Clinical presentation and indications for treatment
Mild forms of the disease may remain completely asymptomatic for a long time, yet they frequently cause infertility (occurring in 91% of cases with isolated lesions).
When lesions invade the muscular layer of the rectum or pararectal tissue, pronounced symptoms develop:
- Chronic pelvic pain.
- Dyspareunia (painful intercourse).
- Specific sign: pain intensity peaks immediately before and right after menstruation.
The presence of these symptoms, as well as the formation of endometrioid ovarian cysts (formations containing thick, tar-like chocolate-colored fluid), serves as a direct indication for initiating combination therapy.
Diagnostic minimum before treatment
To select the correct management strategy, the extent of the process must be accurately assessed. The primary imaging method is laparoscopy, which allows not only visualization of the lesions but also biopsy sampling.
- Ultrasound with CDI: helps assess blood flow in the walls of formations (e.g., in the capsule of endometrioid ovarian cysts).
- Laboratory screening: a panel of three tumor markers is used to monitor treatment efficacy. Normally in endometriosis, CA 19-9 ranges from 13.3 to 29.5 IU/mL, CA 125 does not exceed 35 IU/mL in 95% of cases (averaging 27.2 IU/mL), and CEA is approximately 4.3 ng/mL.
Surgical treatment and preoperative preparation
Surgery is the leading method in combination therapy. The goal of the operation is maximum excision or destruction of heterotopias. Removal is performed using an argon beam coagulator, ultrasonic scalpel, laser, or cryodestruction.
Preoperative preparation strategy strictly depends on the stage:
- Advanced forms (with infiltration of adjacent organs and adhesions): preliminary hormone therapy (GnRH agonists or antigestagens) is indicated. This limits the lesion zone, reduces tissue destruction, and minimizes blood loss.
- Mild forms: prescribing hormones before surgery is inadvisable. Medications cause blanching, atrophy, and partial regression of lesions, which may cause the surgeon to simply overlook and fail to remove them during laparoscopy.
Hormone-modulating therapy
Medical treatment aims to create an acyclic environment with low estrogen levels or to induce a high-androgen status in the body. This leads to atrophy of the endometrium and the implants themselves.
- Estrogen-progestin drugs (Jeanine, Marvelon, Regulon, etc.): first-line therapy for pelvic pain and menorrhagia. Prescribed continuously for 6–9 months. The main risk is an increased probability of thrombosis.
- Progestogens (dydrogesterone, medroxyprogesterone): cause hyperprogesteronemia. Excellent for pain relief. Taken in courses from 3 to 12 months. Disadvantages include potential edema, weight gain, and mastodynia.
- GnRH agonists (goserelin, buserelin, triptorelin): temporarily block the pituitary gland, inducing reversible amenorrhea. Provide clinical improvement in 85% of patients. Prescribed as depot formulations for 6 months. Limitation: estrogen deficiency symptoms (hot flashes, loss of bone mineral density, depression).
- Antigestogens: mifepristone, gestrinone.
Specific features of treatment for individual localizations
- Cervix and vagina: local destruction is used (radiocoagulation, laser, cryodestruction). Low-dose estrogen-progestin combinations are prescribed for 3–6 months to prevent recurrence.
- Retrocervical endometriosis: requires surgical excision of lesions. In severe cases, hysterectomy with adnexectomy and plastic surgery of adjacent organs (rectum, urinary tract) is indicated.
- Adenomyosis (internal endometriosis): hormone therapy is initiated for pain and bleeding. If ineffective, hysterectomy without adnexa is performed. In patients who have completed their reproductive planning with superficial forms (stage I), endometrial ablation (laser, thermal, cryoablation) can be performed. It is important to remember that any type of ablation leads to the formation of intrauterine synechiae.
- Adenomyosis with uterine fibroids: hormone therapy has low efficacy. Hysterectomy or uterine artery embolization (UAE) is recommended.
To memorize the main drug classes, use the acronym PEGA: Progestogens, Estrogen-progestins, GnRH agonists, Antigestogens.
Class and exam questions
Is it necessary to prescribe hormones before removing small forms of endometriosis?
No, this is not advisable. Hormone therapy causes partial regression and blanching of lesions, which significantly impedes their visualization and complete removal during laparoscopy.
Who is indicated for endometrial ablation in adenomyosis?
Only to patients with superficial forms (stage I) who have already completed their reproductive planning, as the procedure inevitably leads to the formation of intrauterine synechiae.
What side effects limit the use of GnRH agonists?
Drugs of this group induce artificial menopause, which is accompanied by estrogen deficiency symptoms: hot flashes, depression, and impaired bone mineral metabolism.
What else to study on this topic
- Laparoscopic presentation and evolution of endometrioid lesions
- Fallopian tube endometriosis (Endometriosis tubae uterinae) and mechanisms of infertility development
- Characteristics of pain syndrome in invasive growth of heterotopias
- Diagnostic value of tumor markers (CA 125, CA 19-9, CEA)
- Ultrasound diagnostics and color Doppler mapping (CDM)
Master the entire topic in the "Obstetrics and Gynecology" course
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- Complete guideline on "Treatment of Endometriosis" and another 973 pages of the subject
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Other topics in the "Gynecology" section
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