Endometriosis Overview

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Endometriosis Overview

Updated: 30-July-2024

Introduction

Endometriosis is a common yet complex gynaecological inflammatory disease characterised by the growth of endometrial-like tissue outside the uterus (endometrium). As a chronic inflammatory disease, it is also found more often in women with other inflammatory diseases (interstitial cystitis, pelvic inflammatory disorder, irritable bowel syndrome).

Globally endometriosis affects around 190 million women worldwide, impairing quality of life both physically and mentally.1,2 These women, including some adolescents, are predominantly of reproductive age, of which 30 to 40% will suffer from infertility and or chronic pelvic pain.3,4

Male partners can have a positive impact on the symptoms of pain and psychological health of their partner, simply by taking an interest in their condition, and accompanying them to appointments

Source: Facchin F, et al. (2021)

Common locations for endometriotic lesions include:

  • Ovaries
  • Uterine ligaments
  • Pouch of Douglas
  • Bladder wall
  • Bowel serosa
  • Fallopian tube mucosa
  • Myometrium

Clinically speaking endometriotic lesions are classified into 3 subtypes, based on location and histopathology examination.

  1. Superficial endometriosis occurs on the uppermost layer of soft tissues of the peritoneum or internal organs.
  2. Deep infiltrating endometriosis which invades the muscular muscles of the organs.
  3. Ovarian endometriotic cysts, also known as endometriomas (or chocolate cysts), which are attached to the ovaries.

The size and location of these, along with any adhesions, determines the severity of endometriosis according to the rASRM (revised American Society for Reproductive Medicine), which is the most common classification system for endometriosis.5

The rASRM scoring system classifies endometriosis into 4 types:

Stage 1 – Minimal Endometriosis
Stage 2 – Mild Endometriosis
Stage 3 – Moderate Endometriosis
Stage 4 – Severe Endometriosis

However, this scoring system has well known limitations, primarily poor predictive power of pregnancy following surgery, compared to alternative systems.

In fact, the severity of pain or likelihood of infertility does not correlate with the rASRM classification of endometriosis
Source: Zondervan K T, et al. (2020)

In addition, the endometrium of women with endometriosis differs significantly. Increased inflammation, altered microbiome composition, resistance to progesterone and in situ estrogen production, is believed to affect sperm motility, embryo fertilization and or implantation.6,7,8,9,10

Whilst subtle Fallopian tube abnormalities found in 70.9% of women with endometriosis, hinders the transport of the oocyte and fertilisation.

Source: Zheng X, et al. (2021)

Studies show women with endometriosis are also more likely to have blocked fallopian tubes. Even when compared to infertile women without endometriosis.11,12,13 Mayrhofer et al. reports the risk of blocked fallopian tubes is higher according to the severity of endometriosis (rASRM stage III or IV).14

Symptoms of Endometriosis

The most common symptoms of Endometriosis are:

  • Chronic pelvic pain or back pain.
  • Dysmenorrhea (painful periods).
  • Dyspareunia (painful intercourse).
  • Pain with urination, full bladder or bowel movements.
  • Dyschezia (constipation)
  • Menorrhagia (excessive bleeding during menstrual period).
  • Infertility

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Other symptoms, particularly during menstruation, such as bloating, nausea, diarrhoea, constipation and fatigue may also be present. Although the severity of these symptoms is not an indication of the severity of the disease.

Importantly, between 6% to 43.3% of women are asymptomatic (no symptoms) with the presence of the endometriosis lesions only found while undergoing abdominal surgeries for reasons not linked to endometriosis.15

Risks Associated with Endometriosis

Women diagnosed with endometriosis are at higher risk of other diseases.

These include:

  • Ovarian cysts
  • Uterine fibroids
  • Endometrial polyps
  • Pelvic Inflammatory Disease (including endometritis)
  • Inflammatory Bowel Disease
  • Infertility or delay in conceiving
  • Pregnancy loss
  • Complications during pregnancy (venous thrombosis, pre-eclampsia, placenta previa, placental abruption, caesarean section)
  • Interstitial cystitis
  • Urinary Tract Infection (including cystitis)
  • Irritable Bowel Syndrome
  • Constipation / dyschezia
  • Skin issues (eczema and dermatitis)
  • Mental illnesses (stress, anxiety, depression)
  • Fatigue / chronic fatigue syndrome / neurasthenia
  • Restless Leg Syndrome
  • Fibromyalgia
  • Headaches
  • Ovarian / tubal cancer
  • Endometrial cancer
  • Breast cancer
  • Skin cancer (melanoma)
  • Thyroid disorders (Hashimoto thyroiditis)16
  • Autoimmune disorders (Systemic Lupus Erythematosus, Rheumatoid Arthritis, Ankylosing spondylitis, Sjogren’s syndrome, Multiple Sclerosis, Coeliac disease)17

Although more research is continually being done understanding the link between endometriosis and comorbidities, the underlying theme is diseases of an inflammatory nature.18,19

Some of these can be treated independent of endometriosis (e.g. endometritis, fibroids, UTI) and has been shown to improve markers of endometriosis (CA-125).20

Causes of Endometriosis

The exact cause of endometriosis is still unknown, however there are 5 main theories:

  • Retrograde menstruation
  • Coelomic Metaplasia
  • Embryonic Rests
  • Lymphovascular metastasis
  • Stem Cell Origin
  • Low testosterone

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Diagnosis of Endometriosis

See a doctor if you have any typical symptoms of endometriosis regardless of age. It is not uncommon to diagnose girls as young as 12 with endometriosis.21

It is important to find a doctor experienced with endometriosis and similar conditions to minimise a possible delay in diagnosis and self-doubts.

Dismissal of symptoms by doctors contributes to reduced self-esteem and depression.
Source: Bontempo A C, et al. (2021)

The doctor will then talk through your symptoms and signs before recommending some tests.

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Treatment of Endometriosis

A cure for endometriosis is yet to be found however several treatment options, directed towards relieving the symptoms, increasing your fertility and improving quality of life are available.

Your Doctor will discuss with you the various treatment options for endometriosis which are broadly categorised as:

  • Conventional and complementary
  • Fertility

Conventional treatment of endometriosis normally involves medication and surgery. In some cases, complementary (natural) treatments are also helpful but research is ongoing.

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Nevertheless, women with endometriosis trying to conceive naturally sometimes need fertility treatment (a.k.a. medically assisted reproduction). This normally consists of surgery with or without assisted reproductive technologies (IUI/IVF).

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Recurrence of Endometriosis

The normal rate of recurrence following surgery is high in the majority of cases other than abdominal wall endometriosis. Several studies show recurrence rates above 20% one-year post-surgery, especially among Stage III and IV endometriosis patients.

Interestingly the same studies also showed that postoperative hormonal treatment and or pregnancy was associated with a significantly reduced risk of recurrence.

For women considering IVF the risk of endometriosis recurring post-surgery following ovarian stimulation was reported to be no higher than normal.22,23,24

Recurrence of pain post-surgery is linked to the activation of neurogenesis and reduction in apoptosis (programmed cell death).

Source: Radzinsky V, et al. (2020)

HOW QUICKLY DOES ENDOMETRIOSIS GROW BACK AFTER PREGNANCY

For most women, untreated endometriosis is active and growing again 12 months after pregnancy. This coincides with a gradual return of endometriosis related symptoms and normal menstrual cycles. However this period can vary somewhat depending how often and long a woman continues to breastfeed her baby after birth.25,26

References

  1. Zondervan K T. (2020). Endometriosis. https://www.nejm.org/doi/10.1056/NEJMra1810764 ↩︎
  2. O’Hara R, et al. (2020). Self-management factors associated with quality of life among women with endometriosis: a cross-sectional Australian survey. https://academic.oup.com/humrep/article/36/3/647/6055872 ↩︎
  3. Tuominen A, et al. (2023). First live birth before surgical verification of endometriosis—a nationwide register study of 18 324 women. https://academic.oup.com/humrep/article/38/8/1520/7218807 ↩︎
  4. Howard F, (2009). Endometriosis and Mechanisms of Pelvic Pain. https://www.jmig.org/article/S1553-4650(09)00340-9/abstract ↩︎
  5. Canis M, et al. (1997). Revised American Society for Reproductive Medicine classification of of endometriosis: 1996. https://doi.org/10.1016/S0015-0282(97)81391-X ↩︎
  6. Zhang Z, et al. (2024). Vaginal extracellular vesicles impair fertility in endometriosis by favoring Th17/Treg imbalance and inhibiting sperm activity. https://onlinelibrary.wiley.com/doi/10.1002/jcp.31188 ↩︎
  7. Bouic P J, (2023). Endometriosis and infertility: the hidden link between endometritis, hormonal imbalances and immune dysfunctions preventing implantation! https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10279451/ ↩︎
  8. Jin L, et al. (2022). Infertile women with endometriosis possess differences in cytokine levels in various tissues. https://www.tandfonline.com/doi/full/10.1080/09513590.2022.2060961 ↩︎
  9. Ma L, et al. (2021). Epithelial-to-mesenchymal transition contributes to the downregulation of progesterone receptor expression in endometriosis lesions. https://www.sciencedirect.com/science/article/pii/S0960076021001369 ↩︎
  10. Lee S R, et al. (2021). Altered Composition of Microbiota in Women with Ovarian Endometrioma: Microbiome Analyses of Extracellular Vesicles in the Peritoneal Fluid. https://www.mdpi.com/1422-0067/22/9/4608 ↩︎
  11. Nicolaus K, et al. (2020). A two-third majority of infertile women exhibit endometriosis in pre-ART diagnostic hysteroscopy and laparoscopic chromopertubation: only one-third have a tubal obstruction. https://link.springer.com/article/10.1007/s00404-020-05479-5 ↩︎
  12. Approbato F C, et al. (2019). Endometriosis III and IV as a risk factor for tubal obstruction in infertile women. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6798597/ ↩︎
  13. Hager M, et al. (2019). The Prevalence of Incidental Endometriosis in Women Undergoing Laparoscopic Ovarian Drilling for Clomiphene-Resistant Polycystic Ovary Syndrome: A Retrospective Cohort Study and Meta-Analysis. https://www.mdpi.com/2077-0383/8/8/1210 ↩︎
  14. Mayrhofer D, et al. (2022). Are the Stage and the Incidental Finding of Endometriosis Associated with Fallopian Tube Occlusion? A Retrospective Cohort Study on Laparoscopic Chromopertubation in Infertile Women. https://www.mdpi.com/2077-0383/11/13/3750 ↩︎
  15. Gordon H G, et al. (2022). When pain is not the whole story: Presenting symptoms of women with endometriosis. https://obgyn.onlinelibrary.wiley.com/doi/10.1111/ajo.13482 ↩︎
  16. Korošec S, et al. (2024). Coexistence of Endometriosis and Thyroid Autoimmunity in Infertile Women: Impact on in vitro Fertilization and Reproductive Outcomes. https://karger.com/goi/article/doi/10.1159/000539265/907088/Coexistence-of-Endometriosis-and-Thyroid ↩︎
  17. Shigesi N, et al. (2019). The association between endometriosis and autoimmune diseases: a systematic review and meta-analysis. https://academic.oup.com/humupd/article/25/4/486/5518352 ↩︎
  18. Surrey E S, et al. (2018). Risk of Developing Comorbidities Among Women with Endometriosis: A Retrospective Matched Cohort Study. https://www.liebertpub.com/doi/10.1089/jwh.2017.6432 ↩︎
  19. Soliman A, et al. (2016). Incidence of comorbidities among women with endometriosis: a retrospective matched cohort study. https://www.fertstert.org/article/S0015-0282(16)62209-4/fulltext ↩︎
  20. Cicinelli E, et al. (2024). In women with endometriosis, effective treatment of chronic endometritis with antibiotics lowers serum CA-125 levels. https://www.fertstert.org/article/S0015-0282(24)00130-4/abstract ↩︎
  21. Millischer A E, et al. (2022). Adolescent endometriosis: prevalence increases with age on magnetic resonance imaging scan. https://www.fertstert.org/article/S0015-0282(22)02131-8/fulltext ↩︎
  22. Wu Y, et al. (2022). The clinical features and long-term surgical outcomes of different types of abdominal wall endometriosis. https://link.springer.com/article/10.1007/s00404-022-06579-0 ↩︎
  23. Wacharachawana S, et al. (2021). Recurrence Rate and Risk Factors for the Recurrence of Ovarian Endometriosis after Laparoscopic Ovarian Cystectomy. https://onlinelibrary.wiley.com/doi/10.1155/2021/6679641 ↩︎
  24. Li X Y, et al. (2019). Risk factors for postoperative recurrence of ovarian endometriosis: long-term follow-up of 358 women. https://ovarianresearch.biomedcentral.com/articles/10.1186/s13048-019-0552-y ↩︎
  25. Veyrié A, et al. (2022). Endometriosis and pregnancy: The illusion of recovery. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0272828 ↩︎
  26. Farland L V, et al. (2017). History of breast feeding and risk of incident endometriosis: prospective cohort study. https://www.bmj.com/content/358/bmj.j3778 ↩︎

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