Lesions in Pelvis May Be 'Tip of the Iceberg' in Endometriosis

Jake Remaly

May 19, 2021

Recognizing the systemic effects of endometriosis may help doctors better understand the experiences of patients with the disease and guide the approach to diagnosis and treatment, according to the president of the American Society for Reproductive Medicine (ASRM).

Beyond lesions in the pelvis, endometriosis may underlie a range of co-occurring conditions, such as generalized inflammation, fatigue, bowel or bladder dysfunction, depression, and anxiety, Hugh S. Taylor, MD, said at the 2021 virtual meeting of the American College of Obstetricians and Gynecologists.

Its systemic manifestations may explain why women with endometriosis tend to have a lower body mass index, compared with women without the disease, Taylor said.

"Stem cells, microRNAs, and generalized inflammation are some of the mechanisms that mediate these long-range effects on distant organ systems," he said.

Studies have indicated that lesions in the pelvis do not fully explain the disease, and investigators continue to elucidate how "endometriosis that we see in the pelvis is really just the tip of the iceberg," said Taylor, chair of obstetrics, gynecology, and reproductive sciences at Yale University, New Haven, Conn.

Pain, including dysmenorrhea, pelvic pain, and dyspareunia, "can be just as bad with ... stage 1 disease as it can be with stage 4 disease," he said.

Some patients may not have pain, but have infertility. Other women are asymptomatic, and doctors find endometriosis incidentally.

One common definition of endometriosis – ectopic endometrial glands and stroma predominantly caused by retrograde menstruation – "probably overly simplifies this complex disease," said Taylor, who reviewed the current understanding of endometriosis in an article in The Lancet. "The lesions in the pelvis are important. We see them. We treat them. But endometriosis has ... effects throughout the body."

Taylor's research group has shown that stem cells are a potential source of endometriosis. "There are cells from the endometriosis that can be found traveling in the circulation," but their effects are unclear, he said.

Levels of several microRNAs may be increased or decreased in women with endometriosis, and these altered levels may induce the production of inflammatory cytokines. They also may serve as the basis of a blood test for endometriosis that could be ready for clinical use soon, Taylor said.

In a mouse model of endometriosis, the disease changes the electrophysiology of the brain and behavior. "We see changes in anxiety induced by endometriosis. We see changes in pain sensitivity induced by endometriosis. And we also see an increase in depression induced by endometriosis in this animal model," Taylor said.

Although surgical therapy treats local disease, medical therapy may be needed to treat the systemic manifestations.

During a question-and-answer period after the presentation, Marcelle I. Cedars, MD, asked whether analgesic and hormonal management may be sufficient when a woman has suspected or laparoscopically diagnosed endometriosis and pain is the primary complaint.

"Given the understanding of endometriosis, how would you suggest approaching treatment?" asked Cedars, president elect of the ASRM and director of the division of reproductive endocrinology and infertility at the University of California, San Francisco.

Analgesic and hormonal therapies remain "the best treatments we have," Taylor said. He starts treatment with an oral contraceptive and a nonsteroidal anti-inflammatory medication – "not only for pain relief but to tamp some of the inflammation associated with endometriosis," he said. If an oral contraceptive does not work, a gonadotropin-releasing hormone antagonist typically is the next step.

Taylor has disclosed ties to Dot Lab and AbbVie. Cedars had no disclosures.

This article originally appeared on MDedge.com, part of the Medscape Professional Network.

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