What is endometriosis?
In the absence of pregnancy, the endometrium (the mucous membrane that lines the uterus) breaks down every month and is evacuated in the menstrual blood. In women who suffer from endometriosis, fragments of this mucous membrane migrate outside the uterine cavity and attach themselves to certain organs: the uterus, the ovaries, the bladder… “Every month, at the time of menstruation, these fragments of mucous membrane having migrated into the belly bleed, causing irritation of the peritoneum, cysts or nodules”, explains Prof. Philippe Descamps, obstetrician-gynecologist and head of the endometriosis reference center at the CHU d’Angers, EndorefAngers. Consequences: women sometimes feel intense pain during menstruation and some have infertility problems.
What are the stages of endometriosis?
Endometriosis is classified into three types, depending on the location and extent of the lesions.
– Superficial or peritoneal endometriosis
Fragments of uterine mucosa are grafted onto the peritoneum, the envelope that surrounds the bladder, uterus and rectum. “These lesions are not always visible on ultrasound or MRI, but they can lead to pain and adhesions”, specifies Professor Descamps.
– Endometrioma or ovarian endometriosis
Menstrual blood accumulates in an ovary, forming a kind of pocket. This cyst is visible on ultrasound or MRI.
– Deep endometriosis
This type of endometriosis affects certain organs such as the rectum, the intestine, the bladder or the uterosacral ligaments which are inserted behind the uterus.
Deep endometriosis: what symptoms?
Menstrual pain (dysmenorrhea) is characteristic of endometriosis regardless of the form of the disease. The intensity of these pains varies from one patient to another. “There is no parallelism between anatomy and the clinic, explains Professor Descamps. Some women have very painful small lesions. Others have significant lesions but without the pain being very strong. »
– Sexual intercourse can become painful in case of endometriosis, especially when the lesions are located between the uterus and the rectum. We are talking regarding dyspareunia.
– In deep endometriosis, digestive organs (colon or rectum) may be affected with symptoms such as:
– pain during defecation which is explained by the presence of lesions in the rectum.
– An alternation of diarrhea and constipation in the premenstrual period.
Deep endometriosis and IVF
Some women with endometriosis may have difficulty getting pregnant and need to have in vitro fertilization (IVF). In reality, the chances of pregnancy vary greatly from patient to patient. A woman suffering from deep endometriosis can become pregnant naturally or be forced to resort to medically assisted procreation, it all depends on the lesions she suffers from.
Does deep endometriosis surgery improve fertility?
“We don’t have proof of that. A trial is underway in various French centers to try to find the answer,” replies Professor Descamps. In the meantime, only one certainty: the removal of a nodule located in the vagina will relieve pain and facilitate sexual intercourse. So somehow improve fertility.
How do you know if you have deep endometriosis?
In endometriosis, two imaging examinations are essential: ultrasound and magnetic resonance imaging (MRI).
In all cases, we start with an ultrasound to visualize the lesions. For better efficiency, the examination should preferably be carried out in a reference center, where the sonographers are real specialists in endometriosis.
To diagnose deep endometriosis, MRI is used more often. “It helps to locate the lesions and their extension”, says the gynecologist.
Is the vaginal examination essential?
In recent years, women suffering from endometriosis have denounced the systematic practice, in consultation, of extremely painful vaginal examinations. Some have been traumatized. Today, Professor Descamps believes that practices are changing: “There has been an awareness among gynecologists. Most often, it is not necessary to perform a vaginal examination, or even a digital rectal examination, if an ultrasound and a quality MRI are available. These examinations are generally sufficient to provide us with very precise information. In addition, these examinations can be performed in the operating room if the patient is operated (she will therefore be asleep, editor’s note)”
How to treat deep endometriosis?
Whatever the type of endometriosis, the management of the disease is always personalized, adapted to each woman with, at the center of the concerns, the preservation of fertility. Each patient must therefore be accompanied until her menopause, a period during which the endometriosis disappears spontaneously.
The treatment includes different levels:
– The continuous pill: first treatment for endometriosis
Concretely, it is a question of taking contraception every day and without interruption, in order to suppress hormonal variations. The periods will disappear and, consequently, the pains which accompany them. The treatment will also stop the progression of the disease by preventing the lesions from proliferating. “It’s important to explain to young women that it’s okay to stop having periods. The body does not need menstruation blood to purify itself every month,” reminds the gynecologist. Another progesterone drug, dienogest, may also be prescribed. It has, like the continuous pill, the particularity of suppressing menstruation.
To allow pregnancy, treatment is interrupted for as long as necessary. But it will have to be resumed followingwards, otherwise the endometriosis will return. “Pregnancy is often experienced by women suffering from endometriosis as an enchanted parenthesis. Due to the risk of recurrence, it will be necessary to resume treatment following childbirth”, observes the gynecologist.
– Treat pain without hormones
Some women refuse to take hormone therapy. In this case, the pain is combated by other means (analgesic drugs, electrostimulation, etc.). But if they can temporarily relieve the patient, these treatments do not act on the mechanism of the disease.
Deep endometriosis: which surgical treatment?
Surgery is only considered when “the pain is resistant to medical treatment”, explains Professor Descamps. “It is a complex surgery, which must be performed in a reference center by a double team including a gynecologist and a digestive surgeon”, he specifies. Nodules and cysts that have grafted onto the organs are usually removed by laparoscopy (surgical instruments are introduced through small incisions in the abdomen).
In some cases of deep endometriosis, resection of part of the rectum or intestine is sometimes necessary. The anastomosis (the two parts are sewn together) is performed immediately.
“In the event of deep endometriosis in a young woman, it is important to check that the surgery does not affect the integrity of the genital system to preserve the chances of pregnancy”, explains the specialist. In a woman over 40, it is sometimes necessary to remove the uterus (hysterectomy).
Surgery for deep endometriosis: what are the risks of complications?
Any surgical operation involves risks and each woman is informed of this before the intervention. Complications (loss of sutures, fistula, difficulty urinating, etc.) concern 5 to 10% of cases. It is sometimes necessary to re-operate the patient. To limit these risks as much as possible, Professor Descamps recalls the importance of being treated in a reference center for endometriosis, where practitioners trained to perform this surgery practice.
To know : patient associations were created around endometriosis, as EndoFrance et EndoMind.
