Endometriosis
Introduction and Facts
Endometriosis is a medical condition in women characterized by the growth of endometrial cells outside the uterine cavity. Endometrial cells that line the uterine cavity are strongly influenced by female hormones. Under normal circumstances, the endometrial cells of the uterine cavity will thicken during the menstrual cycle so that they are ready to receive the results of the fertilization of the egg by the sperm. If the egg is not fertilized, the thickened endometrial cells will shed and come out as menstrual blood.
In endometriosis, endometrial cells that were originally in the uterine cavity move and grow outside the uterine cavity. Cells can grow and move to the ovaries, fallopian tubes, behind the uterine cavity, uterine ligaments, and can even reach the intestines and bladder. During menstruation, these moving endo-metrial cells will peel off and cause a feeling of pain around the pelvis. Generally, endometriosis appears in the reproductive years. The incidence of endometriosis reaches 5-10% in women in general, and more than 50% occurs in perimenopausal women. Endometriosis is found in 25% of infertile women, and it is estimated that 50%-60% of endometriosis cases will be infertile.
Pathophysiology
Until now the exact etiology of endometriosis is not clear. Several experts have tried to explain the incidence of endometriosis with various theories, namely the theory of implantation and regurgitation, metaplasia, hormonal, and immunologic.
The theory of implantation and regurgitation suggests the presence of menstrual blood that can flow from the uterine cavity through the Fallopian tubes, but cannot explain the occurrence of endometriosis outside the pelvis. The metaplasia theory explains the occurrence of metaplasia in the cells of the coelom that turn into the endometrium. According to this theory, these changes occur due to irritation and infection or hormonal influences on the coelomic epithelium. From an endocrine perspective, this is acceptable because the germinal epithelium of the ovary, endometrium, and peritoneum are derived from the same coelomic epithelium.
The most acceptable is the hormonal theory, which stems from the fact that pregnancy can cure endometriosis. Low levels of FSH (fo-licle stimulating hormone), LH (luteinizing hormone), and estradiol (E2) can eliminate endometriosis. Giving sex steroids can also suppress the secretion of FSH, LH, and E2. This long-held opinion suggests that the growth of endometriosis is highly dependent on estrogen levels in the body, but has recently begun to be debated. According to Kim et al, E2 levels were found to be quite high in cases of endometriosis. Olive (1990) found that serum E2 levels in each group of degrees of endometriosis were within normal limits. This situation is also independent of the severity of endometriosis, and raises more doubt about the true cause of endometriosis. If it is considered that the development of endometriosis depends on the level of estrogen in the body, there should be a significant relationship between the severity of endometriosis and the level of E2. On the other hand, if E2 levels are high in the body, these compounds will be converted into androgens through the aroma-tization process, which will result in increased testosterone (T) levels. In fact, in this study, T levels did not change significantly according to the severity of the disease, even in the peritoneal fluid, the levels tended to decrease in rhythm with E2. Based on this, it can be said that the severity of endometriosis is not purely dependent on estrogen alone.
The theory of endometriosis can be related to the activity of the immune system. The immunological theory explains that embryologically, the epithelial cells covering the parietal peritoneum and the surface of the ovary have a common origin; therefore the endometrial cells will be similar to the mesothelium. It is known that CA-125 is a cell surface antigen that was originally thought to be specific for the ovary. Endometriosis is a destructive process of cell proliferation and will increase CA-125 levels. Therefore, these antigens are used as chemical markers
Clinical Symptoms and Complications
The classic symptoms of endometriosis include dysmenorrhea, dyspareunia, dyschezia and/or infertility. According to a case-control study in the United States, symptoms such as abdominal pain, dysmenorrhea, menorrhagia, and dyspareunia are associated with endometriosis. As many as 83% of women with endometriosis complain of one or more of these symptoms, whereas only 29% of women without endometriosis complain of these symptoms.
Symptoms of external endometriosis:
Catamenial events are common in women with endometriosis. Although this incident is rare, it also often causes other problems. Some catamenials that can occur in endometriosis disorders are pneumothorax, hemoptysis, and endometriosis in other peritoneal organs. Cases have been reported, there is endometriosis in the rectal which causes obstruction, endometriosis in the sigmoid colon which causes symptoms similar to colon cancer.
In endometriosis that attacks the intestinal organs, symptoms that usually arise include bleeding, intestinal obstruction, but rarely with perforation or lead to malignancy. Symptoms can occur in up to 40% of patients, and pain varies depending on the site of endometriosis. Symptoms presented by the patient include abdominal pain, distension, diarrhea, constipation, and tenesmus.
Diagnosis
Physical Examination
Physical examination of endometriosis begins with an inspection of the vagina using a speculum, followed by a bimanual examination and rectovaginal palpation. Bimanual examination can assess the size, position and mobility of the uterus. A rectovaginal examination is necessary to palpate the sacrouterine ligament and rectovaginal septum to look for the presence or absence of endometrial nodules. Examination during menstruation can increase the chances of detecting endometrial nodules as well as assessing pain. According to a histological study in 98 patients with retrosigmoid and retrocervical endometriosis, the deep examination had a sensitivity of 72% and 68%, respectively, specificity 54% and 46%, positive predictive value 63% and 45%, negative predictive value 64% and 69%, respectively. and 63% and 55% accuracy.
Supporting Investigation
Investigations that can be performed in patients with endometriosis are transvaginal ultrasonography and MRI (Magnetic Resonance Imaging) and examination of biochemical markers.
Ultrasound
Vaginal ultrasound is a first-line investigation that has good accuracy, especially in detecting endometrial cysts. Ultrasound does not give good results for the examination of peritoneal endometriosis. In deep endometriosis, the sensitivity and specificity rates vary depending on the location of the endometrial lesion. Transvaginal ultrasound can also be used to diagnose endometriosis of the gastrointestinal tract. From a systematic review of 1105 women, ultrasound sensitivity was 91% with a specificity of 98%, a positive predictive value of 98% and a negative predictive value of 95%.
Magnetic Resonance Imaging
In the case series reported by Stratton et al regarding the use of MRI to diagnose peritoneal endometriosis, sensitivity was 69% and specificity was 75%. In conclusion, MRI is not useful for diagnosing or excluding peritoneal endometriosis
Biochemical Marker Examination
Endometriosis is a disorder caused by inflammation. Cytokines, interleukins, and TNF-a have a role in the pathogenesis of endometriosis. This can be seen from the increase in cytokines in the peritoneal fluid in patients with endometriosis. The IL-6 assay has been used to differentiate women with or without endometriosis, and to identify the degree of endometriosis.
CA-125 Tumor Tumor Marker
Laboratory tests using serum CA-125 markers are often performed in endometriosis, but when compared with laparoscopy CA-125 has no diagnostic value. The RCOG guidelines state that CA-125 has limited value for both screening and diagnostic purposes.
Laparoscopic examination
Until now the definitive method for the diagnosis of endometriosis, including staging and evaluation of post-therapy recurrence, is direct visualization with surgery. Most of these visualization procedures use laparoscopy, namely surgery on the abdomen or pelvis using a small 0.5-1.5 cm incision by inserting a camera into it. Laparoscopy can be performed for diagnostics as well as for surgery
Management and Care
Endometriosis is a chronic disease that causes complaints of pain and/or infertility with an unequal morbidity burden between patients, therefore the treatment of endometriosis should be individualized and directed at improving the quality of life.
Endometriosis Pain Management
Endometriosis is found in 60-80% of patients with pelvic pain which if not treated properly will cause a decrease in quality of life. Medical therapy involving various hormonal drugs and analgesics has been used to treat endometriosis pain, besides surgery with several surgical techniques has also been widely used.
1. Endometriosis Medical Therapy
Medical therapy has been agreed upon and accepted as one of the treatments for endometriosis. Drugs used in medical therapy are aimed at suppressing the ovarian steroid hormone, namely estrogen, so that hypoestrogen conditions occur, causing atrophy of ectopic endometrial lesions. The provision of medical therapy will affect the hormonal balance condition in the menstrual cycle, resulting in chronic anovulation and amenorrhea, which in turn will induce decidualization of the endometrium to cause a state of pseudo-pregnancy. In addition, it will trigger endometrial atrophy until pseudo-menopause occurs. Pathological conditions that occur in the eutopic and ectopic endometrium will have an impact on the suppression of endometrial cells, increased apoptosis and decreased growth of endometrial tissue. The above description forms the basis of medical therapy used to suppress growth, resulting in regression of endometriosis lesions
a, Combined contraceptive pills. The combined contraceptive pill has been widely used to treat dysmenorrhea and pelvic pain associated with endometriosis. This treatment has been shown to be effective, safe and acceptable for the treatment of dysmenorrhea and endometriosis-associated pelvic pain in women who do not wish to have children.
b. Progestogens. Progestogen is one of the most commonly used drugs for the treatment of endometriosis, including medroxy . progesterone acetate (MPA) and nortestosterone derivatives (eg levonorgestrel, noretindrone acetate, and dienogest).
c. Danazol. Danazol is a 17-ethinyltestosterone derivative and works by inhibiting LH surge and steroidogenesis and increasing free . levels testosterone. The use of Danazol causes hyperandrogen side effects which can be in the form of hirsutism, acne, weight gain and obesity voice changes to become heavier like a male voice
d. GNRH analogues, Gonadotropin-releasing hormone (GnRH) analogs are available in two forms, namely GnRH agonists and GnRH antagonists. Both preparations have been used for the treatment of endometriosis pain, but GnRH agonists are longer used and provide effective results for pain management.
e. Aromatase Inhibitors. Aromatase inhibitors have been investigated for their usefulness as drugs to treat endometriosis pain, namely by suppressing the expression of the aromatase P450 enzyme which functions as a catalyst for the conversion of androgens to estrogens. Not in all countries available aromatase inhibitor drugs, the most common are the third generation aromatase inhibitors, namely letrozole and anastrozole. Aromatase inhibitors compete with androgens for occupying aromatase receptors
d. Analgesic , It is known that pain is the main complaint of endometriosis. It has also been shown that prostaglandin levels are increased in peritoneal fluid and endometrial tissue in women with endometriosis.
2. Surgical Therapy for Edomentritis Pain
Endometriosis has various forms of lesions with unique features, can be chronic and easy to recur, so that even after surgery the microscopic lesions can continue to be active. Patient complaints often do not correlate with the size of the lesion and the stage of endometriosis
Reference:
1. Erna Suparman. Penatalaksanaan Endometriosis. Jurnal Biomedik, 2012:4;2:69-78. Internet [Cited 27/8/2021]. Available from:https://ejournal.unsrat.ac.id/index.php/biomedik/article/view/754/12189
2. Himpunan Endokrinologi-Reproduksi dan Fertilitas Indonesia Perkumpulan Obstetri dan Ginekologi Indonesia. Konsensus Tatalaksanan Nyeri Haid pada Endometriosis 2013. Internet [Cited 26/8/2021]. Availabe from:
https://pogi.or.id/publish/download/pnpk-dan-ppk/
3. Hendy Hendarto. Endometriosis. Dari aspek teori sampai penanganan klinis. http://repository.unair.ac.id/85343/1/Buku%20Endometriosis_HAKI_compressed.pdf
