At the KHM Congress in Lucerne, a workshop focused on endometriosis. The speakers, KD Dr. med. Stephanie von Orelli, Frauenklinik Stadtspital Triemli, Zurich, and Dr. med. Birgit Lübben, family physician in Zurich, explained the often difficult therapy decisions. Since the patients are young women who often also wish to have children, the treatment must not be too invasive so as not to jeopardize the ovarian reserve.
“Endometriosis is a chameleon in terms of symptoms,” Dr. von Orelli said. “The majority of patients suffer from dysmenorrhea, but abdominal pain and micturition or defecation problems may also occur.” Endometriosis is also a common cause of infertility: around 38% of all infertility patients have endometriosis. Both pain and subfertility are caused not only by bleeding from the ectopic endometrial foci during menstruation. The foci also promote the production and release of inflammatory mediators that support pain and impair ovarian, tubal, and endometrial function.
Vascularization as in tumors
Endometriosis exclusively affects women exposed to estrogen. Only in them can estrogens stimulate the growth of endometrial foci outside the uterus. Young girls may also already have endometriosis: 50% of all adolescents who undergo laparoscopy for dysmenorrhea have endometriosis.
The pathogenesis of endometriosis is unclear, and various theories are discussed. The most common cause is probably retrograde menstruation, through which endometrial cells enter the abdomen. This occurs in many menstruating women, and in most, the “non-local” cells are immediately cleared by macrophages. Only in about 10-15% of retrograde menstruating women do the cells manage to implant and form foci. Foci larger than 2 mm2 in diameter are supplied by new blood vessels – this angioneogenesis proceeds similarly to the metastasis of tumors.
Three different forms of endometriosis are distinguished: peritoneal superficial, deeply infiltrating endometriosis (DIE), and ovarian endometriosis with the formation of endometriomas (Table 1).
Ultrasound and laparascopy
Diagnostics include anamnesis and gynecological examination as well as ultrasound (vaginal or abdominal). “It is advisable to ultrasound the kidneys as well,” said Stephanie von Orelli, “because endometriosis often closes a ureter and a congested kidney develops. However, small peritoneal foci are not visible on ultrasound – this requires laparascopy, during which a biopsy can also be taken and, if the patient wishes to have a child, the patency of the tube can be checked. In cases of severe dysmenorrhea, the speaker recommended that, when in doubt, a laparascopy should be prescribed rather generously, especially if a patient has a contraindication to prescribing the pill. MRI is usually not necessary, at most for clarification of deep infiltrating endometriosis or for surgical planning. In principle, the diagnosis is only certain after histological confirmation.
Therapy goal: pregnancy or freedom from pain?
Before treatment is started, the goal of therapy should be clear. If you want to treat the disease with an operation resp. a removal of the endometriosis foci “cure”? Or is it more about managing the disease with medication? It is important to consider the wishes of the woman concerned: Does she primarily want to stop having painful menstruation? Or does she want to get pregnant?
There are three options for drug treatment: combined pill, progesterone or GnRH (tab. 2) . The insertion of a hormonal IUD (Mirena® IUD) can help to reduce pain, but the possible side effects of the progestogens must also be considered here (depressive mood, weight gain, headaches/migraines, etc.).
In mild endometriosis, removal of foci increases the chances of pregnancy. However, the “number needed to treat” is 7.7. Thus, more than seven affected women must be operated on for an additional pregnancy to occur. “Surgery also always carries the risk of damaging healthy ovarian tissue and reducing ovarian reserve, which further limits the patient’s fertility,” the speaker said. “Therefore, I am generally reluctant to recommend endometriosis surgery for infertility treatment.” In severe endometriosis, there is no evidence that surgery can improve fertility.
Ovarian endometriomas
Ovarian endometriomas are a special form of endometriosis: “Chocolate cysts” form in the ovary, often strongly fused with the surrounding tissue (intestine, uterus, tubes, ligamentum latum) and can be palpated as a “pelvic mass”. The endometriomas may cause dysmenorrhea, dysparunia, and infertility; rupture results in symptoms of acute abdomen. Isolated endometriomas are rare; most often they are a marker of extensive endometriosis.
In the context of fertility treatment, extirpation of endometriomas is not essential: There is no evidence that removal of endometriomas increases pregnancy rates.
An indication for removal is when the endometriomas are very large, the patient is in severe pain, or the location of the endometriomas makes puncture of follicles impossible. Since endometriomas are covered by healthy ovarian tissue, oocytes are always lost with removal. For this reason, the new two-stage procedure of laser evaporization is recommended for women of childbearing potential who need to have endometriomas removed: first, a laparascopy is performed with drainage of the endometrioma, followed by three months of drug therapy (GnRH analogues and add-back or progestogens), then another laparascopy with gentle evaporization of the endometrioma.
Source: KHM Congress, Lucerne, June 23-24, 2016
HAUSARZT PRAXIS 2016; 11(8): 37-39
