AFJOG

REVIEW INTRODUCTION Endometriosis is a chronic disease that require a life- long management plan with the goal of maximizing the use of medical treatment and avoiding repeated surgical procedures. Instead of assessing endometriosis on the day of diagnosis, gynaecologists should preferably consider the patient’s “endometriosis life”. 1 It is a chronic inflammatory, hormonal, immune, systemic and heterogenous disease with three different phenotypes: superficial, ovarian and deep. The clinical hallmarks of symptomatic endometriosis are chronic pelvic pain and infertility. The prevalence of endometriosis in the general female population is estimated to be 2% - 10% and up to 50% in patients with infertility. Despite the high prevalence, there is a diagnostic delay of 8 -12 years from onset of symptoms to the eventually diagnosis. 2 This delay in diagnosis, is probably one of the reasons that many patients are only diagnosed when they present with advanced stage endometriosis. Adolescent girls with severe period pains are amongst the most frequently misdiagnosed group of patients. Although it is defined as the presence of endometrial glands and stroma outside the uterine cavity, laparoscopy and histological confirmation of endometrial glands and stroma are no longer the gold standard for diagnosing endometriosis. 2 The diagnosis can be made, and treatment commenced based on history and clinical findings only. Pathophysiology of endometriosis Endometriotic tissue arise from the eutopic located intracavitary endometrium. Oligoclones of endometrial glandular epithelial cells with somatic mutations and attached stromal cells may give rise to endometriosis if they travel to the peritoneal surfaces via retrograde menstruation and/or become entrapped in the myometrium to give rise to adenomyosis. 3 The endometrial cell population within the endometriotic tissue, possess survival and growth capabilities conferred by the somatic epithelial mutations and epigenetic abnormalities of the stromal cells. These epigenic defects give rise to excessive local oestrogen biosynthesis by aromatase and abnormal oestrogen action. These patients also have deficient progesterone receptor expression resulting in progesterone resistance. Extra pelvic endometriosis Extra pelvic endometriosis refers to endometriotic lesions implanted outside the pelvic cavity. These include lesions in the gastrointestinal system, diaphragm, pulmonary system, umbilical lesions and skin lesion on surgical scars. The diagnosis of extra pelvic endometriosis is further delayed by the atypical location of symptoms. The rectum and sigmoid colon are the most common GIT sites of endometriosis with the appendix involved in 5 – 20% 0f cases. 4 Endometriosis within the chest involving the lung parenchyma, pleural surfaces or diaphragm present with atypical symptoms such as haemoptysis, haemothorax and catamenial pneumothorax (thoracic endometriosis syndrome). A high index of suspicion is required to make an early diagnosis. Primary umbilical endometriosis is an uncommon form of extra pelvic endometriosis where the disease is confined to the umbilicus only. These patients present with cyclical umbilical bleeding and pain. Figure 1.: Primary umbilical endometriosis J Biko Department of Obstetrics & Gynaecology, Reproductive unit, University of Pretoria, Pretoria, South Africa CORRESPONDENCE: J Biko| Email: drbiko@icloud.com Endometriosis: An overview Keywords: Dysmenorrhea, chronic pelvic pain, infertility, progesterone resistance African Journal of Obstetrics and Gynaecology | Volume 1 | Issue 1 | 2023 | 11