Pathology
Endometriosis is a common condition, affecting approximately 1 in 10 women. It is defined by the presence of endometrial-like tissue, which normally lines the inside of the uterus, located outside the uterine cavity.
It is a multifactorial, hormone-dependent disorder that typically affects individuals of reproductive age. The disease often follows a chronic and progressive course and may recur over time. Its main clinical manifestations include pelvic pain and reduced fertility.
The most frequent sites of endometriotic implants are the ovaries, the pelvic peritoneum, which is the membrane lining the inner pelvis, and the rectovaginal septum, the anatomical space between the rectum and vagina. However, endometriosis can also involve other organs and tissues throughout the body, with the notable exception of the spleen.
Endometriosis has been associated with an increased risk of certain gynecologic malignancies, including ovarian carcinoma, endometrial carcinoma, and endometrial stromal sarcomas. Studies suggest that women with endometriosis have a 3 to 5 fold higher risk of developing ovarian cancer compared with the general population. In absolute terms, ovarian cancer occurs in approximately 1.5 percent of women with endometriosis versus 0.04 percent in the general population. Conversely, endometriosis is also more frequently observed among women with ovarian cancer, with a reported prevalence ranging from 8 percent to 30 percent.
At the Candiolo Cancer Institute, we manage endometriosis through a dedicated multidisciplinary approach that enables early identification of precancerous conditions and timely intervention in lesions with malignant potential. The aim is to provide patients with a safe and effective care pathway, leveraging advanced expertise to deliver targeted, minimally invasive treatments inspired by gynecologic oncology principles.
Clinical Divisions Involved
The diagnostic and therapeutic pathway for endometriosis at the Candiolo Cancer Institute involves multiple clinical divisions, including the Gynecologic Oncology and the Ovarian Cancer Center.
Symptoms
The most common symptoms are:
- Dysmenorrhea, pain during menstruation;
- Chronic pelvic pain;
- Periovulatory pain;
- Dyspareunia, pain during sexual intercourse;
- Dyschezia, pain during defecation;
- Dysuria, pain during urination.
Endometriosis-related pain can be severe and disabling, significantly affecting quality of life and psychological well-being.
In addition to pain, endometriosis may lead to anatomical alterations in several pelvic organs, including the bowel, bladder, and ureters. In some cases, these changes can result in intestinal or urinary stenosis, potential organ damage, or various forms of pelvic dysfunction.
These dysfunctions may include:
- Sexual symptoms, such as dyspareunia and vulvar pain (vulvodynia);
- Urinary symptoms, such as bladder hypersensitivity or overactivity;
- Rectal symptoms, including constipation, diarrhea, irregular bowel habits, intermittent bowel movements, and rectal tenesmus;
- Perineal symptoms, such as pelvic floor hypertonicity.
Risk Factors
Factors that may increase the risk of developing endometriosis include:
- Age and menstrual cycle: endometriosis is more common in women of reproductive age, particularly in those with early menarche or short menstrual cycles (less than 28 days);
- Family history: having a mother, sister, or close relative with endometriosis increases the risk;
- Menstrual flow abnormalities: heavy or prolonged menstruation or impaired uterine drainage;
- Pre-existing infertility: women with fertility problems are more likely to be diagnosed with endometriosis;
- Hormonal factors: elevated estrogen levels or prolonged estrogen exposure may promote disease development;
- Lifestyle and environmental factors: obesity, sedentary lifestyle, and certain environmental exposures may contribute to risk, although evidence remains less conclusive;
- Previous uterine surgery or trauma: such as cesarean section or uterine surgery, which in some cases may facilitate implantation of endometrial tissue in abnormal locations.
Diagnosis and Evaluation
The symptomatology of endometriosis is highly variable and often overlaps with other conditions, such as irritable bowel syndrome or pelvic inflammatory disease, which can contribute to delayed diagnosis.
Diagnosis is based on medical history, assessment of pelvic pain, physical examination, and instrumental investigations, particularly transvaginal or transabdominal pelvic ultrasound, which allows detailed pain mapping. As this technique is operator-dependent, it should be performed in experienced centers.
The Candiolo Cancer Institute has dedicated outpatient clinics for the evaluation of endometriosis, where level II ultrasound examinations are performed by experienced sonographers. These specialists are able to distinguish benign endometriotic ovarian lesions from those with suspicious features of malignancy. Given the significant clinical variability and diverse anatomical presentations, accurate disease assessment is essential to define extent and select the most appropriate therapeutic strategy.
When necessary, complementary investigations are used to support treatment planning:
- Level II transvaginal pelvic ultrasonography;
- Magnetic Resonance Imaging (MRI);
- Uro-CT;
- Cystoscopy.
Therapies
Medical Therapy
Excluding cases with potential malignant transformation, medical therapy for endometriosis is primarily aimed at reducing symptoms, particularly pain and pelvic discomfort. It does not modify the natural course of the disease nor does it provide a definitive cure.
The goal of medical treatment is to maintain disease control and symptom suppression over time, while preserving reproductive potential whenever possible.
Medical management is based on anti-inflammatory drugs and analgesics, such as nonsteroidal anti-inflammatory drugs (NSAIDs), combined hormonal contraceptives (COCs), and progestins, which represent first- and second-line options in the treatment of endometriosis. In selected cases, gonadotropin-releasing hormone (GnRH) analogues may also be used.
Surgical Therapy
Surgical treatment may be indicated during the reproductive years to restore normal pelvic anatomy, manage symptoms that do not respond to medical therapy, and treat complicated, atypical, or potentially malignant forms of the disease.
The surgical approach is individualized according to patient age, desire for pregnancy, clinical presentation, and specific needs, and may include either conservative or radical procedures, both of which are available at the Candiolo Cancer Institute.
Conservative surgery, involving complete excision of visible disease lesions, can lead to significant improvement or resolution of pain in most cases. However, given the chronic and recurrent nature of endometriosis, surgical outcomes may not be definitive. For this reason, structured postoperative follow-up is essential to monitor and detect possible recurrence.
The main objectives of conservative surgical treatment are:
- Complete excision of macroscopic lesions;
Restoration of normal anatomical relationships; - Preservation or improvement of fertility;
- Treatment of complicated endometriosis, including:
Ureteral compression or significant intestinal stenosis with organ impairment;
Ovarian cysts with suspicious features and potential risk of malignancy;
Associated pelvic inflammatory conditions.
Laparoscopy, a minimally invasive surgical technique performed through small abdominal incisions (typically 5 mm and 12 mm), is the preferred approach for the treatment of endometriosis. It offers several advantages compared with laparotomy, which is a more invasive procedure requiring a larger abdominal incision.
Importantly, surgical management should be performed in specialized centers with expertise in nerve-sparing techniques that preserve pelvic nerve plexuses whenever possible.
At the Candiolo Cancer Institute, advanced laparoscopic surgery is performed by highly specialized teams using state-of-the-art technologies, including fluorescence-guided surgery with indocyanine green, an emerging technique that helps distinguish healthy tissue from tissue affected by endometriosis and supports tissue preservation.
The Candiolo Cancer Institute also maintains direct collaboration with reproductive medicine centers, ensuring access to fertility preservation counseling and assisted reproduction pathways when appropriate.
Why Choose Us
The Candiolo Cancer Institute offers comprehensive diagnosis, counseling, and treatment for endometriosis, a condition that is highly prevalent in the female population but often underdiagnosed, leading to significant delays in detection. This integrated approach ensures that each patient is followed by experienced specialists throughout all stages of the care pathway.
For diagnosis, the Institute provides:
- A Level II ultrasound clinic specialized in the detection and characterization of endometriosis
- A gynecological outpatient clinic for the management of deep infiltrating endometriosis
For surgical treatment, an advanced laparoscopic surgery service is available, performed by highly qualified teams. Innovative techniques, such as fluorescence-guided surgery using indocyanine green, are employed to differentiate healthy tissues from those affected by endometriosis, with the aim of preserving organ function.
The Institute also maintains close collaboration with reproductive medicine centers to support fertility preservation and provide counseling on medically assisted reproduction pathways when appropriate.