In endometriosis functioning endometrial tissue is implanted outside the uterine cavity. Symptoms depend on the localization of the implants and can dysmenorrhea, dyspareunia, infertility, dysuria and pain during defecation include. The severity of symptoms depends not on the stage of the disease. The diagnosis is made by biopsy, which is usually obtained by laparoscopy. The treatment consists of anti-inflammatory drugs, drugs that suppress ovarian function and growth of endometrial tissue, surgical removal and excision of endometriosis lesions and – in severe illness and completed their families – hysterectomy with oophorectomy.
Endometriosis is usually confined to the peritoneal or serous surfaces of pelvic organs, v. a. the ovaries, the ligaments. lata, rear Douglas space and ligaments. Sacrouterina. the tubes, serous surfaces of small and large intestine, ureters, bladder, vagina, cervix, surgical scars, pleura and pericardium are rarely affected. Bleeding from Peritonealimplantaten be held responsible for triggering inflammation, attracts the fibrin deposits, adhesions and eventually scarring after themselves, so that the peritoneal surfaces and the pelvic anatomy are distorted.
In endometriosis functioning endometrial tissue is implanted outside the uterine cavity. Symptoms depend on the localization of the implants and can dysmenorrhea, dyspareunia, infertility, dysuria and pain during defecation include. The severity of symptoms depends not on the stage of the disease. The diagnosis is made by biopsy, which is usually obtained by laparoscopy. The treatment consists of anti-inflammatory drugs, drugs that suppress ovarian function and growth of endometrial tissue, surgical removal and excision of endometriosis lesions and – in severe illness and completed their families – hysterectomy with oophorectomy. Endometriosis is usually confined to the peritoneal or serous surfaces of pelvic organs, v. a. the ovaries, the ligaments. lata, rear Douglas space and ligaments. Sacrouterina. the tubes, serous surfaces of small and large intestine, ureters, bladder, vagina, cervix, surgical scars, pleura and pericardium are rarely affected. Bleeding from Peritonealimplantaten be held responsible for triggering inflammation, attracts the fibrin deposits, adhesions and eventually scarring after themselves, so that the peritoneal surfaces and the pelvic anatomy are distorted. There are different data on the prevalence, but is probably among all women at about 6-10%, among infertile women at 25-50%, and among women with chronic pelvic pain at 75-80%. The average age at diagnosis is 27 years, but the endometriosis is also in adolescents. The incidence is increased in women who have relatives first-degree relative with endometriosis have postpone pregnancy to later time, shorter cycles (<27 days) with heavy bleeding and abnormally prolonged bleeding time (> 8 days) have or have abnormalities of Müller gangs , Etiology and Pathophysiology The widest acceptance is the hypothesis that endometrial cells are transported from the uterine cavity and eventually grow to ectopic sites. A retrograde flow of menstrual tissue through the tubes could transport endometrial cells into the abdominal cavity; through the circulation of lymph or blood could endometrial cells to distant locations arrive (z. B. pleural cavity). Another hypothesis is based on a metaplasia of the peritoneal tissue, after which coelomic epithelium is converted to endometrium-like glands. Microscopic endometriotic lesions consist of glands and stroma which are identical with intrauterine endometrium. This tissue contains estrogen – and progesterone receptors, so they grow depending on the hormone levels during the menstrual cycle, differentiate and bleed; next to these tissues can also produce estrogen and prostaglandins. The herd can be self-sufficient or regress, as may occur during pregnancy (probably due to the high levels of progesterone). Finally, it comes through the herd to inflammation and an increase of activated macrophages and the production of proinflammatory cytokines. Since endometriosis first-degree relatives of women with endometriosis occurs more often in relatives, it is believed that heredity may play a role. often there is a infertility in patients with severe endometriosis and pelvic anatomy spoiled, possibly because the spoiled anatomy affects the Eifang- and transport mechanism through the tubes. The reasons why some patients are infertile with little endometriosis and normal pelvic anatomy are unclear; possibly of these conditions can affect fertility: Increased incidence of luteinized, nichtrupturierten follicles ( “trapped oocytes”) increase in peritoneal prostaglandin production and the peritoneal micro phage activity, which can lead to impaired sperm and Oozytenfunktion Missing Nidationsbereitschaft the endometrium (because of progesterone resistance, luteal insufficiency or other disorders) factors that can apparently protect against endometriosis, multiple pregnancies, taking low-dose oral contraceptives (continuous or cyclical) and regular physical activity (especially in the beginning before the age of 15, a frequency of> 4 hours / week or two). Symptoms and complaints Cyclic pain in the midline of the pelvis, especially before or during menstruation and during intercourse, are typical and can be progressive. Adnexal tumors and infertility are also typical. Irregular bleeding may occur. Some women with extensive endometriosis have no symptoms; others with minimal disease have extremely severe pain. Dysmenorrhea is an important diagnostic sign, especially after several years of relatively painless menses. Often improve or resolve the symptoms during pregnancy. Depending on the location of the herd may lead to different symptoms. Colon: pain during defecation, feeling of fullness in the abdomen, diarrhea or constipation or rectal bleeding during menses bladder: dysuria, hematuria and / or suprapubic pain (particularly during urination) ovaries: endometrioma (2-10 cm large cystic tumor of the ovary) who occasionally ruptured or leaking and abdominal pain and adnexal structures caused Peritonitissymptome: Adnexadhäsionen, which can lead to a pelvic tumor or pain structures outside the pool (occasionally) diffuse pain in the abdomen, the pelvic exam findings may be normal; possible findings can a retroverted, fixed uterus, enlarged ovaries and a stationary resistance of the ovary, thickening of the rectovaginal septum, hardening in the Douglas-space node to the ligaments. be Sacrouterina and / or adnexal masses. Less often flock to the vulva or cervix or in the vagina, to find in the navel or in surgical scars. Diagnostic biopsy, usually laparoscopically Sometimes imaging tests are saved (for monitoring the progression), but not for diagnostic purposes, the diagnosis is based on the typical symptoms, but must by biopsy (usually via laparoscopy, but sometimes laparotomy), vaginal examination, sigmoidoscopy or cystoscopy , The macroscopic appearance (. Eg transparent, red, brown, black) and the size of the herd change in the course of the menstrual cycle; on the pelvic peritoneum, typical endometriosis foci as point-like red, blue or reddish brown spots> 5 mm in diameter is (often called Schmauchflecken). The diagnosis of endometriosis requires the microscopic identification of both endometrial glands and -stroma. Imaging tests (eg., Ultrasound, barium enema, iv urography, CT, MRI) are not specific or useful for diagnosis, to make the diagnosis. But occasionally they show the extent of endometriosis and can therefore be used for the diagnosis to monitor the disease. Although the CA-125 value in the serum can be increased, but the determination of the value is useful for either diagnosis or treatment. Tests for other causes of infertility are sometimes indicated (infertility). The severity classification (staging) helps the doctor to choose a treatment plan and to evaluate the therapeutic results. After the division of the American Society for Reproductive Medicine endometriosis is according to the number, location, and depth of penetration of the flock and the presence of endometrioma and veil-like dense adhesions or in the stage I (minimal), II (light), III (mäßiggradig) or divided IV (difficult) (see table: classification of severity of endometriosis). Classification of severity of endometriosis stage expression Description I Minimal Some superficially located herd II light always something deeper implants III Mäßiggradig Many deep penetrating herd, small endometriomas on one or both ovaries and some hazy adhesions IV heavy Many deep penetrating herd, large endometriomas on one or both ovaries and many dense adhesions, often adhesion of the rectum to the rear wall of the uterus The Endometriosis Fertility Index (EFI), a new staging system was developed for women who due their endometriosis are infertile; The index provides information on the probability of pregnancy after different treatments. The EFI into account the woman’s age, the number of infertile years, any pregnancies and to evaluate the residual functionality (Least Function Score) of the two tubes, tubal fimbriae and ovaries as well as endometriosis (hearth and total) score of the American Society for Reproductive Medicine. NSAIDs treatment against pain medicines to suppress ovarian function Conservative surgical resection or ablation of endometrial tissue, with or without drug Total abdominal hysterectomy with bilateral Salpingoovarektomie serious illness or after menopause age Symptomatic treatment begins with NSAIDs. A more definitive treatment must be individualized; it depends on the age of the patient, their symptoms, their desire to preserve the fertility and extent of the disease from. Medications and conservative surgical procedures are symptomatic approaches; in the majority of patients, the endometriosis returns within 6 months to 1 year, when treatment is discontinued, unless ovarian function is completely abolished. Drug therapy drugs that suppress ovarian function, inhibit the growth and activity of endometrial tissue. Such drugs include continuously given oral contraceptives (commonly used), progestins, gonadotropin-releasing hormone (GnRH) agonists and Danazol (see Table: drugs for the treatment of endometriosis). Drugs for the treatment of endometriosis drug dosage side effects Combined oral estrogen-progestin contraceptives ethinyl estradiol 20 ug plus a progestogen continuous administration over a longer period (. 1 Tbl 1 time / day for 4-6 cycles, followed by exposure for 4 days) or cyclic administration (analogous to the use of an oral contraceptive, usually no assumption for a few days to 1 week within one month) increase in Abdominalumfangs, tenderness of breasts, increased appetite, edema, nausea, Pieter De hbruchblutungen, deep vein thrombosis, myocardial infarction, stroke, peripheral vascular disease progestins levonorgestrel-releasing intrauterine device (IUD) Approximately 20 ug / day, gradual reduction to 10 micrograms over 5 years (given the IUD) menstrual irregularity, occasionally amenorrhea (entwicklt with time ), weight gain medroxyprogesterone acetate 20-30 mg po 1 time / day for 6 months, then 100 mg i.m. every 2 weeks for 2 months, then 200 mg / month i.m. for 4 months breakthrough bleeding, mood swings, depression, atrophic vaginitis, myocardial infarction, stroke, peripheral vascular disease, weight gain norethindrone acetate 2.5-5 mg po bedtime irregular menstrual cycles, mood swings, depression, weight gain androgen Danazol 100-400 mg po 2 times / day for 3-6 months weight gain, acne, deepening of the voice, hirsutism, hot flushes, atrophic vaginitis, edema, muscle cramps, breakthrough bleeding, decrease in breast size, mood swings, liver dysfunction, carpal tunnel syndrome, adverse effects on blood lipid levels GnRH agonists * leuprolide 1 mg sc 1 time / day hot flushes, atrophic vaginitis, bone demineralization, mood swings, headaches, weakness, muscle pain leuprolide depot 3.75 mg i.m. every 28 days or 11.25 mg i.m. every 3 months As for s.c. Nafarelin 200-400 micrograms intranasally two times / day hot flushes, atrophic vaginitis, bone demineralization, mood swings, headaches, acne, decreased libido, vaginal dryness, leukopenia * The treatment is limited to ? 6 months. leuprolide is frequently with a gestagen (z. B. norethindrone acetate 2.5-5 mg p.o. 1 time / day) given to prevent bone loss during treatment. GnRH = gonadotropin-releasing hormone. GnRH agonists suppress estrogen production temporarily; However, the duration of treatment is limited to ? 6 months because the prolonged use can cause bone loss. With a treatment duration of> 4-6 months a progestin (add-back therapy as so.) Can equal time be given to keep the bone loss as low as possible. Danazol, a synthetic androgen and Antigonadotropin which inhibits ovulation. Its applicability but is limited by the androgenic side effects. The cyclical or continuous intake of oral contraceptives after discontinuation of danazol or GnRH agonists can slow the progression of the disease and is useful in women who want to postpone pregnancy. If none of these Arzeimittel is effective, an aromatase inhibitor plus a combined contraceptive may be tried; This treatment is sometimes successful. Drug treatment has no effect on the fertility of women with minimal or mild Endometriose.Chirurgische interventions in women with moderate to severe endometriosis, the ablation or excision of as many herds with very substantial preservation of the pelvic structures and the most effective fertility treatment. indications for surgical treatment are detection of endometrioma Significant adhesions of pelvic organs laying of the tubes abdominal pain with a strong reduction of the capacity desire to preserve fertility herd can usually be removed by laparoscopy; In particular, adhesions to the peritoneum or the ovary might be elektrokauterisiert with a laser, removed or vaporized. Endometriomas should be removed because their removal recurrence prevented more effectively as a drainage. After such a treatment, fertility rates are in inverse proportion to the severity of the endometriosis. In case of incomplete resection GnRH agonists can be given perioperatively; However, there is no guarantee that these drugs improve the fertility chances. In some cases, the laparoscopic resection of the ligaments can. Sacrouterina relieve pain in the central pelvic area using electrocautery or laser. At low rectovaginal endometriosis continuous progestin therapy is the most effective treatment. Hysterectomy should usually be reserved for patients with intractable abdominal pain and completed their families. To remove adhesions or herd of uterus or in the pouch of Douglas, ovariectomy is performed in addition to hysterectomy. After hysterectomy with oophorectomy women under 50 years of age should any additional estrogen obtained (eg. As for menopausal symptoms). However, a concomitant continuous progestin therapy (eg. For example medroxyprogesterone acetate 2.5 mg p.o. 1 time / day) often recommended, because the sole administration of an estrogen promotes the growth of residual endometriosis tissue and has a recurrence rate of up to 40% result. If symptoms persist after oophorectomy in women over 50 years, a sole companion, continuous progestin therapy may (medroxyprogesterone acetate 2.5 mg po 1 time / day, micronized progesterone 100-200 mg po at bedtime) can be tried. Summary Endometriosis is a common cause of cyclic pelvic pain, dysmenorrhea and infertility. The endometriosis stage no indication of the severity of symptoms. The diagnosis is usually confirmed by laparoscopic biopsy. Pain to be treated (e.g., with NSAIDs.); depending on the patient’s request with respect to fertility drugs are often given to suppress ovarian function to inhibit the growth and activity of the endometriotic lesions. In mäßiggradiger to severe endometriosis ablation or excision of as many herds to obtain fertility should be considered.