endometrioza

INTRODUCERE

Endometrioza este o afectiune in care tesutul similar cu cel care creste in mod normal inauntrul uterului, creste de asemenea si in afara uterului. Tesutul din interiorul uterului se numeste „endometru”, iar tesutul din afara uterului se numeste „endometrioza”. Cel mai frecvent loc unde apare endometrioza sunt ovarele, trompele uterine, intestinul si zonele adiacente din fata, din spatele si din lateralele uterului.

Unele femei cu endometrioza au putine simptome sau chiar deloc in timp ce altele au dureri sau intampina dificultati in a ramane insarcinate. Nu exista tratament definitiv pentru endometrioza, dar exista cateva optiuni de tratament pentru ameliorarea simptomatologiei. Cel mai bun tratament depinde de fiecare situatie in parte.

CAUZE ENDOMETRIOZA

Cauza endometriozei nu este cunoscuta. O teorie cunoscuta este ca o mica cantitate de sange menstrual si endometru trece din uter prin trompele uterine in pelvis, in timpul menstruatiei. Acest tesut creste ulterior in pelvis. Aceasta este numita teoria retrograda a menstruatiei. Mai exista cateva teorii, dar cercetarile continua pentru a afla cauza acestei afectiuni.

SIMPTOME ENDOMETRIOZA

Anumite femei care au endometrioza nu au simptome.

Cel mai comun simptom este durerea in zona pelvina, in special in timpul mestruatiei.

Durerea: – Durerile pelvine cauzate de endometrioza pot sa apara:

– imediat inainte sau in timpul perioadei mestruale. La unele femei, perioadele dureroase se inrautatesc cu timpul

– intre perioadele menstruale, cu agravarea durerii in timpul menstruatiei

– in timpul sau dupa sex

– cu miscarile intestinale sau in timpul urinarii, in special in timpul menstruatiei

Durerea pelvina poate fi cauzata si de spamul muscular al planseului pelvin, infectii pelvice si de sindromul colonului iritabil.

Dificultatea de a ramane insarcinata:

Endometrioza poate face mai dificila aparitia unei sarcini. Acest lucru poate sa apara datorita faptului ca endometrioza poate duce la lezarea tesuturilor, poate produce leziuni la ovare si la trompele uterine. Chiar si daca nu au leziuni ale organelor si tesuturilor, unele femei nu poat ramane insarcinate datorita prezentei endometriozei.

La femeile care raman insarcinate, endometrioza nu impiedica desfasurarea normala a sarcinii. Simptomele endometriozei se amelioreaza de obicei dupa sarcina

Endometriom (chist de ciocolata)

Femeile cu endometrioza pot dezvolta chiste ovariene care contin endometrioza. Endometriomul este de obicei plin cu sange digerat care seamana cu siropul de ciocolata; de aceea acestea sunt denumite uneori chiste de ciocolata. Endometrioamele sunt uneori vizualizate la ecografia pelvina sau palpate in timpul examinarii pelvine.

DIAGNOSTIC ENDOMETRIOZA

Medicul dumneavoastra poate suspiciona diagnosticul de endometrioza pe baza simptomelor dumneavoastra de durere pelvina in timpul menstruatiei. Singurul mod de a sti cu certitudine daca aveti sau nu endometrioza este de a efectua o interventie chirurgicala in urma careia medicul poate observa si efectua biopsie daca exista tesut anormal. Endometrioza nu poate fi diagnosticata prin ecografie, radiografie sau orice alta metoda neinvaziva

Endometrioza poate fi clasificata in usoara, moderata sau severa in functie de ce se gaseste in timpul interventiei chirurgicale.Este posibil ca femeile cu endometrioza usoara sa aiba simptome severe in timp ce femeile cu endometrioza severa sa aiba simptome usoare.

In anumite cazuri, medicul dumneavoastra va poate recomanda initial medicamente pentru simptomele ce il fac sa suspecteze prezenta endometriozei. Acestea pot include antiinflamatoare nesteroidiene (ibuprofen) sau medicamente anticonceptionale.

Daca tratamentul nu amelioreaza durerea dumneavoastra in 3-6 luni se pot incerca alte medicamente sau se poate discuta despre interventia chirurgicala diagnostica.

In alte cazuri este posibil ca medicul dumneavoastra sa va propuna interventia chirurgicala inainte de a va prescrie medicamente.

TRATAMENT ENDOMETRIOZA

Exista cateva posibilitati de tratament pentru femeile cu endometrioza:

  • Medicamente antiinflamatorii nesteroidiene
  • Medicamente anticonceptionale
  • Medicamente hormonale (agonisti de gonadotropina)
  • Chirurgical

Cel mai bun tratament depinde de dorinta de a avea o sarcina in viitor si de ce simptome sunt predominante

Medicamente antiinflamatorii nesteroidiene:

Acestea au efect in durerea cauzata de endometrioza. Inceperea administrarii antiinflamatoarelor nesteroidiene cu una sau doua zile inaintea menstruatiei au efect in reducerea durerii. Poate dura putin timp si cateva doze de AINS pentru reducerea durerii. Aceste medicamente nu micsoreaza si nu previn cresterea endometriozei.

Most NSAIDs are available without a prescription, including:

  • Ibuprofen (sold as Advil, Motrin, and store brands). Follow the package instructions. In general, two tablets are taken for the first dose and one tablet every four to six hours, as needed, thereafter. These should be taken with food and may be most effective if started one to two days before the onset of pain. Physicians may prescribe higher doses.
  • Naproxen sodium (sold as Aleve, Anaprox, Naprosyn, and store brands). Follow the package instructions, as the dose and frequency differ depending on the formulation. In general, two tablets are taken for the first dose, and one tablet is taken every 8 to 12 hours, as needed, thereafter, depending on the formulation. All tablets should be taken with food and a full glass of water. Like ibuprofen, naproxen may be more effective if begun a day or two prior to the onset of typical menstrual pain. Physicians may prescribe higher doses.
  • If over-the-counter NSAIDs are not effective, prescription doses and formulations may be helpful.
  • The disadvantage of NSAIDs is that they do not always relieve endometriosis-related pain. NSAIDs probably work better when combined with another treatment, like hormonal birth control. Serious side effects from NSAIDs, although uncommon, include stomach upset, kidney problems, and worsened high blood pressure.

Hormonal birth control treatments — Hormonal birth control, including the pill, patch, and the vaginal ring are often helpful in treating pain because they reduce heavy bleeding. Injectable and implantable long-acting progestins may be very effective in managing endometriosis-related pain. A progestin-containing intrauterine device can also be very effective in treating pain. Hormonal birth control works best in women who do not have severe pain unrelated to the period.

Women with endometriosis are often advised to take hormonal birth control continuously (skipping the placebo pills) for three or more months. This allows you to have fewer periods and have less pain and bleeding during each period. This is explained in detail separately. (See „Patient education: Hormonal methods of birth control (Beyond the Basics)”, section on ‘Continuous dosing’.)

The most common side effects of estrogen-containing hormonal birth control are:

  • Nausea
  • Breast tenderness
  • Irregular vaginal bleeding or spotting

These side effects usually improve after using the treatment for several months. Serious side effects (eg, blood clots, stroke, heart attack) are rare in women who do not smoke. (See „Patient education: Hormonal methods of birth control (Beyond the Basics)”.)

Progestins — Progestins are a synthetic form of a natural hormone called progesterone. This treatment might be recommended for women who do not get pain relief from or who cannot take hormonal birth control that contains estrogen (such as smokers). Progestins are available by prescription and usually given as a pill or injection. Progestins are not used if you are trying to become pregnant. A progestin-containing intrauterine device delivers very low levels of progestin directly to the uterus and results in markedly lighter and less painful bleeding episodes with fewer systemic side effects.

Side effects of progestins can be bothersome for some women. The most common side effects include: bloating, weight gain, irregular vaginal bleeding, acne, and rarely, worsened depression.

Gonadotropin releasing hormone agonists — Gonadotropin releasing hormone (GnRH) agonists are medicines that work by causing a temporary menopause. The treatment causes the ovaries to stop producing estrogen, which causes the endometriosis implants to shrink.

This treatment reduces pain in over 80 percent of women, including women with severe pain. GnRH agonists are not used if you are trying to become pregnant.

Examples of GnRH agonists include:

  • Nafarelin (Synarel) – Nasal spray taken twice per day
  • Leuprolide (Lupron) – Shot taken once every one or three months
  • Goserelin (Zoladex) – Shot taken once every 28 days

Adult women can take the full dose of a GnRH agonist for up to 12 months. There are concerns about using GnRH agonists at full strength for more than 12 months. Women who use GnRH agonists lose bone density, and this can become serious over time. One way to minimize bone loss is to take hormonal „add-back” treatment (adding very small amounts of either estrogen or a synthetic progestin) in addition to the GnRH agonist.

Taking hormonal add-back can also help to treat the most common side effects of GnRH agonists, which are menopausal symptoms (hot flashes, vaginal dryness, decreased libido, insomnia). (See „Endometriosis: Long-term treatment with gonadotropin-releasing hormone agonists”.)

Aromatase inhibitors — These drugs block the enzyme (aromatase) that increases estrogen levels in tissue. There is increasing evidence that endometriosis tissue makes its own aromatase.

Examples of aromatase inhibitors include letrozole and anastrazole. Both medications are pills that are taken once a day. Combining these drugs with hormonal birth control, progestins, or GnRH agonists may be more effective than any of them alone. This may be a strategy for long-term management of endometriosis pain in women who are not attempting pregnancy since the side effects appear minimal [1,2].

Surgery — Surgery might be an option to treat endometriosis if you:

  • Have severe pain
  • Have tried medicines but still have bothersome pain (attributable to endometriosis)
  • Have a growth or mass in the pelvic area. Surgery may be necessary to remove the mass and figure out if endometriosis, or another problem, is the cause.
  • Are having trouble getting pregnant and endometriosis might be the cause.

The goal of surgery is to remove endometriosis implants and scar tissue. More than 80 percent of women who have surgery have less pain for several months after surgery. However, there is a good chance that the pain will come back unless you take some form of treatment after surgery (like hormonal birth control).

Laparoscopy — Laparoscopy is one way to perform surgery, and is commonly used to diagnose and treat endometriosis. During laparoscopy, a doctor makes several small cuts to place instruments inside the abdomen and pelvis. One of these instruments has a light and camera, which allows the doctor to see the organs on a screen.

Treatment of an endometrioma — Medicines are unlikely to make an endometrioma go away. Surgery to remove the endometrioma if it is larger than 4 to 5 cm, symptomatic or enlarging, is usually recommended because surgery can confirm the diagnosis, prevent complications (such as rupture of the endometrioma), and treat any symptoms, such as pain. (See „Endometriosis: Management of ovarian endometriomas”.)

Removal of the uterus or ovaries — Your doctor might recommend surgery to remove your uterus or ovaries or both if:

  • You have tried other treatments but continue to have severe symptoms
  • You do not want to become pregnant in the future
  • You want a permanent treatment
  • Surgery to remove the uterus is called hysterectomy. (See „Patient education: Abdominal hysterectomy (Beyond the Basics)”.)
  • Surgery to remove the ovaries and fallopian tubes is called salpingo-oophorectomy. It is not always necessary to remove the ovaries to treat endometriosis; this decision will depend on your age and your preferences.

Hormone therapy after surgery — If your ovaries are removed, your doctor or nurse might recommend hormone therapy (estrogen) after surgery. This is especially true for women under age 50 who are not yet menopausal. Estrogen can help to minimize menopausal symptoms like hot flashes, night sweats, vaginal dryness, and bone loss and reduce the long-term health consequences of surgical menopause. (See „Patient education: Menopausal hormone therapy (Beyond the Basics)”.)

INFERTILITY TREATMENT

There are several options for treating infertility in women with endometriosis. The best treatment depends on individual factors, including your age, if there are other fertility issues, and how severe your endometriosis is. Treatment options include:

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