AFJOG

REVIEW Diagnosis Historically, the diagnosis of endometriosis was based on visual inspection of the lesions at laparoscopy with histological confirmation of the presence of endometrial glandular cells and stroma. This unfortunately resulted in many unnecessary laparoscopic procedures simply to confirm the diagnosis. The current opinion is that the diagnosis of endometriosis should be considered in individuals presenting with the following cyclical and noncyclical signs and symptoms: dysmenorrhea, deep dyspareunia, dysuria, dyschezia, painful rectal bleeding, haematuria, shoulder tip pain, catamenial pneumothorax, cyclical cough/haemoptysis, chest pain, cyclical scar swelling and pain and infertility. 2 A thorough clinical examination, including a digital examination were appropriate, should be done to exclude the presence of palpable endometriotic nodules and a transvaginal ultrasound (were appropriate) should be done determine the presence of endometrioma, adenomyosis and endometriotic nodules. Endometriosis associated pain. Pain is one of the predominant clinical features of endometriosis. The pain symptoms include, cyclical period pains, deep dyspareunia, noncyclical pain and dyschezia. Pain relies on the existence of sensory transduction pathways linking peripheral stimuli to the spinal cord for processing and the brain for perception. However, endometrial fragments do not have an intrinsic sensory nerve supply. For endometrial lesions to induce chronic pelvic pain, the development of new sensory nerves to convey these signals need to occur. Studies have now shown that once endometrial fragments adhere to a peritoneal location and become lesions, they undergo a process of neuroangiogenesis. 5 This formation new nerves and blood vessels plays an essential role in the development and progression of endometriosis associated chronic pelvic pain. There is now a significant body of literature demonstrating that chronic pelvic pain, regardless of the cause, is associated with alterations in brain function, particularly about the processing of pain and other sensory information. 6 In another small study, Hanna Grundstrom et al, showed widespread alterations in pain thresholds of women with persistent pelvic pain that are indicative of central sensitization. 7 Current evidence demonstrates that chronic pelvic pain, whilst perceived as a peripheral (pelvic) condition, is in fact associated with significant central changes when compared with healthy pain-free women. These findings support the use of adjunctive medication targeting the central nervous system (such as amitriptyline, duloxitine and gabapentin. 8 Endometriosis – associated pain arises due to initial local inflammatory and nociceptive events and develops as a product of peripheral sensitization, central sensitization and cross- organ sensitization. This pain often coexists with and is further complicated by other pelvic pain syndromes such as irritable bowel syndrome and bladder pain syndrome. 9 Management of endometriosis pain NSAIDs Non-steroidal anti-inflammatory drugs are widely used for symptomatic treatment of pelvic pain. Long – term use is associated with bowel side effects. Progestins The ASRM recommends progestins as first line therapy for the management of endometriosis associated pain. Studies have shown similar efficacy of Dienogest to the GnRh- analogues but with a better tolerability. The 3- monthly injection of Medroxyprogesterone acetate has been shown to be effective but also very economical with less bone loss when compared to GnRH- agonists. MPA is also regarded as first line management of endometriosis by ESHRE. Other recommended progestins include the Levonorgestrel intrauterine system. Combined oral contraceptive pills. The oral contraceptive pill is widely used to treat dysmenorrhea. They have been shown to be superior to placebo in the management of dysmenorrhea. Gonadotropin releasing hormone analogues. The use of GnRH analogues should be reserved for patients who did not respond to first line therapy. Add back therapy with Progestin – only or progestin with low dose oestrogen should be given at the commencement of GnRH therapy to reduce the hypooestrogenic side effects. Other drugs Other drugs such as aromatase inhibitors and Danazol have been shown to reduce pain but they are either not FDA approved or their side effect profile is unacceptable. Adjunctive therapy Medication such as amitriptyline and duloxitine, that modulates the nervous system should be considered in patients with chronic pelvic pain Laparoscopic surgery should only be offered to patients who do not respond to medical management and those with advanced stage endometriosis wishing to conceive. Endometriosis surgery is very challenging and is associated with significant morbidity. It is best done in a center with an experienced multidisciplinary team. Patients must be adequately counselled about the possible side effects of the surgery. It is important to note that surgery does not reduce pain in 20 – 28% of patients, 10 and that up to 60% of patients will require a repeat laparoscopy in 5 years. Endometriosis associate infertility Although endometriosis impairs reproduction, it does not usually completely prevent pregnancy. Ovulation induction with timed intercourse or intrauterine insemination, assisted reproductive techniques and surgery in selected cases, do enhance the chances of conception. The mechanisms underlying endometriosis related infertility are not completely known. In cases of advanced endometriosis (ASRM stage 3 and 4), anatomical changes of the reproductive tract such as peritubal and periovarian adhesions as well as pelvic distortions are implicated as limiting factors which would impair oocyte capture by the fimbriae, its passage through the fallopian tubes as well as gamete interaction. 11 In patients with minimal to mild disease, fertility impairment is thought to be due to inflammatory changes in the peritoneal cavity and follicular environment, sperm function, abnormal endometrial receptivity and possibly progesterone resistance. Patients with minimal to mild endometriosis could be offered controlled ovarian stimulation whilst patient with African Journal of Obstetrics and Gynaecology | Volume 1 | Issue 1 | 2023 | 12