Endometriosis
What is Endometriosis?
The uterus is lined by a tissue called the endometrium, composed of a superficial layer, that undergoes change during the menstrual cycle (growth and shedding) and a basal layer with regenerative functions.
When endometrial-like tissue grows in ectopic locations, it is referred to as endometriosis.
Endometriosis is an inflammatory disease, often referred to as chronic, that affects 10% to 17% of women of reproductive age. This percentage rises to 35%-60% among those women experiencing chronic pelvic pain, infertility, or both, leading to high direct and indirect healthcare costs and a significant impact on a patient’s quality of life.
Because of its often painful symptoms and chronic nature, endometriosis significantly affects women’s physical and psychological health.
Diagnostic delays average 7 to 8 years from the onset of symptoms, particularly in deep infiltrating forms, due to the complexity of diagnosis.
Diagnostic accuracy is closely linked to the specialist’s experience, which generally correlates with the volume of cases managed.
While surgery was once considered the Gold Standard for diagnosis, today advances in technology have made ultrasound and MRI the primary diagnostic tools, as long as they are performed by experienced operators.
The treatment of endometriosis largely depends on the patient’s age, desire for future pregnancy, the degree of pain and the impact on quality of life.
The primary goal in treating endometriosis is to control symptoms and prevent or delay the progression of the disease by reducing endometriotic implants.
This can be achieved through surgery or by pharmacologically inducing atrophy of the ectopic uterine mucosa (e.g., continuous progestins, oral contraceptives, or GnRH analogues).
Good to Know
Endometriosis is a medical condition characterized by the proliferation of endometrial-like tissue (which is normally found inside the uterus) in abnormal pelvic or extra-pelvic locations.
Although it is currently one of the most extensively studied diseases in gynecology, many aspects of its causes and pathogenesis remain unclear.
There are four main types of endometriotic lesions: adenomyosis (within the uterine muscle), endometriomas (in the ovary), superficial endometriosis (often associated with adhesions) and deep infiltrating nodules (penetrating pelvic or extra-pelvic organs). These endometriotic lesions cause an inflammatory process often associated with painful symptoms.
Depending on its location, endometriosis can cause menstrual pain (Dysmenorrhea), pain during intercourse (Dyspareunia), bowel habit alterations (Constipation/Diarrhea/Bloating and Gas), pain during defecation (Dyschezia), pain during urination (Dysuria) and sometimes chronic pelvic pain.
These symptoms, when severe, can significantly impact quality of life. However, the severity of symptoms does not always correlate with the extent of the disease: although rare, there may be cases of severe endometriosis with mild symptoms or, alternatively, patients experiencing intense symptoms despite having minimal or even no visible endometriosis.
Given the extreme variability in clinical presentation and the possible lesion location, a thorough preliminary assessment of the medical condition is crucial. This includes medical history, gynecological examination, pelvic and abdominal ultrasound by an experienced operator and additional tests if needed. Only after this evaluation, the most appropriate therapeutic approach can be chosen, based on the specific characteristics of the case and the patient’s individual needs.
The cornerstone of endometriosis treatment is medical therapy (hormonal therapy) to control symptoms, slow disease progression, and prevent recurrence after surgery.
INDICATIONS FOR SURGERY:
- Failure of medical therapy
- Contraindications to medical therapy
- Poor long-term tolerance to medical therapy
- Functional impairment of organs
- Intestinal stenosis or sub-stenosis
- Ureteral stenosis
- Bladder infiltration
- Nerve structure infiltration
- Infertility with no compliance to ART (Assisted Reproductive Techniques)
- Infertility associated with 2 or more failed ART attempts
Surgical treatment of endometriosis involves complete removal of macroscopically visible endometriotic lesions during a single procedure, performed laparoscopically (a minimally invasive technique involving the insertion of surgical instruments and a camera into the abdomen through small incisions).
The recurrence rate is generally related to the radicality of the surgery. Therefore, the more complete and accurately performed the surgical procedure, the lower the likelihood of disease recurrence.
The goal of surgical treatment is to eradicate endometriotic lesions, relieve pain and restore the anatomy of affected organs. In some cases, this may also increase the chances of conception in infertile patients. Endometriosis is a chronic, recurrent disease, meaning recurrence of both pain and lesions is possible even after properly performed surgery, especially if the patient does not follow a post-operative medical therapy.
According to scientific literature, the risk of disease recurrence after surgery ranges from 2% to 50% within the first 5 years. It is important to note that the presence of lesions after incomplete surgery should be considered persistent disease, not recurrence.
In our case series, the recurrence rate of deep infiltrating endometriosis (two years after surgery) is below 5%.
However, ovarian recurrence is more common, ranging from 2% to 12% in patients undergoing continuous progestin or combined estrogen-progestin therapy, and rising to approximately 40% in patients who are not receiving any pharmacological treatment.
Tips for a Healthy and Balanced Nutrition
An anti-endometriosis diet plays an important complementary role in supporting therapy, enhancing its effectiveness and alleviating related pain symptoms by substantially reducing inflammation and circulating estrogen levels.
This diet is based on a combination of anti-inflammatory, detoxifying, and hormone-free foods known for their ability to slow disease progression.
Women affected by endometriosis should be aware that some foods, although generally considered healthy, may worsen inflammation due to their pro-inflammatory components.
On the other hand, other foods help counteract and reduce inflammation (anti-inflammatory).
Therefore, dietary choices can significantly support in managing endometriosis.
The anti-endometriosis diet must always be tailored to the woman’s symptoms, clinical history and social and professional needs.
The guide available for download has been prepared by the Head of the Clinical Nutrition Unit at the National Endometriosis Center.
The numbers of the National Endometriosis Center
outpatient visits per year