What is endometriosis?

From the Guidelines

The most effective approach to managing endometriosis involves a combination of medical therapies and surgical excision by a specialist, with preoperative imaging playing a crucial role in reducing morbidity and mortality. Endometriosis is a common condition impacting approximately 10% of individuals assigned female at birth 1. The disorder is caused by endometrial-like tissue located outside of the endometrial cavity, associated with inflammation and fibrosis, on or extending below the peritoneal surface 1.

Diagnosis and Treatment

The diagnosis of endometriosis is challenging due to variable presenting symptoms and nonspecific physical examination findings 1. Historically, the diagnosis of endometriosis was made by diagnostic laparoscopy with histologic inspection. However, studies have shown that preoperative imaging is associated with decreased morbidity and mortality and reduces the need for repeat surgeries by reducing the number of incomplete surgeries 1.

Some key points to consider in the management of endometriosis include:

• The use of expanded protocol transvaginal ultrasound (TVUS) studies to identify and “map” deep endometriosis (DE) 1
• The importance of special training for performing these expanded TVUS examinations, which are associated with a learning curve of at least 40 examinations 1
• The recommendation to use an MRI protocol tailored for detection of DE, with moderate bladder distention and vaginal contrast to help improve lesion conspicuity involving these structures 1
• The potential role of fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)-PET/CT and the radiopharmaceutical fluoroestradiol in detecting endometriosis, although further research is needed 1

Quality of Life and Morbidity

The clinical presentation of endometriosis is variable, ranging from asymptomatic to severe symptoms that interfere with daily activity 1. Pelvic pain is the most common symptom, which can manifest as dysmenorrhea, dyspareunia, dyschezia, dysuria, or menorrhagia. Approximately one-half of patients with endometriosis experience infertility 1. Treatment of endometriosis should prioritize reducing morbidity and mortality, while also improving quality of life, and may involve a combination of medical therapies and surgical excision by a specialist. Health care spending on endometriosis is similar to other chronic diseases with an estimated annual economic burden of $69.4 billion 1.

In terms of specific treatments, options may include:

• Medical therapies such as nonsteroidal anti-inflammatory drugs (NSAIDs) or hormonal treatments like combined oral contraceptives or GnRH agonists
• Surgical options ranging from conservative laparoscopy to remove endometriotic lesions while preserving fertility, to hysterectomy with removal of ovaries in severe cases when fertility is no longer desired
• The use of preoperative imaging to inform patient decision making, surgical planning, and management 1

From the Research

Definition and Prevalence of Endometriosis

• Endometriosis is a chronic benign disease that affects women of reproductive age, with a prevalence of about 10% 2.
• It is characterized by the presence of endometrial-like tissue outside the uterus, leading to various symptoms such as pain and infertility.

Medical Treatment Options

• Medical therapy is often the first line of management for women with endometriosis, aiming to ameliorate symptoms or prevent post-surgical disease recurrence 3.
• Available medical options include:
  • Non-steroidal anti-inflammatory drugs (NSAIDs) for relieving primary dysmenorrhea 3.
  • Combined oral contraceptives and progestins as first-line hormonal therapies, which have been shown to improve pain symptoms in the majority of patients 3, 2.
  • Gonadotropin-releasing hormone-agonists (GnRH agonists) for women who do not respond to first-line therapies, although they have a less favorable tolerability profile 3.
  • Gonadotropin-releasing hormone antagonists, which have shown promise in late-stage clinical development 3, 4.

Hormonal Treatments

• Hormonal treatments aim to block menstruation or cause pseudodecidualization, impairing the progression of endometriotic implants 5.
• Options include:
  • GnRH agonists and antagonists, which act on pituitary-ovarian function 5.
  • Progestins, such as dienogest, which act on multiple sites of action 5.
  • Combined oral contraceptives, which inhibit ovarian function 5.
• Add-back therapy, including estrogens, may be used to prevent bone loss and improve quality of life 6.

Current Research and Future Directions

• Research is ongoing to develop new treatments for endometriosis, including selective progesterone receptor modulators, selective estrogen receptor modulators, and aromatase inhibitors 5.
• Oral GnRH antagonists, such as elagolix, relugolix, and linzagolix, have shown efficacy in reducing endometriosis-associated pain and are currently being investigated in clinical trials 4.