Endometriosis - This painful condition is unknown
L & S.- Some time ago, lineaysalud.com he published an article on what is endometriosis (see "Endometriosis"), a subject that arouses much interest, perhaps because it is unfortunately more common than we would like among women of reproductive age. Age ranging between menarche and menopause.
On that occasion, they addressed different aspects of the disease and thought it was good maybe, endometriosis look from the perspective of someone who lives daily the problem with their patients. Through the lens of an authority on the subject.
Line and Health, echoes a very complete interview with Dr. Francisco HBakkali Herrera Carmona, Head of Gynaecology Hospital Clinic of Barcelona is made. An authority on the subject and today, considered an international benchmark.
These are the questions and the answers in the interview: Endometriosis
Q. What is endometriosis? How is your process?
A. Endometriosis is a benign, chronic and very common gynecological disease. The uterus or matrix is composed of three distinct layers. The outermost is called serous and functions as a protective case. The middle layer, called the myometrium, is composed of muscle and has the function of pushing the baby, with contractions at the time of delivery to make it go outside. The innermost layer is called the endometrium each month prepares to host the embryo if pregnancy occurs. If this does not occur, the innermost part of this layer is ejected each month as a rule for the next month re-prepared to receive the embryo. In endometriosis, the innermost layer of the matrix (the endometrium) appears in addition to its normal place in common sites like ovaries, the lining inside the abdomen (peritoneum), intestine, urinary system, etc. As this tissue outside their usual place is completely normal also it responds to the action of female hormones and prepares each month to receive the embryo. If the woman does not become pregnant, in addition to normal menstrual bleeding, there is also a "rule" in the foci of endometrium that are outside their normal place. As these are not connected with the outside bleeding blood that causes severe pain (usually with the rule but also during sexual intercourse or during the cycle) and some tissue adhesions with others.
In addition, the ectopic endometrial tissue (which is off-site) can be implemented (take root), develop and spread by contiguity (to tissues next) and distance (to places distant body) such as described cases of endometriosis foci in the liver, lung or brain. Ectopic endometrial tissue and blood from the same, in addition to the above, a state of chronic inflammation inside the abdomen that helps perpetuate the disease and develop other symptoms of illness, such as infertility, cause and perpetuate and aggravate other such as pain and adhesions.
Q. How you can present this condition?
A. Depending on the location and degree of penetration of tissue foci in the three different forms of disease are distinguished: peritoneal endometriosis, which appear superficial implants in the peritoneum (the lining inside the abdomen) , ovarian endometriosis (forming cysts of varying size and filled with a liquid with achocolatado aspect called endometriomas) and deep endometriosis in implants penetrate deep beneath the peritoneum where important structures such as the pelvic nerves are located, ureters, rectum, bladder, etc. what makes this the most severe form of endometriosis.
In many patients different types of disease are associated. In fact, pure forms of endometriosis are rare.
The endometriosisP.- Where does endometriosis between benign gynecological conditions?
A. Very often. It is estimated that 20% of patients may have endometriosis (ie 1 woman in 5). This frequency represents is more common than asthma, diabetes, epilepsy and AIDS together. The exact frequency of endometriosis is not well known because many women are not diagnosed correctly.
In addition to its frequency, it is important because many of the patients (especially those who have deep endometriosis, but also having ovarian or peritoneal endometriosis) have disabling symptoms that prevent them from making normal life.
Q. Is endometriosis a disease that presents symptoms?
A. Yes. Although it may be asymptomatic in some patients, in most cases, endometriosis causes symptoms (often) very intense. Unfortunately, these symptoms are not always properly classified as abnormal.Q. In women where endometriosis has not manifested symptoms, the prognosis is worse?
A. Not necessarily. In some women the disease can be mild and take almost no symptoms and unaltered. In others, however, deep endometriosis can take insidiously with little or no symptoms until the first signs appear which can be as serious as a cancellation of the function of a kidney loss.
Q. What are the most serious complications that can result from this disease?
A. In addition to infertility and chronic pain with the loss of quality of life that have associated, complications resulting from endometriosis are related to the involvement of pelvic organs such as the intestine, ureter or bladder and resulting from repeated surgeries that may become subject these patients.
In this sense, surgery for endometriosis, especially deep endometriosis, is very complex and high technical requirements so it should only be done by highly experienced and skill and enough knowledge gynecologists to operate in non-gynecologic organs as the bowel or urinary or, failing that, by gynecologists able to lead a multidisciplinary team of general surgeons and / or urologists so that maximum safety is guaranteed to the patient. However, the high frequency of endometriosis and the fact that in many cases (especially when the damage is only ovarian or peritoneal) can be carried out without too much difficulty makes many cases where deep endometriosis is associated are operated by inexperienced surgeons can not offer maximum guarantees to the patient. These surgeries without the maximum guarantees can be associated with severe complications such as loss of function of the ovaries (in the form of permanent sterility), involvement of pelvic innervation (as chronic pelvic pain) or the urinary or defecation functions.
Q. At what age is most common detection?
A. Endometriosis is related to ovarian hormones and therefore only appears in women of reproductive age (between 15 and 45The endometriosis years old, approximately). It has to do with the inability of cells to clean the pelvis to destroy the endometrial cells that reach the pelvic cavity.
Therefore, usually occurs after a certain number of periods and the age of maximum frequency of diagnosis is between 20 and 40 years. However, it is possible to diagnose the disease before age 20 and after 40.
What are the diagnostic tests that must undergo the patient with endometriosis?
The main element for diagnosis of endometriosis is suspected of it. When a patient has severe pain during menses and / or during sexual intercourse or during other phases of the cycle, this can not be considered normal and the doctor must implement all diagnostic tests. These play an important role physical examination can help detect foci of deep endometriosis and ovarian endometriomas. Gynecologic ultrasound is essential to analyze the state of the ovaries and every day is more useful to confirm or rule out the presence of deep endometriosis. If the doctor or center have the necessary training to use ultrasound to diagnose deep endometriosis is indicated conducting nuclear magnetic resonance. In some special cases it may be indicated special tests such as colonoscopy, endoscopic ultrasound or special tests to study the urinary system.
Today, now outdated use of diagnostic laparoscopy has been replaced by less invasive procedures including analysis of the response to some medical treatments such as administering analogues of gonadotrophin releasing factor.
Q. What stage of the disease is usually make the diagnosis?
A. Unfortunately, endometriosis often diagnosed after years of suffering of patients. It is estimated that the average time from the onset of symptoms and diagnosis exceeds five years. This is unacceptable from every point of view and because society too often seen as normal pain patients.
Q. What factors may predispose to suffer from endometriosis?
A. There are different risk factors predisposing to endometriosis. Many of them have to do with factors that either increase the amount of blood lost during the rule of the patient or increase the number of rules presented by patients. Remember that the main theory about the origin of endometriosis associated with retrograde menstruation and impaired cell function cleaning of the pelvic cavity. So the more blood reaches the pelvis in women with these altered cells, the greater the risk of endometriosis by these patients. In this sense factors such as menorrhagia (abundant rules), abnormal genital system that prevent the normal outflow of blood from the cervix early (congenital malformations or acquired), menarche (age at first menstrual period), no pregnancies, etc.
Other risk factors are related to genetic factors related to the disease. In this sense, having close relatives affects of endometriosis increases the risk of the patient suffering from it.
Other factors probably have to do with the ease with which the patient can access health services. Thus, women of high socioeconomic level, university education, Caucasian appear to have a higher incidence of this disease although it is more than likely this is a spurious relationship.
Recently it has been reported that women in adolescence suffered severe menstrual pain and forced them to bed rest during the rule and to take oral contraceptives for the treatment of pain because it was resistant to the effect of analgesic drugs and / or common anti-inflammatory have a very high developing deep endometriosis risk in adulthood.
Q.- Currently in Spain, what is the incidence of this disease?
A. is not well known which are the incidence and prevalence of endometriosis accurate. It is estimated that between 10 and 20% of women of reproductive age in the general population suffer from endometriosis (between 1 and 2 million women in Spain) although this percentage is much higher in some specific groups of patients such as those women suffering chronic pelvic or group of women pains with difficulty becoming pregnant.
Q. And at the transnational level?
A. There is no difference between the figures observed in our country and those reported in the rest of the Western world. There are some partial statistics incidence in China, India, the Middle East and parts of Africa similar to the figures indicated above.
Q. Endometriosis and pregnancy, how can affect the fertility of women?
A. There is a clear relationship between endometriosis and infertility. The prevalence of endometriosis among infertile women endometriosis is more altaLa (> 50%) than among the general population. Women with endometriosis have a monthly fecundity rate (2-10%) lower than that of healthy women (15-20%). There are many more data confirming the relationship between endometriosis and infertility, yet despite all this evidence has not yet been able to establish whether this is a cause-effect relationship in one way or another.
The mechanisms of infertility related to endometriosis is not understood accurately and may be different depending on the degree of progression of the disease.
Q. In women with deep endometriosis, sexual relations can become very painful, how to address this?
A. The best way is the proper treatment of the disease and the pain associated with it. However, psychological and sexological therapies may play an important role as feelings such as guilt, humiliation, etc., they are often a problem to be addressed independently.
Nor should we forget the treatment of the spouse who may also be very affected psychologically by the illness suffered by her partner.
Q. What is the therapeutic approach to this disease?
A. The main goal of treatment of endometriosis must be relieving symptoms of the disease, both pain and infertility. There are, today, many treatments to achieve it. Often they have to employ combinations thereof and enlist the help of different specialists (experts gynecologists in surgery, experts gynecologists in sterile, surgeons from other specialties, psychologists, experts in sexology, expert in pain therapy, etc.) so that in this disease, possibly more than in many others, it is necessary to individualize treatment deciding, patient to patient, the best on each occasion.
Therefore, the best therapeutic approach is multidisciplinary and can only be done in specialized units formed by professionals who are familiar with the disease and its treatment. Of these there are some in our country who are at the top of those that exist worldwide.
For the treatment of pain of endometriosis, the first line of existing treatments include the type of analgesic drugs nonsteroidal anti-inflammatory (such as ibuprofen and the like) or the type of paracetamol. As a second option analgesic drug morphine derivatives such as codeine and tramadol are located. Finally, other more potent analgesics should be used only by the pain specialist. These drugs can be combined with other drugs used, always trying to get the best outcome for the patient.
The second line of drugs (as we say, can be combined with the first or used as first choice for some women) is formed by hormonal medications. The viability of the foci of ectopic endometrium depends on the ovarian hormones, especially estrogen. This is the basis of use of hormonal treatments in endometriosis. These treatments are of two types. The first type consists analogues gonadotropin releasing factor. This medicine creates in a similar women menopausal hormone status. Its effectiveness is very high (both used as a treatment test when you are not sure of the diagnosis: if administered and patient improvement is having endometriosis) to get the atrophy of endometriosis. The problem is that its side effects are also very common and may cause women to stop treatment. These side effects are caused by drug-induced menopause and are similar to those of natural menopause: hot flashes, nervousness, insomnia, vaginal dryness and, if use is prolonged in time, bone loss and osteoporosis. It is therefore not recommended for use for more than six months.
Another option in hormonal treatments are drugs with effect progestin (a hormone with opposite effects to estrogen). Among them they have been used some as gestrinone or danazol who have stopped using because of side effects (menstrual disorders with bleeding in the case of gestrinone and masculinizing effects in the case of danazol). Currently other drugs of this type (progestin) with fewer side effects and proven as dienogest, medroxyprogesterone, levonorgestrel both orally and via intrauterine, etc., which are also very high efficacy and side effects are generally used well tolerated by patients.
The last option, within this group are combined hormonal contraceptives. These drugs get atrophied, very effectively, foci of ectopic endometrium. They are very well tolerated and inexpensive. They can be used long term and have few side effects. One option, appropriate for many patients, continued administration (without resting between box and box) so that the woman has no menstrual bleeding symptoms decrease much. Also, they are the only drugs that have shown they are able to reduce relapses when administered after surgery.
Q. How can affect fertility treatment?
A. From the point of view of fertility, no medical treatment gets better (in fact, all hormonal treatments prevent pregnancy so they are only indicated in the treatment of pain). That is why in cases of infertile women with endometriosis is indicated resorting quickly to assisted fertilization techniques (artificial insemination, in vitro fertilization, etc.), even before surgery as this can have opposite effects to those intended.
Q. When you should resort to surgery?
A. The surgery continues, despite the consequences that may result (including worsening and sterility, abnormal bladder function or defecation or chronic pelvic pain), a leading role in the treatment of endometriosis. It is indicated only in cases of ovarian endometriosis and / or deep still controversial use in peritoneal endometriosis-associated infertility. No indication as pain associated with endometriosis peritoneal.
You must resort to surgery as the first option in those patients with endometriosis that affects non-genital organs (intestine, ureter, ...) and producing stenosis of the organ in question (decrease in diameter at risk of intestinal occlusion or loss kidney) function and in those patients in whom medical treatment has failed and continue to suffer pain. The surgical goal should be radical with endometriosis (destroying all injuries and eliminating all adhesions that may exist) and conservative with the body (in a way that respects the most of the functionality of all affected organs) and restoring the anatomy pelvic to normal. That is why this surgery can be so difficult (to be both radical and conservative time) being needed to perform it experienced surgeons. In some cases where all medical and surgical solutions have failed and the patient has already completed gestational desire it may be indicated radical surgery with removal of uterus, ovaries and all endometriosis.
Q. What is the role of "alternative therapies"?
R. The role they can play the misnamed "alternative therapies" can be beneficial in many women. It has been demonstrated by scientific evidence quality the beneficial effect of acupuncture for the treatment of pain in patients with endometriosis. Herbal therapy with red and black maca has also been proven effective in many cases. Moderate physical exercise, physical therapy, relaxation therapies and psychological treatments are also helpful in many patients. Finally, there's not forget that it is often necessary to also treat the couple and close family that can also withstand a great emotional burden.
Q. What factors determine the success of the treatment of endometriosis?
A. The main factor is the correct choice of treatment. In endometriosis is vital individualize treatment. There is no single treatment but must be built (from the different options) best for each patient. That is why it is vital to the establishment of reference units where patients can be treated from a multidisciplinary point of view and where you can offer them all the existing therapeutic options.
Q. Can this condition be a causal factor of cancer in women?
Finally, remember the possibility of existence of vaginal endometriosis in the background and the cervix and that this can be confused with some frequency with cancer of those locations. Again, an experienced team in the disease will be crucial to avoid such errors.
Q. What has the disease prognosis now?
R- Fortunately, the current prognosis of endometriosis is good and this should be the message to be transmitted to patients.
Although it is a chronic disease and prone to relapse it is possible today getting the quality of life of patients is absolutely normal and that patients meet their full reproductive desires.
It is therefore very important both early diagnosis of the disease and the proper choice of treatments followed by the patient, which may vary over the life of the patient based on the different life stages and desires of the patient in each from them. This point emphasizes again the importance of specialized units in the diagnosis and treatment of disease to which patients can access easily.
Q. Is it possible to prevent endometriosis?
A. No. Today it is not possible to prevent endometriosis. However, it is certainly possible to reduce the scandalous that some women endure time between onset of symptoms and diagnosis of the disease. No one should consider as normal suffering severe pain, sometimes disabling, by the mere fact that coincides with menstruation. The exhibit this symptom or other painful symptoms during the menstrual cycle should be forced to make a proper diagnosis study.
Q. How does endometriosis affect the quality of life of patients?
A. Endometriosis affects young women of reproductive age and produces, as main symptom, especially pain during menstruation and during and sex. The average time from onset of symptoms and diagnosis over five years. Many times, the intensity of symptoms is so high that prevents women to leave home to meet their work or school obligations. Indicated treatments often have side effects that are also disabling. Surgeries often are incomplete or have complications and consequences that may be permanent.
Q. In addressing this disease, what measures do you think urge (greater specialization, better information)?
A. They are necessary measures at different levels. First the formal establishment of specialized units reference to which patients have easy access is required. It should be noted that there are specialized units in Spain only in some regions and that due to the current referral system between communities is very difficult for many women the access to existing units. A first step, before the creation of units in all communities, would be that the existing units were known to all doctors in the national health system and that patients could be referred to them easily.
Secondly, it is urgent to increase the level of training of both general gynecologists and family physicians and other specialists in the sense noted above that is not acceptable considered normal menstrual pain invalidating presented by these patients. It is also necessary to increase the level of training of many gynecologists that although they may have done correctly diagnosing endometriosis are able attempting to operate too complex for what they are not prepared cases. The right decision is to be the lead these patients to specialized centers rather than cause unnecessary harm to patients.
Finally, it is necessary to increase the level of awareness of the disease among the same patients and the general population. Again, it is not acceptable to have to endure a crippling pain by the mere fact of being a woman ( "is that women do not aguantáis nothing") or because the mother, sister or aunt also have suffered ( "me too me He passed "). Information campaigns in the media, a greater presence of endometriosis help them a better understanding of the disease and therefore diagnosis and treatment earliest.
Q. What have been the most important advances in recent years in addressing endometriosis? What remains to be done?
A. Certainly, there has been an increase in awareness of the disease both by the general public and by specialists (you only need to review the published literature on this subject over the past 30 years to observe a notable increase in the last 5 ). Another highlight, and parallel to this, progress is the degree of understanding of the epidemiology of endometriosis, its pathophysiology of molecular changes present in the disease. All this is contributing to the development and application of new treatments which, although they are still in experimental phase will certainly contribute in the coming years to combat endometriosis. In this sense, the emergence of new medical treatments that can be applied to patients with desire to promote fertility and that is one of the major milestones to achieve.
Moreover, and similarly, the emergence of technological advances in surgery, specifically the development of laparoscopy, has been, in our view, the most significant progress in recent years. This technique has allowed treat minimally invasively to the vast majority of patients very significantly decreasing the rate of complications and increased the precision of surgery and cure rate achieved with the same.
Also very important it is being able to define the role of transvaginal ultrasound in the diagnosis of endometriosis and increasingly use this tool, familiar to gynecologists. In the coming years it is expected that new technological advances allow progress in both surgical techniques and techniques of imaging.
It is investigating the possibility via augmented reality techniques, to incorporate laparoscope screen images obtained by ultrasound or magnetic resonance so that the surgeon dispose of them during surgery superimposing the actual image obtained with the endoscope. Other authors investigate the possibility of using specific contrasts for endometriotic tissues that make it easy to identify both during the diagnostic process and during surgery.
Q. When speaking of endometriosis, what are the main myths against those who would have to fight?
A. The most important is the one that says that women must endure the pain, sometimes intolerable, which causes the disease. It is frowned upon socially that women stay home "just because it has the rule". Both bosses and colleagues ( "other than hold a simple pain rule") and family ( "me too happened to me") as the patient herself ( "I have to set an example") minimize many times the victim's suffering . This makes patients feel misunderstood and alone in their illness leading to develop real feelings of guilt and depression "for being unable to endure" and not being able to go to work or having sex with your partner. It is important to listen and reassure patients. They are not crazy. They are not loose. They are not weak. They're just sick. It is the duty of physicians and society help them.
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