Abstract
Endometriosis is an inflammatory oestrogen dependent disease defined by the presence of endometrial glands and stroma at extrauterine sites. The modern advance in treatment of endometriosis management is tackling the debilitating pain it causes, besides the infertility in patients desiring fertility in reproductive age group. This can be achieved by surgical or medical means, although in most cases a combination of both treatments is required. Usually, long term treatment is required in most cases. Unfortunately in most cases, pain symptoms recur between 6months and 12 months once treatment is stopped. A lot of research has gone in understanding the pathogenesis and further medical management of endometriosis besides surgery to be useful in relieving pain and use in patients desiring fertility besides hormonal treatments used earlier like hormonal contraceptives (oral, transdermal or vaginal administration), progestogens, danazol, Gonadotrophic releasing hormone agonist (GnRH), aromatase inhibitors. Newer agents like antiangiogenic drugs, phytochemical agents like resveratrol, TNF-α inhibitors, GnRH antagonists like egalogolix, statins, antiinflammatory agents like COX2 Inhibitors and PPARγ inhibitors like pioglitazone etc., with recent work of combined efficacy of telmesartan of both PPARγ partial agonism along with angiotensin 1 receptor agonism having more efficacy, role of immunomodulators like rapamycin, lipoxin 4 and pentoxyphylline, GnRH antagonists like egalogolix are still under study undergoing phase III trials although preliminary results show promising results with fewer side effects as compared to similar duration of GnRH agonist and much less BMD side effects. Increasing number of trials show the safety of SPRM’s, along with efficacy although disadvantage is suppression of fertility so cannot be used for women desiring fertility. Currently, only mifepristone and ulipristal have received FDA approval for indication in fibroid treatment, MTP and not for endometriosis as yet. The advantages and disadvantages of all the recent advances are discussed in an update in the pathophysiology as well medical treatment of endometriosis.
Highlights
Endometriosis is a benign disease which is characterized by the presence of endometriotic lesions, consisting of functional endometrial glands and stroma outside the uterine cavity [1]
More nerve fibres are present on the peritoneal wall of women with endometriotic lesions compared with women without the condition [9]
Mckinnon et al reported that presence of endometriosis associated nerve fibres appear to be related to both the pain experienced by women with endometriosis and the concentration of follicular fluid cytokines, this association varies with the lesion/location e.g. rectovaginal septum lesions are significantly more commonly associated with nerve fibres along with higher peritoneal fluid glycodelin concentrtions
Summary
Endometriosis is a benign disease which is characterized by the presence of endometriotic lesions, consisting of functional endometrial glands and stroma outside the uterine cavity [1]. The prevalence of the disease is high ranging from 6% - 10% of women of reproductive age group and it affects significantly on the annual costs in the heallh care systems [2] It may cause a broad spectrum of pain symptoms ranging from no symptoms to severe dysmenorrhoea, dyspareunia, dyscachexia, chronic pain [3] and in fertility [4] [5], which leads to a severely limited quality of patients private and professional life [6]. Santuli et al showed that the expression of enzymes implicated in the regulation of the sphingosine 1 phosphate level balance and its receptors were heavily dysregulated in endometriotic lesions in favour of a decrease sphingosine-1 phosphate catabolism. They proposed for a role for sphingosine pathway in establishing and survival of endometriotic lesions [16]
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