Pathology
Endometriosis is a widespread condition (affecting about one in 10 women), characterized by the presence of the tissue that normally lines the inside of the uterus (endometrium) outside the uterine cavity itself.
Endometriosis is a multifactorial and hormone-dependent condition typical of childbearing age. It generally has a chronic, progressive course with possible recurrence, and manifests mainly with pelvic pain and difficulty in conception(infertility).
The most common sites where endometriosis implants develop are the ovaries, the pelvic peritoneum (the membrane that lines the pelvis internally), and the recto-vaginal septum (the space between the rectum and vagina). However, this disease can also affect other organs and tissues of the body, with the exception of the spleen.
Endometriosis is also associated with an increased risk of some gynecologic cancers, including ovarian carcinoma, endometrial carcinoma, and sarcomas of the endometrial stroma. Indeed, studies have shown that women with endometriosis have a 3- to 5-fold higher risk of developing ovarian cancer than the general population. In numbers, ovarian cancer is observed in 1.5 percent of women with endometriosis, compared with 0.04 percent in the general population. At the same time, endometriosis is more common among women with ovarian cancer, with an incidence of 8% to 30%.
At the Candiolo Institute, we treat this disease with a specific approach that allows us to accurately recognize precancerous forms and intervene early on those that could develop into cancer.
The goal is to offer patients a safe and effective course of care, thanks to advanced expertise that allows for gentle and targeted treatments similar to gynecologic oncology surgery, but with a less invasive approach.
Clinical divisions involved
The diagnostic and therapeutic pathway of endometriosis at Candiolo involves several clinical divisions, including the Gynecologic Oncology and theOvarian Cancer Center.
Symptoms
The most common symptoms are:
- Dysmenorrhea (pain during menstruation);
- chronic pelvic pain;
- periovulatory pain;
- Dyspareunia (pain during sexual intercourse);
- Dyschezia (pain in defecation);
- Dysuria (pain to urinate).
Endometriosis-related pain can be very intense and disabling, significantly affecting the quality of life and psychological well-being of affected women.
In addition to pain, endometriosis can cause anatomical changes in several pelvic organs: bowel, bladder, and ureters. In some cases, these changes can lead to intestinal or urinary stenosis and even organ damage, or result in pelvic dysfunction of various kinds:
- sexual: pain during intercourse (dyspareunia), vulvar pain (vulvodynia);
- Urinary: bladder hypersensitivity or overactivity;
- rectal: constipation, diarrhea, irregular alvus, intermittent alvus, rectal tenesmus;
- Perineal: pelvic floor hypertone.
Risk factors
Factors that may increase the risk of developing endometriosis include:
- Age and menstrual cycle: it is more common in women of childbearing age, with early menarche or short menstrual cycles (<28 days);
- Family history: having a mother, sister, or relative with endometriosis increases the risk;
- Menstrual flow abnormalities: heavy, prolonged menstruation or difficulty with uterine drainage;
- Pre-existing infertility: women with fertility problems are more likely to have endometriosis;
- Hormonal factors: high estrogen levels or prolonged exposure to estrogen can promote the development of the disease;
- lifestyle and environment: obesity, sedentary lifestyle and some environmental exposures could influence risk, although the data are less definitive;
- previous uterine surgery or trauma: such as cesarean section or surgery on the uterus, which in some cases can facilitate implantation of endometrial tissue in abnormal locations.
Diagnosis and examination
The symptomatology of endometriosis is highly variable and similar to other diseases, such as irritable bowel syndrome or pelvic inflammatory disease, often causing a delay in diagnosis.
Diagnosis of endometriosis is based on history and assessment of pelvic pain, physical examination, and instrumental investigations, particularlytransvaginal or transabdominal pelvic ultrasound, which allows accurate “pain mapping.” Since it is operator-dependent, it should be performed in experienced centers.
Candiolo IRCCS Institute has outpatient clinics dedicated to the study of endometriosis, with level II ultrasound scans performed by experienced sonographers who can distinguish benign endometriotic ovarian masses from lesions with suspicious features of cancer. Given theextreme clinical variability and different localizations, an accurate assessment of the disease is essential to define the extent and choose themost appropriate therapeutic approach.
When necessary, complementary investigations can be used to plan the best course of treatment:
- Level II transvaginal pelvic ultrasonography
- Magnetic Resonance Imaging (MRI)
- Uro-TAC
- Cystoscopy
Therapies
Medical therapy
Excluding the possible evolution in a cancerous direction, medical therapy of endometriosis mainly serves to reduce symptoms, such as pain and pelvic discomfort, but does not change the course of the disease or achieve a complete cure.
Medical treatment of endometriosis aims to maintain the pathology in a state of stand-by as a function of the woman’s reproductive life.
Medical therapy is based on the use of anti-inflammatories and painkillers (NSAIDs), the combined hormonal contraceptives (COCs) and progestins which are considered the medical therapy of first and second choice in the treatment of endometriosis, GnRH analogs.
Surgical Therapy
Surgical therapy may be necessary within the fertile life span of affected women to reestablish the anatomy of the abdomen, resolve symptomatology that does not respond to drug therapy, treat “complicated” or atypical or cancerous forms of the disease.
The surgical approach (depending on the patient’s age, desire for pregnancy, clinical picture, and specific needs of the patient) involves either conservative or radical treatment offered in our center.
Conservative surgery with complete removal of disease lesions can lead to resolution of painful symptoms in most cases. The effectiveness of surgical treatment, given the chronic-recurrent nature of the condition, may not be definitive. Therefore, regular postoperative follow-up should be performed to highlight any recurrence of disease.
The objectives Of conservative surgical treatment are:
- Complete excision of macroscopic lesions;
- Restoring normal anatomical relationships;
- Preserving or improving fertility;
- Treatment of complicated endometriosis:
- Organ impairment (ureteral compression or significant intestinal stenosis);
- Suspected ovarian cysts (risk of cancerization);
- Pelvic inflammatory picture.
The laparoscopy (minimally invasive surgery performed by making 4 incisions of 5 mm and 12 mm at the level of the abdomen) is the preferred surgical approach in the treatment of endometriosis because it offers numerous advantages over laparotomy (more invasive surgery that involves opening the abdomen).
Crucially, the surgery should be performed in specialized centers capable of performing a nerve-sparing surgery that spares the nerve plexuses.
At the Candiolo Institute, there is an advanced laparoscopic surgery service performed by extremely qualified staff using state-of-the-art techniques such as fluorescence-guided surgery with indocyanine green (an experimental technique to preserve healthy tissues from those infiltrated by endometriosis).
The Candiolo Institute IRCCS also offers direct connections with reproductive medicine centers so as to provide fertility preservation support and counseling for medically assisted procreation pathways where needed.
Why choose us
The Candiolo Institute offers diagnosis, counseling and treatment for this condition that is very common in the female population but often goes unrecognized for a long time, resulting in delays in diagnosis. In this way, each patient can be followed by experienced professionals at all stages of the treatment pathway.
For diagnosis, the Institute provides:
- A Level II ultrasound clinic that specializes in detecting endometriosis;
- A gynecological outpatient clinic dedicated to deep endometriosis.
For surgical treatment, an advanced laparoscopic surgery service is available, performed by highly qualified personnel. Innovative techniques, such as fluorescence-guided surgery with indocyanine green, are used to distinguish healthy tissues from those affected by endometriosis, preserving the function of the organs involved.
The Institute also offers direct links with reproductive medicine centers to support fertility preservation and provide counseling on medically assisted procreation pathways when needed.