Endometriosis – or is it? And...a diagnostic dilemma

Endometriosis can present with mild adhesions or deep infiltrative lesions whereupon the endometriosis has penetrated deep into organs and adnexa.

There is no medical cure for endometriosis. Surgery is the gold standard for amelioration. Ablative therapy cauterizes the endometriosis on the surface and can penetrate deeper and deeper but without precision and therefore can be dangerous to underlying tissue and surrounding structures. Excision is precise and safer.

There are four stages of endometriosis of endometriosis from stage one to stage four with stage four being the most severe.
This staging is in fact, inadequate, as there are cases of endometriosis that are far more severe than that which is shown in the above photo. There should probably be six stages to facilitate greater accuracy in determining and tracking disease.

Endometriosis is an autoimmune disease with a genetic predisposition.

There are several theories as to the etiology of endometriosis including Sampson's theory which postulates that retrograde menstruation carries blood through the fallopian tubes out and onto surrounding organs and tissue depositing epithelial remnants that attach and proliferate and act in response to hormones in the same way that eutopic endometrium does.; displaced coelimic epithelium; the lymphatic route; and surgery whereupon there is deposition of endometrial epithelial cells in other parts of the body (C-section).

Stem cells may also play a role in endometriosis. This is evident from the fact that total hysterectomy is not a cure for endometriosis and endometriosis can form in the absence of the uterus and ovaries. As stem cells are totipotent, they may, especially with dysregulation of the KRAS gene (Molecular Human Reproduction Vol.12, No.11 pp. 671–676, 2006) contribute to the development of endometriosis.

The gold standard for detection of endometriosis is via laparoscopic exploration, followed by therapeutic excision if endometriosis is found.

If a patient has an endometrioma it can typically be seen via TVU. But the absence of an endometrioma should in way be construed as an absence of endometriosis.

A woman with endometriosis may present with these symptoms – and she may be asymptommatic

1. Doubling over in pain

2. Missing school or work due to menstrual pain

3. Pain with defecation

4. Requirements of narcotics to reduce menstrual pain

5. The use of birth control pills or GnRH agonisits for pain reduction - which are not effective

6. Pelvic pain during adolescence

7. Infertility

8. A family history of severe menstrual pain

9. Endometriosis at stage 4 can be asymptomatic

10. Endometriosis at stage 1 can present with severe pain

When is laparoscopy appropriate?

I would certainly recommend laparoscopic review in an infertile patient who is under thirty-four years old and has a diagnosis of idiopathic infertility where there is also an absence of male factor, where there are at least three of the above sypmtoms manifest. Of course one problem with this algorhythmic approach is that endometriosis can be prevalent in the absence of symptomatology.

Even with negative hysterosalpingographic findings and negative TVU findings, endometriosis many be extant.

Infertility

Endometriosis is causative of infertility via several pathways including tubal damage, endometrial abnormality, inflammation in the uterine cavity, and low libido as a result of painful intercourse.

The endometrium is dysregulated in the patient with endometriosis: this can cause implantation failure. There is extra macrophage proliferation emitting proinflammatory cytokines within the uterine cavity: this may cause an inflammatory uterine environment that can be destructive to the embryo. There is also an inappropriate presence of MMP’s in the endometrium of the endometriosis patient during the window of implantation causing inappropriate and excessive tissue destruction and possibly preventing implantation (Ann N Y Acad Sci. 2002 Mar; 955:37-47; discussion 86-8, 396-406.)

Pregnancy

Some patients get pregnant even though they have endometriosis some do not. Some conceive after a laparoscopy and some do not. These variances exist perhaps because of varying degrees of disease; this of course, presupposes an absence of other pathologic states that may be contributory factors to inability to conceive. Another possibility is that not all of the endometriosis was excised and therefore there is still a hostile uterine environment as a result of continued prevalence of an inflammatory environment.

Chronic pelvic pain

Interstitial cystitis can mimic some symptoms of endometriosis.

IC is a chronic inflammation of the bladder wall.

Symptoms

1. Painful intercourse

2. Pelvic pain

3. Painful urination

4. Frequent urination (up to 60 times a day in severe cases)

5. Urgency to urinate

Treatment is symptomatic

Diagnosis is made by ruling out other causes. Tests include:

1. Bladder biopsy

2. Cystoscopy (endoscopy of bladder)

3. Urine analysis

4. Urine culture

5. Urine cytology

6. Video urodynamics (shows how much urine must be in the bladder before you feel the need to urinate)

Data about IC was obtained from: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001508/


Traditional Chinese medicine

The dilemma of differential diagnosis

When a patient reports to the clinic for care and presents with chronic pelvic pain and dyspareunia one may immediately think of endometriosis.

If the pain is dull and aching one will undoubtedly state that stagnation of liver qi is the diagnostic foundation. If the pain is sharp and stabbing one will conclude that stasis of blood is the culprit. Of course in the chronic presentation both qi and blood will be stuck.

Typically the diagnosis which is commonly arrived at in the patient who reports a history of endometriosis is stagnation of liver qi and stasis of liver blood.

But we know that endometriosis is an inflammatory disorder and we also know that endometriosis is only manifest where there is ectopic endometrial epithelial cells.

This then renders the diagnosis of qi stagnation and stasis of blood incorrect. If there is ectopic deposition of cells and tissue – those cells could only have arrived in ectopic locations via rebellion. So rebellious qi and blood must be part of the differential diagnosis. If endometriosis is an inflammatory disease where inflammatory cytokines end up in the uterine cavity then we must include heat as part of the diagnosis. So, rather than qi stagnation and stasis of blood, I would diagnose this patient as being afflicted with rebellious qi and blood with heat trapped in the uterus. Frequently the endometriosis patient will not present with heat signs and then I diagnose the case as rebellious qi and blood with hidden heat trapped in the uterus.

Then there is another diagnostic dilemma: when the patients reports to you status post laparoscopy and complains of still having chronic pelvic pain, do we consider that her diagnosis of endometriosis is of value in helping us to formulate a TCM differential diagnosis? No – because the endometriotic implants have been excised and therefore the endometriosis, at least for the time being is no longer extant.

Then we can safely state that the diagnosis is stagnation of liver qi and stasis of liver blood based strictly on the patients symptoms. So: what once was – no longer is – and therefore, the diagnosis must change.

If the patient presents in clinic with a chief complaint of chronic pelvic pain and a Western medical diagnosis of IC, the TCM diagnosis is damp-heat in the bladder. This is a very different diagnosis than that of the endometriosis patient – with or without active endometriosis.

The patient with IC may not present with signs of damp-heat. Her only symptoms may be dyspareunia and CPP. Therefore, without the Western diagnosis available to us we may in fact miss a diagnostic pearl.

Based on the above it is my contention that having knowledge of the Western medical diagnosis can be very helpful in leading us to a more precise TCM differential diagnosis.

The fact is, in China today, most hospitals that have a Western wing and a TCM wing share data on cases and work together; so, the TCM doctor typically does know the Western medical diagnosis before he or she starts treating the patient.

We are not living in ancient China and we must remember that all knowledge which can help us to help our patients should be actively sought after, obtained and used. To not do this indicates a romantic belief that TCM is all our patients need and that the four examinations are all we need. This is ignorant and dangerous thinking based on dogma. This does not bode well for optimal patient care.

Acupuncturists - What Would You Do?

If a 38 year old female patient had 4 donor egg cycles where there were no pregnancies during the first two and one pregnancy each in each subsequent cycle ending in miscarriage at the third week?

There is no male factor and no pelvic distortion in the reproductive organs. The patient has elevated fsh and diminishes AMH – hence – donor egg.

She is symptomatic for endometriosis, has hypothyroidism as too does her mother and maternal grandmother. There is h/o infertility or miscarriage in the family.

Patient is normomorphic.

Her reproductive endocrinologist recommends another donor-egg cycle. I advised her against this.

What would you advise this patient to do from a Western medical perspective?