Endometriosis is characterized by the presence of ectopic endometrium causing pain, infertility or lesion progression; it affects ∼5% of women of reproductive age, with a prevalence peak between 25 years and 35 years of age
Interaction of the number and amount of menstrual flows with genetic and environmental factors seems to determine the likelihood of development as well as the phenotypic manifestation of the disease
Although pain can be managed via pharmacological inhibition of ovulation and menstruation, lesions are not eradicated; surgery is generally associated with pain relief, but its benefit is often temporary
Medical therapy for infertility is inefficacious, whereas laparoscopic elimination of endometriotic lesions and adnexal adhesions increases the chances of conception moderately; in vitro fertilization is a valid alternative to surgery
Endometriosis is associated with a 50% increase in the risk of ovarian cancer; preventive interventions are possible, but screening of patients with endometriosis for ovarian cancer is presently not justified
Primary prevention of endometriosis is not currently feasible; treatment should be tailored to fit individual needs, and a shared decision-making approach between patient and clinician is encouraged
Endometriosis is defined as the presence of endometrial-type mucosa outside the uterine cavity. Of the proposed pathogenic theories (retrograde menstruation, coelomic metaplasia and Müllerian remnants), none explain all the different types of endometriosis. According to the most convincing model, the retrograde menstruation hypothesis, endometrial fragments reaching the pelvis via transtubal retrograde flow, implant onto the peritoneum and abdominal organs, proliferate and cause chronic inflammation with formation of adhesions. The number and amount of menstrual flows together with genetic and environmental factors determines the degree of phenotypic expression of the disease. Endometriosis is estrogen-dependent, manifests during reproductive years and is associated with pain and infertility. Dysmenorrhoea, deep dyspareunia, dyschezia and dysuria are the most frequently reported symptoms. Standard diagnosis is carried out by direct visualization and histologic examination of lesions. Pain can be treated by excising peritoneal implants, deep nodules and ovarian cysts, or inducing lesion suppression by abolishing ovulation and menstruation through hormonal manipulation with progestins, oral contraceptives and gonadotropin-releasing hormone agonists. Medical therapy is symptomatic, not cytoreductive; surgery is associated with high recurrence rates. Although lesion eradication is considered a fertility-enhancing procedure, the benefit on reproductive performance is moderate. Assisted reproductive technologies constitute a valid alternative. Endometriosis is associated with a 50% increase in the risk of epithelial ovarian cancer, but preventive interventions are feasible.
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D. Alberico, D. Dridi, A. M. Sanchez and C. Vercellini are greatly acknowledged for their support.
The authors declare no competing financial interests.
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Vercellini, P., Viganò, P., Somigliana, E. et al. Endometriosis: pathogenesis and treatment. Nat Rev Endocrinol 10, 261–275 (2014). https://doi.org/10.1038/nrendo.2013.255
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