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3. Enter: "Endometriosis" in the Search box and click: "Go"
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Endometriosis
Endometriosis represents a significant health problem for women of reproductive age. Defined as the presence of endometrial-like glands and stroma in any extrauterine site, endometriosis continues to defy our complete understanding regarding etiology, the relationship between extent of disease and the degree of symptoms, its relationship to fertility, and the most appropriate means of therapy. Background
Incidence
Endometriosis is a gynecologic condition that occurs in 7-10% of women in the general population and up to 50% of premenopausal women, with a prevalence of 38% (range, 20-50%) in infertile women, and in 71-87% of women with chronic pelvic pain. Contrary to much speculation, there are no data to support the view that the incidence of endometriosis is increasing, although improved recognition of endometriosis lesions may have led to an increase in the rate of detection. There also appears to be no particular racial predisposition to endometriosis.
A familial association of endometriosis has been documented, and patients with an affected first-degree relative have nearly a 10-fold increased risk of developing endometriosis. The proposed inheritance is characteristic of a polygenic-multifactorial mechanism.
Etiology
Although the pathogenesis of endometriosis remains unclear, leading theories include retrograde menstruation, hematogenous or lymphatogenous transport, and coelomic metaplasia. It has been suggested that virtually all women are potentially vulnerable to the development of the lesions of endometriosis, but appropriate immunocompetency in most eradicates such lesions in a timely fashion, preventing clinical sequelae. Menstrual flow that produces a greater volume of retrograde menstruation may increase the risk of developing endometriosis. Cervical or vaginal atresia with outflow obstruction also is linked with the development of endometriosis. Early menarche, regular cycles (especially without intervening pregnancy-induced amenorrhea), and a longer and heavier than normal flow are associated with this disease. Because endometriosis is an estrogen-dependent disease, factors that reduce estrogen levels, such as exercise-induced menstrual disorders, decreased body-fat content, and tobacco smoking, are associated with reduced risk of developing endometriosis.
Clinical Manifestations
The clinical manifestations of endometriosis are variable and unpredictable in both presentation and course. Dysmenorrhea, chronic pelvic pain, dyspareunia, uterosacral ligament nodularity, and adnexal mass (either symptomatic or asymptomatic) are among the most well-recognized manifestations. A significant number of women with endometriosis remain asymptomatic.
The association between endometriosis and infertility remains the subject of considerable debate. It is clear that endometriosis may induce infertility as a result of anatomic distortion secondary to invasive endometriosis and related adhesions. Although it was previously believed that patients with minimal and mild endometriosis displayed reduced monthly fecundity rates, a cause-and-effect relationship has not been proven, and more recent prospective controlled trials suggest that minimal to mild endometriosis is not associated with reduced fecundity and may not be a direct cause of infertility.
Pelvic pain that is typical of endometriosis is characteristically described as secondary dysmenorrhea (with pain frequently commencing prior to the onset of menses), deep dyspareunia (exaggerated during menses), or sacral backache with menses. Endometriosis that involves specific organs may result in pain or physiologic dysfunction of those organs, such as perimenstrual tenesmus or diarrhea in cases of bowel involvement or dysuria and hematuria in cases of bladder involvement.
The pain associated with endometriosis has little relationship to the type or location of the lesions that are visible at laparoscopy. Surgical assessment is complicated by the varying, and subtle appearances of endometriosis, and may be demonstrated histologically in a normal-appearing peritoneum. It has been shown that the depth of infiltration of endometriosis lesions correlates best with pain severity. Systematic analysis of the source of pain in awake patients undergoing laparoscopy (sometimes referred to as "pain mapping") demonstrates that pain arises from stimulation of adjacent normal peritoneal surfaces that extend well beyond the visible lesions of endometriosis. This suggests that painful lesions are those involving peritoneal surfaces innervated by peripheral spinal nerves, rather than those innervated by the autonomic nervous system.
Diagnosis
Direct visualization confirmed by histologic examination, especially of lesions with nonclassical appearance, remains the standard for diagnosing endometriosis. The presence of two or more of the following histologic features is used as the threshold criteria for the diagnosis by a pathologist:
* Endometrial epithelium
* Endometrial glands
* Endometrial stroma
* Hemosiderin-laden macrophages
Visual inspection as the sole means for making the diagnosis of endometriosis requires an experienced surgeon who is familiar with the protean appearances of endometriosis. Experience is associated with increased diagnostic accuracy, but the correlation between visual inspection and histologic confirmation of the presence of endometriosis in biopsy specimens is imperfect. The finding of microscopic endometriosis in normal-appearing peritoneum exemplifies the inaccuracy of diagnosis by visualization alone. Peritoneal biopsy may be used for diagnosing questionable peritoneal lesions. Because tissue confirmation of the diagnosis of endometriosis requires a surgical procedure, investigators have searched for a noninvasive alternative. The correlation between the presence of moderate and severe endometriosis and an increased concentration of CA 125 in serum has been known for more than 10 years. Although the specificity of CA 125 measurements had been reported to be greater than 85%, with sensitivities between 20% and 50%, the clinical utility of measuring CA 125 as a diagnostic marker for endometriosis appears to be limited. Determining the level of CA 125 in serum appears to be useful in detecting women with severe endometriosis but is of questionable value in detecting women with minimal or mild disease. Measurement of peritoneal fluid levels, however, appears to be better for detecting minimal and moderate disease.
Concentrations of CA 125 in serum also have been studied as a marker to determine the response to medical therapy for endometriosis. Although CA 125 levels may decrease during treatment when compared with pretreatment values, posttreatment values that are normal do not confirm the absence of endometriosis, nor are they useful for predicting disease recurrence. Imaging studies, such as ultrasonography, magnetic resonance imaging, and computed tomography, appear to be useful only in the presence of a pelvic or adnexal mass. Ovarian endometriomas, visualized ultrasonographically, typically appear as cysts that contain low-level, homogeneous internal echoes consistent with old blood. Imaging studies alone appear to have greater predictive accuracy in differentiating ovarian endometriomas from other adnexal masses than when used in combination with measurement of CA 125 levels in plasma. Magnetic resonance imaging may detect deeply infiltrating endometriosis that involves the uterosacral ligaments and the cul-de-sac, but lacks sensitivity in detecting rectal involvement