AETIOLOGY OF ENDOMETROSIS

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Introduction
This is one of the most common benign conditions faced in gynecology. This condition is usually identified surgically.

Definition: Endometriosis is the presence of endometrial gland and stroma tissue outside it's normal cavity (endometrial cavity).

This is different from a similar term adenomyosis which is the findings of endometrial tissues in the myometrium. The endometrial is the inner tissue of the uterus.
The symptoms arise from bleeding from the deposits in other organs. The most common site of affectation is the ovary where the cyclical bleeding produces an inflammatory response that leads to scare tissue formation the edometriuma generally has a chocolate colour.
The condition affects women so long as they are in their reproductive years. Caucasians in their teens and early twenties have been found with advanced stages of the disease. If there is too much time between the onset and discovery of the condition medically, the standard of living of the girl might be greatly affected. The woman may have issues with work absenteeism and marital issue due to dyspareunia (painful coitus).

https://en.m.wikipedia.org/wiki/Pyometra

Aetiology
The cause this condition is not well understood but certain theories have been brought forward as the the reason why endometrial tissues might be present outside the endometrial cavity. The risk factors surrounding this disease include factors that have been found to common amongst those with endometriosis such as:

•Asian or Caucasian race
•Family history of endometriosis
•Estrogen status
•women within the age 34-44
•Women with increased menstrual flow or decrease cycle length
•Enviromental exposure to Diethylstilbestrol

Decreased risk has been found among women who are Current and recent contraceptive users, current intrauterine device users, and smokers (smokers still have short life span so consider stopping it)

Theories of the aetiology
•Retrograde menstruation/Implantation theory
•Immunological theories
•Genetic theory
•Adverse environment
•Hormonal theories

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Retrograde menstruation/Implantation theory
This theory was put forward by Sampson in 1928 and is one of the most popular theories as to the cause of endometriosis. Research don e found that for this condition to hold water when Retrograde menstruation occurs the blood has to contain endometrial cells. Also endometrial cells have to adhere to proliferate through adhesion molecules.

https://www.google.com/search?q=immunology+images&tbm=isch&ved=2ahUKEwjIhYeO2IXfAhVJU1AKHdP1D24Q2-cCegQIABAC&oq=immu&gs_l=mobile-gws-wiz-img.1.0.35i39j0i67j0j0i67j0.3787.6066..7501...1.0..4.583.3349.0j6j1j1j1j2......0....1.......5.Ie_Vq9cJTP0&ei=jzEGXIiCNsmmwQLT67_wBg&safe=active&tbs=sur%3Af&hl=en-NG#imgrc=PkXQ_1vo9KpA-M

Immunological theories
The theories include those of reduced immunological and increased immunological reactions. As early as 1984 the activation of macrophages was known to be a factor in the pathogenesis of endometriosis. The pathway through this is now known to involve inflammation (which is the response of living vascularised tissue to injurious agent). The inflammation activates a cascade of cytokinins and tumor necrosis factor (which are molecular messengers) which have the ability to cause vascular growth enabling the Endometrial tissue to implant. The other immunological theory was proposed by Barcz et al in the year 2000 this theory suggested that women with endometriosis have deficient immunity and when Retrograde menstruation occurs the cells are allowed to implant and grow. The women in the study were found to be deficient immunologically and did not respond to the abnormally place endometrial cells.

https://www.maxpixel.net/Science-Genetics-Strands-Of-Dna-Biology-Gout-2870583

Genetic theories
One of the factors that increase the risk of having this condition is a family history. A study done in Oxford has identified this by genotyping the first 94 sister-pair families. The Oxford group gound proof of linkage to 5 chromosome regions. Kyoto group also found an association with polymorphism of the ER alpha gene with increased risk of developing endometriosis, adenomyosis, and leiomyoma. Kosugital in 1999 found chromosome 17 aneuploidy as significantly greater in endometriosis specimen (65%) than in normal Endometrial cells (25%).
Genetic research is still ongoing and is intended to find a perfect link between the ye condition and genetics.

https://pixabay.com/en/butanamina-organic-chemistry-amines-2879842/

Adverse Environment
Environmental exposure to certain chemicals can also lead to endometriosis. One chemical implicated is Diethylstilbesterol which was give in the 1970's to prevent miscarriage resulted in increased endometriosis in the daughters of these pregnant women. Also Dioxins in a study with rhesus monkeys caused endometriosis.

https://en.m.wikipedia.org/wiki/Pioneer_factor

Hormonal theory
Endometriosis is not seen in prepubertal girls, that is before the girl has seen her first period, therefore the hormonal theory might hold true. The implants have oestrogen, progestin and other hormones such as androgens. Based on this theory, the treatment medical treatment for endometriosis has been aimed at suppressing the hypothalamic-pituitary-ovarian axis, thus reducing oestrogen levels.

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Symptoms
About 25% of women have no symptoms. The symptoms are dependent on the location of the implant. For example

a) Reproductive tract-Spasmodic dysmenorrhoea, lower abdominal pain, pelvic pain deep dyspareunia (painful sexual intecourse), rupture of endometrioma.

b) Urinary Tract- cylical haematuria, ureteric obstruction.

c) Gastrointestinal Tract- dyschezia (pain on dedication) cyclical rectal bleeding.

d) Lungs - cyclical hameoptysis (spitting blood) pneumothorax.

e) umbilical/abdominal scars- cyclical pain, bluish swelling and bleeding.

f)Brain - epileptic seizures.

A major cause of concern is the infertility associated with the condition which is secondary to: inflammation and distorted pelvic anatomy

Diagnosis
The diagnosis of this condition is mostly through surgical means. But according to sequence it would include: the symptoms given by the patient, the signs elicited by the physician and the investigations carried out such as laproscopy, ultrasound, magnetic resonance imaging and the use of markers

Management
The management could be medical or surgical.

Medical management
This includes use of:
•hormones
•synthetic androgens
•growth hormone releasing hormone agonist

Surgical management
This is done to remove the Endometrioma. It could be conservative or radical.

Conclusion
Endometrosis is one of the challenges facing gynecologist as a result of the fact it is chronic and progressive, there is also no definite treatment for the condition.

Reference
• Textbook of Obstetrics and gynecology for medical students by Akin Agbloola.
•https://en.m.wikipedia.org/wiki/Endometriosis

For further reading
• https://www.mayoclinic.org/diseases-conditions/endometriosis/symptoms-causes/syc-20354656
•https://www.healthline.com/health/endometriosis
•http://obgyn.ucla.edu/endometriosis
•https://www.webmd.com/women/endometriosis/know-endometriosis-18/video-endometriosis-explained
•https://www.webmd.com/women/endometriosis/ss/slideshow-endometriosis-overview

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