Abstract
ABSTRACTObjective:To evaluate clinical features and complications in patients with bowel endometriosis submitted to hormonal therapy.Methods:Retrospective study based on data extracted from medical records of 238 women with recto-sigmoid endometriosis treated between May 2010 and May 2016.Results:Over the course of follow-up, 143 (60.1%) women remained in medical treatment while 95 (39.9%) presented with worsening of pain symptoms or intestinal lesion growth (failure of medical treatment group), with surgical resection performed in 54 cases. Women in the Medical Treatment Group were older (40.5±5.1 years versus 37.3±5.8 years; p<0.0001) and had smaller recto sigmoid lesions (2.1±1.9 versus 3.1±2.2; p=0.008) compared to those who had failed to respond to medical treatment. Similar significant reduction in pain scores for dysmenorrhea, chronic pelvic pain, cyclic dyschezia and dysuria was observed in both groups; however greater reduction in pain scores for dyspareunia was noted in the Surgical Group. Subjective improvement in pain symptoms was also similar between groups (100% versus 98.2%; p=0.18). Major complications rates were higher in the Surgical Group (9.2% versus 0.6%; p=0.001).Conclusion:Patients with recto-sigmoid endometriosis who failed to respond to medical treatment were younger and had larger intestinal lesions. Hormonal therapy was equally efficient in improving pain symptoms other than dyspareunia compared to surgery, and was associated with lower complication rates in women with recto-sigmoid endometriosis. Medical treatment should be offered as a first-line therapy for patients with bowel endometriosis. Surgical treatment should be reserved for patients with pain symptoms unresponsive to hormonal therapy, lesion growth or suspected intestinal subocclusion.
Highlights
Endometriosis is the presence of endometrial tissue outside the uterus
The estimated prevalence of the disease ranges from 10% to 15% in child-bearing age women, and may amount to 70% and 48% in patients with chronic pelvic pain and infertility respectively.[1]. Three different types of endometriosis have been described: deep endometriosis, peritoneal endometriosis and ovarian endometrioma.[2,3] Deep endometriosis accounts for almost half of endometriosis cases, with bowel involvement in 50% of them.[4,5]
Surgery is required for cases of intestinal endometriosis refractory to medical treatment, and cases with obstructive lesions or intestinal obstruction.[3]. Resection of endometriosis implants has been shown to improve pelvic pain and patient’s quality of life, and to decrease disease recurrence rates.[22,23,24,25] major complications associated with surgical treatment of bowel endometriosis were reported in 6.3% of cases, including thrombosis, infection, hemorrhage, anastomotic leakage and injured bowel, ureter, bladder and large vessels during surgical procedure.[26,27]
Summary
Endometriosis is the presence of endometrial tissue outside the uterus. The estimated prevalence of the disease ranges from 10% to 15% in child-bearing age women, and may amount to 70% and 48% in patients with chronic pelvic pain and infertility respectively.[1]. The clinical suspicion of endometriosis is based on history and physical examination.[6,7] The diagnostic imaging modality of choice is transvaginal ultrasound (TVUS) with bowel preparation, given its low cost, ease access and high accuracy. Progestogens and combined contraceptives are recommended and, according to current evidence and gynecological society guidelines, the different hormone treatments are effective.[13,14,15,16,17,18,19,20,21,22] Treatment choice should be based on patient’s pregnancy desire and clinical characteristics, and location of endometriotic lesions.[23] Clinical management aims to relieve pain symptoms and quality of life, as well as lesion stabilization.[3] it is an obstacle to women who want to get pregnant.[13]. Resection of endometriosis implants has been shown to improve pelvic pain and patient’s quality of life, and to decrease disease recurrence rates.[22,23,24,25] major complications associated with surgical treatment of bowel endometriosis were reported in 6.3% of cases, including thrombosis, infection, hemorrhage, anastomotic leakage and injured bowel, ureter, bladder and large vessels during surgical procedure.[26,27]
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