Ovarian endometriosis

What is ovarian endometriosis? It is a complex gynecological disease in the form of the presence in one or both ovaries of abnormal foci of ectopic endometrium - growing outside the uterus tissue that covers its cavity. [1]

Epidemiology

According to statistics, endometriosis affects up to 10% of women of reproductive age, and 20-40% of endometriosis patients are diagnosed with ovarian endometriosis.

This condition is diagnosed in 20-50% of women with infertility.

In 17-44% of patients with endometriosis, ovarian endometrioma is found, accounting for at least 35% of all benign ovarian cysts. At the same time, endometriomas are almost twice as often localized in the left ovary.

Causes of the ovarian endometriosis

Researchers see the causes of this disease:

• in the overgrowth of the inner mucous membrane of the uterus - endometrial hyperplasia, and in uterine adenomyosis;
• in hormonal disorders - imbalance of sex steroids produced by ovaries, in particular estrogen (estradiol) and progesterone, which are the main regulators of endometrial tissue. Estrogen stimulates the proliferation of its cells, while progesterone suppresses it. And also in the disorder of hypothalamic gonadotropin-releasing hormone (gonadotropin) production, in which there are disorders of the menstrual cycle and cyclic phases of endometrial changes, especially its proliferative phase;
• in pronounced hyperestrogenism.

The main etiologic factor of endometriosis affecting the ovaries, most experts consider the so-called retrograde menstruation, in which women experience particularly severe pain during menstruation. And its prevalence in women, according to some data, reaches 75-80%.

Risk factors

Among the risk factors for the development of this ovarian disease are:

• surgical interventions on the uterus;
• prolonged use of barrier (intrauterine) contraception;
• genetic predisposition;
• weakened immune system;
• Thyroid or adrenal diseases resulting in endocrine disruption;
• obesity (excess adipose tissue produces sufficient levels of estrone, which is further converted into 17-β-estradiol).

There is an increased likelihood of developing endometriosis in women with early menarche, as well as those with short menstrual cycles (less than 25 days) or longer menstrual periods (longer than a week).

Pathogenesis

Endometriosis (endometrioid disease) is a common gynecologic disease and is considered estrogen-dependent. The process of overgrowth outside the uterus of the tissue lining its cavity, the endometrium, accounts for the pathogenesis of ovarian endometriosis. But the mechanism of development of ovarian endometriosis is still a subject of research.

Endometrial cells in deep endometriosis are transferred from the uterine cavity through the fallopian tubes to the ovaries. And most experts attribute this to retrograde menstruation, when part of the blood released during menses (containing epithelial, mesothelial, stromal and even endometrial stem cells) does not exit through the cervix and vagina, but through the open fallopian tubes into the abdominal cavity-filling (peritoneal) fluid. Then the cells of the rejected endometrial tissue by adhesion are implanted into the tissues of the pelvic organs, including the ovaries, with the formation of pathological (ectopic) foci - the so-called endometrioid heterotopias or implants. [2]

Not only are endometrioid tissue cells capable of growth; they have been found to differ from normal uterine endometrium in having an increased number of nuclear estrogen receptor beta (ERβ) and more active estrogen metabolism, as well as producing cytokines and inflammatory mediators (prostaglandins).

According to recent studies, in patients with endometriosis, peritoneal fluid contains an increased number of activated macrophages and other immune cells that secrete growth factors and cytokines. Acting on endometrial cells, they increase its proliferative activity, change the structure and function of tissues.

The disease is particularly severe when endometrial stem cells spread outside the uterus, as they retain the ability to extensive adhesion, multiplication and differentiation.

With inversion and progressive invagination of the ovarian cortex by overgrowing endometrioid tissue of the superficial ectopic focus, a benign endometrioid cyst of the ovary or endometrioma may form. This is a so-called "chocolate cyst" that has dark brown contents - hemolyzed blood. [3]

Symptoms of the ovarian endometriosis

The first signs of ovarian endometriosis can be manifested by heavy menstrual bleeding and dysmenorrhea (painful periods).

Most patients suffer from excruciating pelvic pain with ovarian endometriosis, which can be sharp, stabbing, pulling and throbbing. This non-menstrual pelvic pain may be worse during urination, defecation or sexual intercourse.

In addition, clinical symptoms are manifested by menstrual irregularities, heaviness in the abdomen and its bloating, a constant feeling of fatigue, anemia.

Stages

The classification system used by most gynecologists distinguishes four stages or degrees of endometriosis - depending on the number of lesions and the depth of infiltration of endometrioid tissue:

• Stage I or minimal, with the presence of a few small superficial endometrioid heterotopias;
• Stage II or mild - the number of heterotopias is greater and they are deeper, there may be an endometrioma on one ovary;
• Stage III is moderate, with multiple deep areas of lesions, small cysts on one or both ovaries, and localized filmy adhesions around the ovary;
• Stage IV is severe, with many deep endometrioid foci, large cysts (on one or both ovaries), and many dense adhesions.

There are such types of this disease as internal endometriosis of the ovaries or cystic ovarian endometriosis, in which an endometrioma of the ovary is formed, that is, a cyst, as well as external endometriosis of the ovaries with pathological foci of ectopic endometrium on their surface.

By localization, a unilateral lesion is distinguished: endometriosis of the right ovary or endometriosis of the left ovary. And endometriosis of both ovaries is called bilateral.

Complications and consequences

The list of possible complications and consequences of ovarian endometriosis includes:

• chronic pelvic pain;
• ovarian dysfunction;
• formation of adhesions in the pelvis;
• Associated peritoneal lesions suggestive of deep infiltrative, i.e., generalized endometriosis (which can lead to urinary and/or bowel obstruction);
• The ovaries adjoining each other behind the uterus - in bilateral endometriomas;
• Rupture of cysts (with sudden severe abdominal pain, fever, vomiting, bleeding, dizziness or fainting), which is fraught with the spread of endometriosis into the pelvic cavity.

A separate problem is ovarian endometriosis and pregnancy. This pathology is closely related to a woman's fertility: up to 50% of patients with ovarian endometriosis experience difficulties with pregnancy. According to one version, the endometrial tissue growing outside the uterus can block the movement of eggs through the fallopian tubes (due to their obstruction) and disrupt the process of ovulation. And in the case of complete replacement of ovarian tissue with modified endometrium, pregnancy after ovarian endometriosis is impossible, and almost a third of infertile women suffer from endometriosis. [4]

Malignant transformation of endometrioma into endometrioid or clear cell carcinoma is not excluded, but data on the incidence of malignization are contradictory: some sources cite only 1% of cases, while others cite over 70%.

Diagnostics of the ovarian endometriosis

Timely diagnosis of this pathology will help to start treatment in time and avoid serious negative consequences. Studies show that the longer the diagnosis is delayed, the later the stage of endometriosis.

In addition to collecting anamnesis and gynecological examination, it is necessary to take blood tests: general and biochemical, for the level of sex hormones (estrogen and free 17-β-estradiol, progesterone, FSH, etc.), for cancer antigen CA-125 in blood.

To visualize pathological changes, instrumental diagnostics is performed using:

• Transvaginal ultrasound - Pelvic and uterine ultrasound;
• Ovarian Doppler;
• a CT or MRI;
• diagnostic laparascopy.

There are ultrasound signs of ovarian endometriosis such as the presence of hypoechogenic masses, and in the case of endometrioma, ultrasound also reveals an anechogenic mass in the ovary.

MRI in ovarian endometriosis is more specific, especially for the diagnosis of endometriomas, since localized fluid accumulations - lesions containing blood products - can be detected with MRI in TT1 and T2-weighted modes. [5]

Differential diagnosis

The differential diagnosis includes other benign and malignant ovarian masses: ovarian tumors and all types of cystic masses (dermoid and follicular ovarian cysts, corpus luteum cysts and cystomas). Given the significant similarity of symptoms, endometriosis and polycystic ovarian syndrome - polycystic ovarian syndrome, as well as endometriosis of the ovary and uterine myoma (fibroid) should be differentiated.

Treatment of the ovarian endometriosis

Usually the treatment of ovarian endometriosis is aimed at reducing the intensity of its clinical symptoms, since there is currently no cure for this pathology. [6]

First, progestin-based hormonal contraceptives (e.g., Marvelon, Orgametril, Regulon, etc.) are prescribed to help control the hormones responsible for the overgrowth of endometrial tissue.

Hormonal progestogenic agents are used. For example, orally taken tablets Dufaston in endometriosis of the ovary increase the level of the sex hormone progesterone (because they contain its synthetic analog dydrogesterone). Its side effects include headaches and breakthrough bleeding.

About the hormonal (progestogenic) drug Vizanna (synonym - Dienogest Alvogen) in detail in the article - Vizan.

Preparations of the group of gonadotropin-releasing hormone agonists are used, in particular, Buserelin or its synonyms - Difelerin, Zoladex and others.

More details in the publication - Drugs for the treatment of endometrial hyperplasia

About what suppositories for ovarian cysts and endometriosis are recommended by gynecologists, read in the material - Suppositories for endometriosis

Depending on the patient's examination findings, age, history and symptomatology, surgical treatment is performed, including:

• Ovarian cyst laparoscopy;
• endometrioma drainage;
• Cystectomy (removal of the endometrioma wall);
• Sclerosing destruction of an endometrioid cyst of the ovary;
• ablation of ovarian endometriomas.
• Enucleation of ovarian cysts.

In the most severe cases, ovarian resection - surgery to remove the ovaries, as well as hysterectomy (removal of the uterus) is attempted.

Treatment of ovarian endometriosis with folk remedies

In mild cases, it is also possible to treat endometriosis of the ovary with folk remedies, which are similar to those suggested:

• Folk treatment of endometrial hyperplasia
• Folk treatment of ovarian cysts

Keep in mind that herbs for ovarian endometriosis are herbs that increase progesterone, which include yarrow, angelica medicinalis, common twig, hog uterus (ortilia lopsided) and others.

Containing phytoestrogens hog uterus with endometriosis of the ovary helps and establish a broken menstrual cycle, but is contraindicated in menstrual and other bleeding. Usually taken decoction or infusion of this plant - 100 ml twice a day.

Also in the form of an infusion or decoction, as a styptic, cuff is used from endometriosis on the ovaries.

And Rhodiola quadrifida (Rhodiola quadrifida) of the family Crassulaceae or red brush for endometriosis and ovarian cysts (decoction or alcohol tincture of the root and rhizome of the plant) can be used to improve the general tone of the body and humoral immunity, as well as anti-inflammatory and antidepressant. In addition, among the official recommendations for its therapeutic use are thyroid disorders, the presence of thickened mammary glands (mastopathy) and uterine myoma.

Nutrition in ovarian endometriosis

Emphasizing the important role in symptom control that nutrition plays in ovarian endometriosis, experts advise patients to switch to vegetarianism: according to studies, estrogen levels in women who follow a vegetarian diet are on average 15-20% lower than in those who are unable to give up meat.

In principle, the diet for ovarian endometriosis involves the consumption of whole-grain products; foods high in polyunsaturated omega-3 fatty acid (marine fish, walnuts, flaxseed oil and seeds); fresh fruits and vegetables. Especially useful are cabbage (white cabbage, cauliflower, Brussels sprouts), broccoli, and legumes. It is recommended to replace red meat with white meat (chicken).

Prevention

There is currently no known way to prevent endometriosis, including ovarian endometriosis.

Forecast

As with many gynecologic diseases, the prognosis of the outcome of endometriosis of the ovary is determined by the stage - the degree of its severity at the time of diagnosis, and also depends on the results of treatment. This pathology after surgical intervention can recur, but with a mild stage of the disease, symptoms often disappear after menopause.