Definition: Endometriosis is a chronic disease caused by the migration of endometrial cells (uterine mucosa) into nearby or distant organs, where they proliferate. They thus create pseudo-tumorous islands which behave like uterine mucosa according to the menstrual cycle.

The location of the nodes varies widely: fallopian tubes, peritoneum, intestine, bladder, and even further afield, having been found in the lungs.

Symptoms of the disease

The symptoms of the disease directly linked to the location of the ‘grafted’ mucosal nodes. There are therefore almost as many symptoms as there are patients, and this is what makes diagnosis so difficult and sometimes so late (five years or more). The symptoms can be divided into three groups: bleeding, pain and infertility. There are also asymptomatic forms or forms with few signs, with no anatomo-clinical linkage, which means that the extent of the symptoms in no way indicates the seriousness of the disease, and vice versa. Endometriosis affects around 10% of women.

a) Bleeding may present as very painful and abundant periods, or sometimes as acute abdominal syndrome in the case of intra-peritoneal bleeding. There may also be urinary or digestive signs.

b) Pain is the main symptom. It occurs in a variety of locations, often the pelvis but not exclusively: dyspareunia (painful sexual intercourse), digestive pain, sometimes accompanied by brief losses of consciousness, and vomiting.

The pain can be incapacitating to the point of preventing normal professional, family and conjugal life.

As the symptoms are linked to the menstrual cycle, this is the trigger prompts the diagnosis.

c) Infertility is the third pillar of the diagnosis and it is not uncommon for endometriosis to be diagnosed during a fertility assessment.

Whether it is tubal or peritoneal adhesions, or ovarian cysts caused by the disease, there are still many unanswered questions about the causes of endometriosis and infertility.

Treatments

The gynaecological treatments available depend on when the diagnosis is made, the objective of the treatment and the desire for a child. Some of the treatments available are:

a) Analgesics and NSAIDs (non-steroidal anti-inflammatory drugs). These aim to calm the pain and restore the patient's ability to live a normal life. However, the pain is sometimes so intense that we are forced to resort to morphine, which has its own drawbacks, particularly in terms of alertness and the risk of addiction.

These treatments are purely symptomatic and have no curing effect on the disease itself.

• Continuous use of the contraceptive pill, without the one-week break. This leads to amenorrhoea (stopping of menstruation) and progressive atrophy of the endometrium in the uterine cavity, as well as in ectopic mucosa nodes.

• The fitting of an IUD (intrauterine coil), impregnated with hormones, will act according to the same principles.

• Hormones taken by injection to induce an artificial menopause have the disadvantage of causing menopausal symptoms: hot flushes, irritability, drop in libido, reduced bone density, etc.

  The treatment duration is usually limited to one year, with a gradual return of symptoms over six to twelve months.

In addition to the fact that these treatments do not cure endometriosis but rather mask its symptoms, they have the disadvantages of long-term hormone treatments: including weight gain, skin disorders, and headaches.

Surgical treatment is often effective, but unfortunately not always, because let's not forget that endometriosis is a chronic and recurrent disease!

Surgery to remove endometriotic nodes can be considered, particularly if this can be done by laparoscopy, however depending on the location, this is not always the case. Some cases may lead to major complex surgery.

In some cases, a straightforward hysterectomy has been proposed, but even this is not absolutely effective.

It is therefore clear that the choice of treatment cannot be a unilateral decision by the gynaecologist, but must be decided after the patient has been fully informed of the advantages and disadvantages of each treatment.

The treatment of infertility is even more delicate in the context of endometriosis. An infertility assessment must be carried out, which must be accompanied by laparoscopy, to determine the extent of the localised endometriosis and the possibility of removal.

Ovarian stimulation, IVF, etc. can then be considered within 6 to 12 months.

Endometriosis is a chronic, recurrent and disabling disease which remains enigmatic and which is still diagnosed late. For this reason, it should be considered in all infertility assessments.

Dr Latouche is the general manager of Management Medical International.

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