancysts may indicate advanced endometriosis and often is associated with reduced fertility or

infertility.Smoking causes decreased estrogens with breakthrough bleeding and shortened lutealphases. Smokers have an earlier than normal (by about 1.5-3 years) menopause which suggests

that there is some toxic affect of smoking on the follicles directly. Chemically, nicotine has beenshown to concentrate in cervical mucous and metabolites have been found in follicular fluid and

been associated with delayed follicular growth and maturation. Finally, there is some affect ontubal motility because smoking is associated with an increased incidence of ectopic pregnancy as

well as an increased spontaneous abortion rate.

Endometriosis and Pregnancy

It is quite common for women to pursue educational and career opportunities and put off

childbearing into the late 20's and early 30's. Aging, however, brings with it many effects thatwill decrease fertility. Depletion over time of ovarian follicles affects menstrual regularity.

Endometriosis has more time to produce scarring of the ovary and tubes so they cannot movefreely or it can even replace ovarian follicular tissue if ovarian endometriosis persists and grows.

Leiomyomata (fibroids) can slowly grow and start causing endometrial bleeding that disruptsimplantation sites or distorts the endometrial cavity which affects carrying a pregnancy in the

very early stages. Abdominal adhesions from other intraabdominal surgery, or ruptured ovariancysts can also affect tubal motility needed to sweep the ovary and gather an ovulated follicle

(egg).

Endometriosis in postmenopausal women does occur and has been described as an aggressiveform of this disease characterized by complete progesterone resistance and extraordinarily high

levels of aromatase expression.[8]

In less common cases, girls may have endometriosis symptoms

before they even reach menarche.[9][10]

Co-morbidity

Endometriosis bears no relationship to endometrial cancer. Current research has demonstrated anassociation between endometriosis and certain types of cancers, notably ovarian cancer, non-

Hodgkin's lymphoma andbrain cancer.[11][12][13]

Endometriosis often also coexists withleiomyoma oradenomyosis, as well as autoimmune disorders. A 1988 survey conducted in the


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US found significantly more Hypothyroidism, fibromyalgia, chronic fatigue syndrome,autoimmune diseases, allergies and asthma in women with endometriosis compared to the

general population.[14]

[edit] Pathology and locations

Endoscopic image of endometriotic lesions at theperitoneum of the pelvic wall.

Micrograph of the wall of an endometrioma. All features ofendometriosis are present(endometrial glands, endometrial stroma and hemosiderin-laden macrophages. H&E stain.

Active endometriosis produces inflammatory mediators that cause pain and inflammation, as

well as scarring or fibrosis of surrounding tissue. Triggers of various kinds, including menses,toxins, and immune factors, may be necessary to start this process. Typical endometriotic lesions

show histologic features similar to endometrium, namely stroma, endometrial epithelium, andglands that respond to hormonal stimuli. Older lesions may display no glands but hemosiderin

deposits as residual. To the eye, lesions can appear dark blue or powder-burn black and vary insize; red, white, yellow, brown or non-pigmented. Some lesions within the pelvis walls may not

be visible to the eye, as normal-appearing peritoneum of infertile women reveals endometriosis

on biopsy in 613% of cases.[15]

Additionally other lesions may be present, notablyendometriomas of the ovary, scar formation, and peritoneal defects or pockets. Endometrioma onthe ovary of any significant size (Approx. 2 cm +) must be removed surgically because hormonal

treatment alone will not remove the full endometrioma cyst, which can progress to acute painfrom the rupturing of the cyst and internal bleeding. Endometrioma is sometimes misdiagnosed

as ovarian cysts.


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Early endometriosis typically occurs on the surfaces of organs in the pelvic and intra-abdominalareas. Health care providers may call areas of endometriosis by different names, such as

implants, lesions, or nodules. Larger lesions may be seen within the ovaries as endometriomas or"chocolate cysts", "chocolate" because they contain a thick brownish fluid, mostly old blood.

Endometriosis may trigger inflammatory responses leading to scar formation and adhesions.

Endoscopic image of endometriotic lesions in the Pouch of Douglas and on the right sacrouterineligament.

Most endometriosis is found on these structures in thepelvic cavity where it can produce mild,

moderate, and/or severe pain felt in the pelvis and/or lower back areas. The pain is often moresevere before, during, and/or after the menstrual period:

y Ovaries (the most common site)y Fallopian tubesy The back of the uterus and the posteriorcul-de-sacy The front of the uterus and the anterior cul-de-sacy Uterine ligaments such as the broad or round ligament of the uterusy Pelvic and back wally Intestines, most commonly the rectosigmoidy Urinary bladderand ureters

Bowel endometriosis affects approximately 10% of women with endometriosis, and can cause

severe pain with bowel movements.

Endometriosis may spread to the cervix and vagina or to sites of a surgical abdominal incision.

Less commonly lesions can be found on the diaphragm. Diaphragmatic endometriosis is rare,most always on the right hemidiaphragm, and may inflict cyclic pain of the right shoulder just

before and during menses. Rarely, endometriosis can be extraperitoneal and is found in the lungsand CNS.[16]

Pleural implantations are associated with recurrent right pneumothoraces at times of menses,termed catamenial pneumothorax.

Endometriosis may also present with skin lesions in cutaneous endometriosis.


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Complications

Endoscopic image of a ruptured chocolate cystin left ovary.

Complications of endometriosis include:

y Internal scarringy Adhesions[17]y Pelvic cystsy Chocolate cyst of ovarysy Ruptured cysty Blocked bowel/bowel obstruction

Infertility can be related to scar formation and anatomical distortions due to the endometriosis;

however, endometriosis may also interfere in more subtle ways: cytokines and other chemicalagents may be released that interfere with reproduction.

Complications of endometriosis include bowel and ureteral obstruction resulting from pelvicadhesions. Also,peritonitis from bowel perforation can occur.

Diagnosis

A health history and a physical examination can in many patients lead the physician to suspect

endometriosis. Surgery is the gold standard in diagnosis. However, most insurance plans will notcover surgical diagnosis unless the patient has already attempted to become pregnant and failed.


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Micrograph an endometrioma. H&E stain.

Use of imaging tests may identify endometriotic cysts or larger endometriotic areas. It also may

identify free fluid often within the cul-de-sac. The two most common imaging tests are

ultrasound and magnetic resonance imaging (MRI). Normal results on these tests do noteliminate the possibility of endometriosis. Areas of endometriosis are often too small to be seenby these tests.

The only way to diagnose endometriosis is by laparoscopy or other types of surgery with lesion

biopsy. The diagnosis is based on the characteristic appearance of the disease, and should becorroborated by abiopsy. Surgery for diagnoses also allows for surgical treatment of

endometriosis at the same time.

Although doctors can often feel the endometrial growths during a pelvic exam, and your

symptoms may be telltale signs of endometriosis, diagnosis cannot be confirmed without

performing a laparoscopic procedure. Often the symptoms of ovarian cancer are identical tothose of endometriosis. If a misdiagnosis of endometriosis occurs due to failure to confirmdiagnosis through laparoscopy, early diagnosis of ovarian cancer, which is crucial for successful

treatment, may have been missed.[18]

Staging

Surgically, endometriosis can be staged IIV (Revised Classification of the American Society ofReproductive Medicine).[19] The process is a complex point system that assesses lesions and

adhesions in the pelvic organs, but it is important to note staging assesses physical disease only,not the level of pain or infertility. A patient with Stage I endometriosis may have little disease

and severe pain, while a patient with Stage IV endometriosis may have severe disease and nopain or vice versa. In principle the various stages show these findings:

y Stage I (Minimal)Findings restricted to only superficial lesions and possibly a few filmy adhesions

y Stage II (Mild)In addition, some deep lesions are present in the cul-de-sac

yStage III (Moderate)

As above, plus presence of endometriomas on the ovary and more adhesions

y Stage IV (Severe)As above, plus large endometriomas, extensive adhesions.


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Markers

An area of research is the search for endometriosis markers. These markers are substances made

by or in response to endometriosis that health care providers can measure in the blood or urine. Ifmarkers are found, health care providers could diagnose endometriosis by testing a woman's

blood or urine which might show high levels of estrogen or low levels of progesterone, andreduce the need for surgery. The antigen CA-125 is known to be elevated in many patients withendometriosis[20] but is not specifically indicative of endometriosis.

Research is also being conducted on potential genetic markers associated with endometriosis so

that a saliva-based diagnostic may replace surgical procedures for basic diagnosis.[21]

However,this research remains very preliminary and the diagnostic standard continues to be surgical

intervention.

Potential causes

While the exact cause of endometriosis remains unknown, many theories have been presented tobetter understand and explain its development. These concepts do not necessarily exclude eachother.

1. Estrogens: Endometriosis is a condition that is estrogen-dependent and thus seenprimarily during the reproductive years. In experimental models, estrogen is necessary toinduce or maintain endometriosis. Medical therapy is often aimed at lowering estrogen

levels to control the disease. Additionally, the current research into aromatase, anestrogen-synthesizing enzyme, has provided evidence as to why and how the disease

persists after menopause and hysterectomy.2. Retrograde menstruation: The theory of retrograde menstruation, first proposed by

John A. Sampson, suggests that during a woman's menstrual flow, some of theendometrial debris exits the uterus through the fallopian tubes and attaches itself to theperitoneal surface (the lining of the abdominal cavity) where it can proceed to invade the

tissue as endometriosis. While most women may have some retrograde menstrual flow,typically their immune system is able to clear the debris and prevent implantation and

growth of cells from this occurrence. However, in some patients, endometrial tissuetransplanted by retrograde menstruation may be able to implant and establish itself as

endometriosis. Factors that might cause the tissue to grow in some women but not inothers need to be studied, and some of the possible causes below may provide some

explanation, e.g., hereditary factors, toxins, or a compromised immune system. It can beargued that the uninterrupted occurrence of regular menstruation month after month for

decades is a modern phenomenon, as in the past women had more frequent menstrual restdue to pregnancy and lactation. Sampson's theory certainly is not able to explain all

instances of endometriosis, and it needs additional factors such as genetic or immunedifferences to account for the fact that many women with retrograde menstruation do not

have endometriosis. In addition, at least one study found that endometriotic lesions arebiochemically very different from transplanted ectopic tissue, which casts doubt on

Sampson's theory.[22]


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3. Mllerianosis: A competing theory states that cells with the potential to becomeendometrial are laid down in tracts during embryonic development and organogenesis.

These tracts follow the female reproductive (Mullerian) tract as it migrates caudally(downward) at 810 weeks of embryonic life. Primitive endometrial cells become

dislocated from the migrating uterus and act like seeds orstem cells. This theory is

supported by foetal autopsy.

[23]

4. Coelomic Metaplasia: This theory is based on the fact that coelomicepithelium is the

common ancestor ofendometrial andperitoneal cells and hypothesizes that later

metaplasia (transformation) from one type of cell to the other is possible, perhapstriggered by inflammation.

[1]This theory is further supported by laboratory observation

of this transformation.[24]

5. Genetics: Hereditary factors play a role. It is well recognized that daughters or sisters of

patients with endometriosis are at higher risk of developing endometriosis themselves;for example, low progesterone levels may be genetic, and may contribute to a hormone

imbalance. There is an about 10-fold increased incidence in women with an affected first-degree relative.

[6]A 2005 study published in the American Journal of Human Genetics

found a link between endometriosis and chromosome 10q26.

[25]

One study found that infemale siblings of patients with endometriosis the relative riskof endometriosis is 5.7:1

versus a control population.[26]

6. Transplantation: It is accepted that in specific patients endometriosis can spread

directly. Thus endometriosis has been found in abdominal incisional scars after surgeryfor endometriosis. It can also grow invasively into different tissue layers, i.e., from the

cul-de-sac into the vagina. On rare occasions endometriosis may be transplanted bybloodor by the lymphatic system into peripheral organs such as the lungs andbrain.

7. Immune system: Research is focusing on the possibility that the immune system may notbe able to cope with the cyclic onslaught of retrograde menstrual fluid. In this context

there is interest in studying the relationship of endometriosis to autoimmune disease,allergic reactions, and the impact oftoxins.

[27]It is still unclear what, if any, causal

relationship exists between toxins, autoimmune disease, and endometriosis.8. Environment: There is a growing suspicion that environmental factors may cause

endometriosis, specifically some plastics and cooking with certain types of plasticcontainers with microwave ovens.

[28]Other sources suggest that pesticides and hormones

in our food cause a hormone imbalance.9. irth Defect: In rare cases where imperforate hymen does not resolve itself prior to the

first menstrual cycle and goes undetected, blood and endometrium are trapped within theuterus of the patient until such time as the problem is resolved by surgical incision. Many

health care practitioners never encounter this defect, and due to the flu-like symptoms itis often misdiagnosed or overlooked until multiple menstrual cycles have passed. By the

time a correct diagnosis has been made, endometrium and other fluids have filled theuterus and fallopian tubes with results similar to retrograde menstruation resulting in

endometriosis. The initial stage of endometriosis may vary based on the time elapsedbetween onset and surgical procedure.

Cause of pain


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The way endometriosis causes pain is the subject of much research. Because many women withendometriosis feel pain during or around their periods and may spill further menstrual flow into

the pelvis with each menstruation, some researchers are trying to reduce menstrual events inpatients with endometriosis.

Endometriosis lesions react to hormonal stimulation and may "bleed" at the time ofmenstruation. The blood accumulates locally, causes swelling, and triggers inflammatoryresponses with the activation ofcytokines. It is thought that this process may cause pain.

Pain can also occur from adhesions (internal scar tissue) binding internal organs to each other,

causing organ dislocation. Fallopian tubes, ovaries, the uterus, the bowels, and the bladder can bebound together in ways that are painful on a daily basis, not just during menstrual periods.

Treatments

While there is no cure for endometriosis,[citation needed]

in many patients menopause (natural or

surgical) will abate the process. In patients in the reproductive years, endometriosis is simplymanaged: the goal is to provide pain relief, to restrict progression of the process, and to relieveinfertility if that should be an issue. In younger women with unfulfilled reproductive potential,

surgical treatment tends to be conservative, with the goal of removing endometrial tissue andpreserving the ovaries without damaging normal tissue. In women who do not have need tomaintain their reproductive potential, hysterectomy and/or removal of the ovaries may be an

option; however, this will not guarantee that the endometriosis and/or the symptoms ofendometriosis will not come back, and surgery may induce adhesions which can lead to

complications.

In general, patients are diagnosed with endometriosis at time of surgery, at which time ablative

steps can be taken. Further steps depend on circumstances: patients without infertility can bemanaged with hormonal medication that suppress the natural cycle and pain medication, whileinfertile patients may be treated expectantly after surgery, with fertility medication, or with IVF.

Sonography is a method to monitor recurrence of endometriomas during treatments.

Treatments for endometriosis in women who do not wish to become pregnant include:

Hormonal medication

y Progesterone orProgestins: Progesterone counteracts estrogen and inhibits the growth ofthe endometrium. Such therapy can reduce or eliminate menstruation in a controlled andreversible fashion. Progestins are chemical variants of natural progesterone.

y Avoiding products with xenoestrogens, which have a similar effect to naturally producedestrogen and can increase growth of the endometrium.

y Hormone contraception therapy: Oral contraceptives reduce the menstrual pain associatedwith endometriosis.

[29]They may function by reducing or eliminating menstrual flow and

providing estrogen support. Typically, it is a long-term approach. Recently Seasonale was

FDA approved to reduce periods to 4 per year. Other OCPs have however been used like


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this off label for years. Continuous hormonal contraception consists of the use ofcombined oral contraceptive pills without the use of placebo pills, or the use ofNuvaRing

or the contraceptive patch without the break week. This eliminates monthly bleedingepisodes.

y Danazol (Danocrine) and gestrinone are suppressive steroids with some androgenicactivity. Both agents inhibit the growth of endometriosis but their use remains limited asthey may cause hirsutism and voice changes.

y Gonadotropin Releasing Hormone (GnRH) agonist: These agents work by increasing thelevels ofGnRH. Consistent stimulation of the GnRH receptors results in downregulation,inducing a profound hypoestrogenism by decreasing FSH and LH levels. While effective

in some patients, they induce unpleasant menopausal symptoms, and over time may leadto osteoporosis. To counteract such side effects some estrogen may have to be given back

(add-back therapy). These drugs can only be used for six months at a time.o Lupron depo shot is a GnRH agonist and is used to lower the hormone levels in

the woman's body to prevent or reduce growth of endometriosis. The injection isgiven in 2 different doses a once a month for 3 month shot with the dosage of

(11.25 mg) or a once a month for6

month shot with the dosage of (3.75 mg).

[30]

y Aromatase inhibitors are medications that block the formation of estrogen and have

Other medication

y NSAIDs Anti-inflammatory. They are commonly used in conjunction with other therapy.For more severe cases narcotic prescription drugs may be used. NSAID injections can behelpful for severe pain or if stomach pain prevents oral NSAID use.

y MST Morphine sulphate tablets and other opioid painkillers work by mimicking theaction of naturally occurring pain-reducing chemicals called endorphins. There are

different long acting and short acting medications that can be used alone or in

combination to provide appropriate pain control.y Diclofenac in suppository or pill form. Taken to reduce inflammation and as an analgesic

reducing pain.

Surgery

Procedures are classified as

y conservative when reproductive organs are retained,y semi-conservative when ovarian function is allowed to continue, andy radical when the uterus and ovaries are removed.

Conservative therapy consists of removal, excision or ablation of endometriosis, adhesions,resection of endometriomas, and restoration of normal pelvic anatomy as much as is possible.

[3]

Radical therapy in endometriosis removes the uterus (hysterectomy) and tubes and ovaries

(bilateral salpingo-oophorectomy) and thus the chance for reproduction. Radical surgery isgenerally reserved for women with chronic pelvic pain that is disabling and treatment-resistant.

Not all patients with radical surgery will become pain-free.


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Semi-conservative therapy preserves a healthy appearing ovary, and yet, it also increases the riskof recurrence.

[32]

For patients with extreme pain, apresacral neurectomy may be indicated where the nerves to the

uterus are cut. However, strong clinical evidence showed that presacral neurectomy is more

effective in pain relief if the pelvic pain is midline concentrated, and not as effective if the painextends to the left and right lower quadrants of the abdomen.[3]

This is due to the fact that thenerves to be transected in the procedure are innervating the central or the midline region in the

female pelvis. Furthermore, women who had presacral neurectomy have higher prevalence ofchronic constipation not responding well to medication treatment because of the potential injury

to the parasympathetic nerve in the vicinity during the procedure.

Comparison of medicinal and surgical interventions

Efficacy studies show that both medicinal and surgical interventions produce roughly equivalentpain-relief benefits. Recurrence of pain was found to be 44 and 53 percent with medicinal and

surgical interventions, respectively.[6]

However, each approach has its own advantages anddisadvantages.

[1]

Advantages of medicinal interventions

1. Decrease initial cost2. Empirical therapy (i.e. Can be easily modified as needed)3. Effective for pain control

Disadvantages of medicinal interventions

1.

Adverse effects are common2. Not likely to improve fertility3. Some can only be used for limited periods of time[citation needed]

Advantages of surgery

1. Has significant efficacy for pain control.[33]2. Has increased efficacy over medicinal intervention for infertility treatment3. Combined with biopsy, it is the only way to achieve a definitive diagnosis

Disadvantages of surgery

1. Cost2. Risks are "poorly defined... and probably underestimated." In one study, 3-10%

experienced major complications from surgery.[34]

3. Efficacy is questionable. In the same study, substantial short-term pain relief was

experienced by approximately 70-80% of the subjects. However, at 1 year follow-up,approximately 50% of the subjects needed analgesics or hormonal treatments.

[34]


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Treatment of infertility

While roughly similar to medicinal interventions in treating pain, the efficacy of surgery is

especially significant in treating infertility. One study has shown that surgical treatment ofendometriosis approximately doubles the fecundity (pregnancy rate).

[35]The use of medical

suppression after surgery for minimal/mild endometriosis has not shown benefits for patientswith infertility.

[4]Use of fertility medication that stimulates ovulation (clomiphene citrate,

gonadotropins) combined with intrauterine insemination (IUI) enhances fertility in these

patients.[4]

In-vitro fertilization (IVF) procedures are effective in improving fertility in many women withendometriosis. IVF makes it possible to combine sperm and eggs in a laboratory and then place

the resulting embryos into the woman's uterus. The decision when to apply IVF inendometriosis-associated infertility takes into account the age of the patient, the severity of the

endometriosis, the presence of other infertility factors, and the results and duration of pasttreatments.

Other treatments

y Eating foods high in indole-3-carbinol, such as cruciferous vegetables appears to behelpful in balancing hormones and managing pain,

[36]as do omega 3 fatty acids,

particularly EPA.[37]

The use of soy has been reported to both alleviate pain and to

aggravate symptoms, making its use questionable.[38]y Physical therapy for pain management in endometriosis has been investigated in a pilot

study suggesting possible benefit.[39]

Physical exertion such as lifting, prolonged standingor running does exacerbate pelvic pain. Use of heating pads on the lower back area, may

provide some temporary relief.

Prognosis

Proper counseling of patients with endometriosis requires attention to several aspects of thedisorder. Of primary importance is the initial operative staging of the disease to obtain adequate

information on which to base future decisions about therapy. The patient's symptoms and desirefor childbearing dictate appropriate therapy. Not all therapy works for all patients. Some patients

have reoccurrences after surgery or pseudo-menopause. In most cases, treatment will givepatients significant relief from pelvic pain and assist them in achieving pregnancy.

[40]It is

important for patients to be continually in contact with their physician and keep an open dialogthroughout treatment. This is a disease without a cure but with the proper communication, one

with endometriosis can attempt to live a normal, functioning life.

Recurrence

The underlying process that causes endometriosis may not cease after surgical or medicalintervention, and the annual recurrence rate is given as 520 % per year reaching eventually

about 40% unless hysterectomy is performed or menopause reached.[3]

Monitoring of patients


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consists of periodic clinical examinations and sonography. Also, the CA 125 serum antigenlevels have been used to follow patients with endometriosis.

Endometriosis in the male

Endometriosis has been described in men receiving a very high estrogen medication (TACE) aspart of treatment for prostatic cancer.[41]

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Definition of 1