Endometriosis

Endometriosis cramp pain

It is estimate that up to 10% of the general female population and 2 to 11% of asymptomatic women  are affected by endometriosis. In addition, 11% of women in a general population have undiagnosed endometriosis that can be seen on magnetic resonance imaging. Endometriosis is most common in those in their thirties and forties; however, it can begin in girls as early as eight years old.

Endometriosis is typically associated with  two challenges : problem becoming pregnant and pain. Becoming pregnant means that you've overcome the first of those challenges (congratulations), and the good news even gets better. Being pregnant may actually help  with the second challenge.

The hidden suffering of millions of women revealed, endometriosis is a condition in which tissues resembling the lining of the inside of the women's uterus is found elsewhere in the body (usually in the pelvis)..

10% of women with cystic ovarian lesions, and 5% of women with deep endometriosis do not have pain. It chiefly affects adults from premenarche to post menopause,  regardless of race or ethnicity or whether or not they have had children. It is primarily a disease of the reproductive years.

Introduction

Endometriosis (en-doe-me-tree-O-sis) is an often painful disorder in which tissue similar to the tissue that normally lines the inside of your uterus - the endometrium - grows outside your uterus. Endometriosis most commonly involves your ovaries, fallopian tubes and the tissue lining your pelvis. In rare cases it may also occur in other parts of the body.  Endometriosis can have both social and psychological effects. The areas of endometriosis bleed each month (menstrual period), resulting in inflammation and scarring. The growths due to endometriosis are not cancer.

The rate of recurrence of endometriosis is estimated to be 40-50% for adults over a 5-year period. The rate of recurrence has been shown to increase with time from surgery and is not associated with the stage of the disease.

Endometriosis is a chronic disease that has direct and indirect costs which include loss of work days, direct costs of treatment, symptom management, and treatment of other associated conditions such as depression or chronic pain.

Endometriosis causes pain in the pelvic area because tissues from the uterine lining (called endometrium) grows outside the uterus and react to the hormonal changes of the menstrual cycle by thickening , breaking down and bleeding  (as uterine lining normally does). During pregnancy when ovulation and menstruation take a hiatus and progesterone increases, there so called endometrial implants become smaller and less tender, often inducing a bit of remission from the pain endometriosis causes. In fact many moms to be  are symptom free or nearly so  during the entire pregnancy- though some way start to feel  discomfort as  baby grows and begins packing a strong punches and kick reach tender areas.

The less happy news is that pregnancy provides only a break from the symptoms of endometriosis, not a cure. After pregnancy and breastfeeding (and sometimes earlier), the symptoms usually returns. The other less happy news is that women with endometriosis do face an increased risk of ectopic pregnancy (so be sure to be alert for associated signs, as well as preterm birth. 

Because of these increased risks, your practitioner will likely monitor your your pregnancy more frequently (with more frequent ultrasounds), for instance. Finally in the very unlikely case that you've had uterine surgery for your condition, your practitioner will probably opt to deliver via C section.

                                            "Pain is the primary symptom of endometriosis"

Pathophysiology

Laparoscopic image of endometriotic lesion at the peritoneum of the pelvic wall.

Retrograde menstruation theory

The theory of retrograde menstruation (also called the implantation theory or transplantation theory) is the most commonly accepted theory for the dissemination and transformation of ectopic endometrium into endometriosis. It suggests that during a woman's menstrual flow, some of the endometrial debris flow backward through the Fallopian tubes and into the peritoneal cavity, attaching itself to the peritoneal surface (the lining of the abdominal cavity) where it can proceed to invade the tissue as or transform into endometriosis. It is not clear at what stage the transformation of endometrium, or any cell of origin such as stem cells or coelomic cells to endometriosis begins.

Other theories

• Stem cells: Endometriosis may arise from stem cells from bone marrow and potentially other sources. In particular, this theory explains endometriosis found in areas remote from the pelvis such as the brain or lungs. stem cells may be from local cells such as the Peritoneum or cells disseminated in the blood stream  such as those from the bone marrow.
• Vascular dissemination: Vascular dissemination  of bone-marrow stem cells involved in pathogenesis.
• Environment: Environmental toxins (e.g. dioxin, nickel) may cause endometriosis. Toxins such as dioxin and dioxin like compounds  tend to bioaccumulate  within the human body. 
• Müllerianosis: A theory supported by foetal autopsy is that cells with the potential to become endometrial, which are laid down in tracts during embryonic development called the female reproductive (Müllerian) tract as it migrates downward at 8–10 weeks of embryonic life, could become dislocated from the migrating uterus and act like seeds or stem cells.
• Coelomic metaplasia: Coelomic cells which are the common ancestor of endometrial and  peritoneal cells may undergo metaplasia (transformation) from one type of cell to the other, perhaps triggered by inflammation.
• Vasculogenesis: Up to 37% of the microvascular endothelium  of ectopic endometrial tissue originates from endothelial progenitor cells,  which result in de novo formation of micro-vessels by the process of Vasculogenesis rather than the conventional process of angiogenesis.
• Autoimmune: Graves disease  is an autoimmune disease characterized by hyperthyroidism, goiter, ophthalmopathy, and dermopathy. People with endometriosis had higher rates of Graves disease. One of these potential links between Graves disease and endometriosis is autoimmunity.
• Oxidative Stress : : Influx of iron is associated with the local destruction of the peritoneal mesothelium, leading to the adhesion of ectopic endometriotic cells. Peritoneal iron overload has been suggested to be caused by the destruction of erythrocytes, which contain the iron-binding protein hemoglobin, or a deficiency in the peritoneal iron metabolism system. Oxidative stress activity and  reactive oxygen species (such as superoxide anions  and  peroxide levels) are reported to be higher than normal in people with endometriosis. Oxidative stress and the presence of excess ROS can damage tissue and induce rapid  cellular division. Mechanistically, there are several cellular pathways by which oxidative stress may lead to or may induce proliferation of endometriotic lesions, including the mitogen activated protein (MAP) kinase pathway and the extracellular signal-related kinase (ERK) pathway. Activation of both of the MAP and ERK pathways lead to increased levels of  c-Fos and c-c-Jun, which are proto- oncogenes that are associated with high grade leisions.

Localization

Chocolate cyst on ovaries / Ovarian endometriomas 

                                    

Most often, endometriosis is found on the:

• Ovaries
• Fallopian tubes
• Tissues that hold the uterus in place (ligaments)
• Outer surface of the uterus

Less common pelvic sites are:

• Vagina 
• Cervix 
• Vulva 
• Bowel
• Bladder 
• Rectum

Endometriosis may spread to the cervix and vagina or to sites of a surgical abdominal incision, known as "scar endometriosis." 

Deep infiltrating endometriosis (DIE) has been defined as the presence of endometrial glands and stroma infiltrating more than 5 mm in the sub-peritoneal tissue. The prevalence of DIE is estimated to be 1 to 2%. Deep endometriosis typically presents as a single nodule in the vesicouterine fold or in the lower 20 cm of the bowel. Deep endometriosis is often associated with severe pain.

Possible location s of Endometriosis

Extra-pelvic endometriosis

Rarely, endometriosis appears in extra-pelvic parts of the body, such as the lungs, brain and skin "Scar endometriosis" can occur in surgical abdominal incisions. Risk factors for scar endometriosis include previous abdominal surgeries, such as a hysterotomy or cesarean section, or ectopic pregnancies, salpingostomy puerperal sterilization, laparoscopy, amniocentesis, appendectomy, episiotomy, vaginal hysterectomies, and hernia repair.

Endometriosis may also present with skin lesions in cutaneous endometriosis.

Less commonly lesions can be found on the diaphragm or lungs. Diaphragmatic endometriosis is rare, almost always on the right hemidiaphragm, and may inflict the cyclic pain of the right scapula  (shoulder) or cervical area (neck) during a menstrual period. Pulmonary endometriosis can be associated with a thoracic endometriosis syndrome that can include catamenial (occurs during menstruation) pneumothorax seen in 73% of women with the syndrome, catamenial  hemothorax in 14%, catamenial hemoptysis in 7%, and pulmonary nodules in 6%.

Grades

Types

Risk Factors for endometriosis

• Family history.
• First degree relative with endometriosis
• Low body mass index
• Nulliparity
• Prolonged menstruation (> more than 5 days)
• Shorter lactation intervals
• Shorter menstrual cycle (< less than 28 days)
• White race (compared with black race)
• Genetic  factor,  low progesterone levels may be genetic, and may contribute to a hormone imbalance.
• Environmental factor : Environmental toxin:
• late menopause (Prolonged exposure to estrogen;)
• Early menarche (Prolonged exposure to estrogen;)
• Müllerian anomalies : obstruction of menstrual outflow.

Diagnosis

• History
• Physical examination
• Criteria that are commonly used to establish a diagnosis include pelvic pain, infertility, surgical assessment, and in some cases, magnetic resonance imaging. An ultrasound can identify large clumps of tissue as potential endometriosis lesions and ovarian cysts but it is not effective for all patients, especially in cases with smaller, superficial lesions.

Ultrasound :  There is a clear benefit for undergoing an ultrasound diagnostic procedure (TVUS) as a first step of testing for endometriosis. The most common sites of endometriosis are the ovaries, followed by the Douglas pouch, the posterior leaves of the broad ligaments, and the sacrouterine ligaments.

Vaginal ultrasound has a clinical value in the diagnosis of endometrioma and before operating for deep endometriosis. This applies to the identification of the spread of disease in individuals with well-established clinical suspicion of endometriosis. Vaginal ultrasound is inexpensive, easily accessible, has no contraindications and requires no preparation. Healthcare professionals conducting ultrasound examinations need to be experienced. By extending the ultrasound assessment into the posterior and anterior pelvic compartments the sonographer is able to evaluate structural mobility and look for deep infiltrating endometriotic nodules noting the size, location and distance from the anus if applicable. An improvement in sonographic detection of deep infiltrating endometriosis will not only reduce the number of diagnostic laparoscopies, it will guide management and enhance quality of life.

• As for deep infiltrating endometriosis, TVUS, TRUS (trans uterus ultrasonography) and MRI are the techniques of choice for non-invasive diagnosis with a high sensitivity and specificity
• Medical imaging Magnetic Resonance Imaging (MRI)
• Biopsy is the gold standard for diagnosing the condition.
• Laparoscopy

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  Transvaginal ultrasonography (TVUS) showing a 67x40 mm endometrioma as distinguished from other  types of ovarian cysts by a somewhat grainy and not completely anechoic content.

  
  

A surgical procedure where a camera is used to look inside the abdominal cavity, is the only way to accurately diagnose the extent and severity of pelvic/abdominal endometriosis. Laparoscopy is not an applicable test for extra-pelvic sites such as umbilicus, hernia sacs, abdominal wall, lung, or kidneys.

Laparoscopy permits lesion visualization unless the lesion is visible externally (e.g., an endometriotic nodule in the vagina) or is extra-abdominal. 

During a laparoscopic procedure lesions can appear dark blue, powder-burn black, red, white, yellow, brown or non-pigmented. Lesions vary in size. Some within the pelvis walls may not be visible, as normal-appearing peritoneum of infertile women reveals endometriosis on biopsy in 6–13% of cases. Early endometriosis typically occurs on the surfaces of organs in the pelvic and intra-abdominal areas. Health care providers may call areas of endometriosis by different names, such as implants, lesions, or nodules. Larger lesions may be seen within the ovaries as  ovarian endometriomas or "chocolate cysts", "chocolate" because they contain a thick brownish fluid, mostly old blood.

Frequently during diagnostic laparoscopy, no lesions are found in individuals with chronic pelvic pain, a symptom common to other disorders including adenomyosis , pelvic adhesions, pelvic inflammatory disease, congenital anomalies, of the reproductory tract, and ovarian or tubal masses.

Biopsy : If the growths (lesions) are not visible, a  biopsy must be taken to determine the diagnosis. A Biopsy is the gold standard to diagnose endometriosis,

Ovarian cyst 

Medical imaging Magnetic Resonance Imaging (MRI)

Use of MRI is another method to detect lesions in a non-invasive manner. MRI is not widely used due to its cost and limited availability, however, it has the ability to detect the most common form of endometriosis (endometrioma) with a sufficient accuracy. It is recommended for the patient to receive an anti-spasmodic agent (hyoscine butylbromide for example), a big glass of water (if bladder is empty), to undergo MRI scanning in supine position and applying abdominal strap for having a better image quality from the MRI.
Phased coil arrays are also recommended.

Sequences

MRI sequence

T1W with and without suppression of fat is recommended for endometriomas; meanwhile, sagittal, axial and oblique 2D T2W are recommended for deep infiltrating endometriosis.

Staging

Surgically, endometriosis can be staged I–IV. The process is a complex point system that assesses lesions and adhesions in the pelvic organs, but it is important to note staging assesses physical disease only, not the level of pain or infertility. A person with Stage I endometriosis may have a little disease and severe pain, while a person with Stage IV endometriosis may have severe disease and no pain or vice versa. In principle the various stages show these findings: 

Stage I (Minimal)

Findings restricted to only superficial lesions and possibly a few filmy adhesions .

Stage II (Mild)

In addition, some deep lesions are present in the cul-de-sac.

Stage III (Moderate)

As above, plus the presence of endometriomas on the ovary and more adhesions.

Stage IV (Severe)

As above, plus large endometriomas, extensive adhesions. Implants and adhesions may be found beyond the uterus. Large ovarian cysts are common.

Endometriosis Markers CA-125

The one biomarker that has been in use over the last 20 years is CA-125. A 2016 review found that this biomarker was present in those with symptoms of endometriosis; and, once ovarian cancer  has been ruled out, a positive CA-125 may confirm the diagnosis. Its performance in ruling out endometriosis is low. CA-125 levels appear to fall during endometriosis treatment, but it has not shown a correlation with disease response

• Surgery for diagnoses also allows for surgical treatment of endometriosis at the same time.

Histopathology

For a histopathological diagnosis, at least two of the following three criteria should be present:

• Endometrial type stroma.
• Endometrial epithelium  with glands
• Evidence of chronic hemorrhage, mainly hemosiderin deposits.

Immunohistochemistry has been found to be useful in diagnosing endometriosis as stromal cells have a peculiar surface antigen, CD10, thus allowing the pathologist go straight to a staining area and hence confirm the presence of stromal cells and sometimes glandular tissue is thus identified that was missed on routine H&E staining.

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  Endometriosis, abdominal wall

 
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  Micrograph showing endometriosis (right) and ovarian stroma (left)

 
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  Micrograph of the wall of an endometrioma. All features of endometriosis are present (endometrial glands  endometrial stroma and hemosiderin -laden macrophages).

Pain quantification

The most common  pain scale for quantification of endometriosis-related pain is the visual analogue scale (VAS); VAS and  numerical rating scale (NRS) were the best adapted pain scales for pain measurement in endometriosis. For research purposes, and for more detailed pain measurement in clinical practice, VAS or NRS for each type of typical pain related to endometriosis (dysmenorrhea, deep  dyspareunia and non-menstrual chronic pelvic pain), combined with the clinical global impression (CGI) and a  quality of life scale, are used.

Signs and Symptoms

 Symptoms

The symptoms of endometriosis tend to come on or get worse before and during your period. Symptoms include:

• About 25% women who have endometriosis experience few or no symptoms.
• Chronic Fatigue
• Recurring pelvic pain occur in both side of pelvic. in the lower back and rectal area, and even down the legs. The amount of pain a person feels correlates weakly with the extent or stage (1 through 4) of endometriosis, with some individuals having little or no pain despite having extensive endometriosis or endometriosis with scarring, while others may have severe pain even though they have only a few small areas of endometriosis. The most severe pain is typically associated with menstruation. Pain can also start a week before a menstrual period, during and even a week after a menstrual period, or it can be constant. The pain can be debilitating and result in emotional stress. Symptoms of endometriosis-related pain may include:
• Dysmenorrhea (64%) painful, sometimes disabling cramps during the menstrual period; pain may get worse over time (progressive pain), also lower back pains linked to the pelvis
• Chronic pelvic pain : Typically accompanied by lower back pain or abdominal pain
• Dyspareunia painful sexual intercourse,  
• Dysuria : urinary urgency, frequency, and sometimes painful voiding.
• Mittelschmerz : pain associated with ovulation.
• Bodily movement pain : Present during exercise, standing, or walking. Compared with patients with superficial endometriosis, those with deep disease appear to be more likely to report shooting rectal pain and a sense of their insides being pulled down. Individual pain areas and pain intensity appear to be unrelated to the surgical diagnosis, and the area of pain unrelated to the area of endometriosis.

There are multiple causes of pain. Endometriosis lesions react to hormonal stimulation and may "bleed" at the time of menstruation. The blood accumulates locally if it is not cleared shortly by the immune, circulatory, and lymphatic system. This may further lead to swelling, which triggers inflammation with the activation of Cytokines, which results in pain. Another source of pain is the organ dislocation that arises from adhesions  binding internal organs to each other. The ovaries, the uterus, the oviducts, the peritoneum, and the bladder can be bound together. Pain triggered in this way can last throughout the menstrual cycle, not just during menstrual periods.

Also, endometriotic lesions can develop their own nerve supply, thereby creating a direct and two-way interaction between lesions and the central nervous system,  potentially producing a variety of individual differences in pain that can, in some cases, become independent of the disease itself. Nerve fibers and blood vessels are thought to grow into endometriosis lesions by a process known as neuroangiogenesis.

• Infertility  : About a third of women with  infertility have endometriosis. Among those with endometriosis, about 40% are infertile. The pathogenesis of infertility is dependent on the stage of disease: in early stage disease, it is hypothesized that this is secondary to an inflammatory response that impairs various aspects of conception, whereas in later stage disease distorted pelvic anatomy and adhesions contribute to impaired fertilization.
• Heavy periods
• Sciatica or nerve pain that travels from your lower back to the back of your thighs
• Stomach issues, such as diarrhea or constipation
• Nausea and vomiting
• Migraines
• Low-grade fevers
• Heavy (44%) and or irregular periods (60%), and 
• Hypoglycemia. 
• There is an association between endometriosis and certain types of cancers, notably some types of  ovarian cancer, non Hodgkin's lymphoma and brain cancer. Endometriosis is unrelated to endometrial cancer. Rarely, endometriosis can cause endometrium-like tissue to be found in other parts of the body. Thoracic endometriosis occurs when endometrium-like tissue implants in the lungs or pleura. Manifestations of this include coughing up blood,  a collapsed lung  or bleeding into the pleural space.
• Stress may be a cause or a consequence of endometriosis

Complications

Physical Health

Complications of endometriosis include internal scarring, adhesions,  pelvic cysts, chocolate cysts of ovaries,  ruptured cysts, and bowel and ureter obstruction resulting from pelvic. adhesions, Endometriosis - associated infertility,  can be related to scar formation and anatomical distortions due to the endometriosis.

Ovarian endometriosis may complicate pregnancy by decidualization,  abscess and/or rupture. Thoracic endometriosis can be associated with recurrent thoracic endometriosis syndrome at times of a menstrual period that includes catamenial pneumothorax in 73% of women, catamenial  hemothorax in 14%, catamenial hemoptysis  in 7%, and pulmonary nodules  in 6%.

A 20-year study of 12,000 women with endometriosis found that individuals under 40 who are diagnosed with endometriosis are 3 times more likely to have heart problems than their healthy peers.

Sciatic endometriosis also called catamenial or cyclical sciatica is a sciatica whose cause is endometriosis and whose incidence is unknown. Diagnosis is usually made by an MRI or CT-myelography.

Mental Health

"Endometriosis is associated with an elevated risk of developing depression and anxiety disorders". Studies suggest this is partially due to the pelvic pain experienced by endometriosis patients." It has been demonstrated that pelvic pain has significant negative effects on women's mental health and quality of life; in particular, women who suffer from pelvic pain report high levels of anxiety and depression, loss of working ability, limitations in social activities and a poor quality of life" 

Lifestyle

• Avoiding large amounts of alcohol.
• Avoidance of caffeine.
• Use a hot water bottle and heating pads to relieve painful symptom.

Exercise

Exercise  may also be preventive.

Yoga

●    Diamond Pose /Thundebolt Pose / Adamintine Pose  Vajra asana  ( वज्रासन )

                                                 

Benefits

• Only Asana which can be done after meals. It is good for flatulence and constipation. It helps release excessive gas from the abdomen and relieves flatulence.
• It  is  good poses for stimulating the digestive system and reducing acidity. 
• It stretches the hip, thighs, knees, ankles and feet. Improves circulation and relieves tired legs, strengthens foot arches  relieving flat foot. Improves digestion and relieves gas. Help relieves symptoms of menopause. Improves posture.

●   Squat or Garland Pose Malasana (मलासना )

                                      

             

Squatting is one of the most effective ways to tone the entire lower body. As the pelvis descends it encourages the downward flowing energy of Apana Vayu and thus helps in constipation.
To learn to squat or if you are pregnant: Separate your feet about 6 to 8 inches, and place a folded blanket under your heels until you are able to lower your pelvis and maintain balance.

Benefit :

• This asana strengthens abdominal and pelvic muscles, increases blood circulation and aids in digestion.

But treating this condition can be hard and may cause unwanted effects. For these and other reasons, you may want to look for natural ways to improve or replace your healthcare provider's treatments.

Natural remedies don't fall under mainstream care. Rather, they're considered complementary and alternative medicine 

Little evidence exists to support the various forms of CAM for this condition. Even so, they're low-risk treatments, and using them is not likely to make endometriosis worse.

Treatment 

There is no cure for endometriosis, but a number of treatments may improve symptoms.

Management

While there is no cure for endometriosis, there are two types of interventions; treatment of pain and treatment of  endometriosis- associated infertility. In many cases, menopause (natural or surgical) will abate the process. In the reproductive years, endometriosis is merely managed: the goal is to provide pain relief, to restrict progression of the process, and to restore or preserve fertility where needed. 

 "laparoscopic surgery improves over all pain compared to diagnostic laparoscopy"

Hormone treatments 

Hormonal medications

Hormonal medication that suppresses the natural cycle, 

• Hormonal birth control therapy: Birth control pills reduce the menstrual pain and recurrence rate for endometrioma following conservative surgery for endometriosis.
• Progesterone : Progesterone counteracts estrogen and inhibits the growth of the endometrium.  Danazol (Danocrine) and gestrinone  (Dimetrose, Nemestran) are suppressive steroids with some androgenic activity. Both agents inhibit the growth of endometriosis but their use has declined, due in part to virilizing  side effects such as excessasive hair growth  and voice changes. There is tentative evidence based on cohort studies that dienogest and norethisterone acetate  (NETA) may help patients with DIE in terms of pain. There is tentative evidence based on a prospective study that vaginal danazol reduces pain in those affected by DIE.
• Gonadotropin-releasing hormone (GnRH) modulators: These drugs include GnRH agonist such as leuprorelin  (Lupron) and GnRH antagonists such as  elagolix (Orilissa) and are thought to work by decreasing estrogen levels. 
• Aromatase inhibitors are medications that block the formation of estrogen and have become of interest for researchers who are treating endometriosis. Examples of aromatase inhibitors include anastrozole and letrozole. Evidence for aromatase inhibitors is confirmed by numerous controlled studies that show benefit in terms of pain control and quality of life when used in combination with gestagens or oral contraceptives with less side-effects when used in combination with oral contraceptives like norethisterone acetate. Despite multiple benefits, there are lot of things to consider before using AIs for endometriosis, as it is common for them to induce functional cysts as an adverse effects. 
• Progesterone receptor modulators like  mifepristone and  gestrinone have the potential (based on only one RCT each) to be used as a treatment to manage pain caused by endometriosis.

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• Hormonal medication that suppresses the natural cycle, 
• Combine oral contraceptives reduces the risk of endometriosis.
• Using an Intra uterine device (IUD)  with Progesteron may also be useful
•  Gonadotropin- releasing hormone agonist  (GnRH agonist) may improve the ability of those who are infertile to get pregnant

• Advice pregnancy or create a Pseudopregnancy state.
• Oral contraceptive  for 6 months.
• Ladogal or cap Danogen (Danazol) 600 to 800 mg daily for 3-6 months. Therapy  should begin during menstruation
• Dose adjusted so as to keep the patient amenorrhoeic. (create a pseudopregnancy state)
• Note :Make sure patient is not pregnant while on therapy
• Suppression with GnRh agonists, intranasally {Nafarelin) sub cutenously (Suprafact/Leupride) once a month. Depot preparations (Lupron-Depot Goserelin) for 6 months.
• Or Tab Deviry (oral Progesteron 10 mg BD TDS for 3 months.
• OR Tab Duphaston 1-2 tab or TDS for 6 months.
• Tab Regesterone (Ciba) (Norethirdone acetate 5 mg)1 tab TDS for 6 month.
• Inj Depoprovera 150mg during or in first 5 weeks post partum LNG. IUD/ 3 months. into 2

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• Pain medicine
• Non steroid anti inflammatory drug  (NSAID), such as Naproxen

Pain  Medicines

• NSAIDs are anti-inflammatory medications commonly used for endometriosis patients 
• Melatonin, there is tentative evidence for its use (at a dose of 10 mg) in reducing pain related to endometriosis.
• Opioids : Morphine sulphate tablets and other opioid painkillers work by mimicking the action of naturally occurring pain-reducing chemicals called "endorphins". There are different long acting and short acting medications that can be used alone or in combination to provide appropriate pain control.
• Chinese herbal medicine was reported to have comparable benefits to gestrinone and danazol in patients who had had laparoscopic surgery.
• Serrapeptase a Digestive enzyme  found in the intestines of silkworms. Serrapeptase is widely used in Japan and Europe as an anti-inflammatory treatment.  Serrapeptase may be used by endometriosis patients to reduce inflammation.
• Pentoxifylline, an immunomodulating agent, has been theorized to improve pain as well as improve pregnancy rates in individuals with endometriosis. 

Laparoscopic diagnosis and staging of the disease is must before embarking on treatment, since the treatment is prolonged, expensive and not without side effects.

Treatment of infertility

while an infertile individual may be treated expectantly after surgery, with fertility medication, or with intra vitro fertilization (IVF). Surgery is more effective than medicinal intervention for addressing infertility associated with endometriosis. Surgery attempts to remove endometrium-like tissue and preserve the ovaries without damaging normal tissue. Receiving hormonal suppression therapy after surgery might be positive regarding endometriosis recurrence and pregnancy. In-vitro fertilization (IVF) procedures are effective in improving fertility in many individuals with endometriosis.
During fertility treatment, the ultralong pretreatment with GnRH-agonist has a higher chance of resulting in pregnancy for individuals with endometriosis, compared to the short pretreatment.

Surgery

"laparoscopic surgery improves over all pain compared to diagnostic laparoscopy"

In general, the diagnosis of endometriosis is confirmed during surgery. Surgery, if done, should generally be performed laparoscopically (through keyhole surgery) rather than open. Treatment consists of the ablation or excision of the endometriosis, electrocoagulation, lysis of adhesions , resection of endometriomas, and restoration of normal pelvic anatomy as much as is possible.  When laparoscopic surgery is used, small instruments are inserted through the incisions to remove the endometriosis tissue and adhesions. Because the incisions are very small, there will only be small scars on the skin after the procedure, and most individuals recover from surgery quickly and have a reduced risk of adhesions. Many endometriosis specialists believe that excision is the ideal surgical method to treat endometriosis.

As for deep endometriosis, a  segmental resection or shaving of nodules is effective but is associated with an important rate of complications which about 4,6% is major.

Historically, a  hysterectomy (removal of the uterus) was thought to be a cure for endometriosis in individuals who do not wish to conceive. Removal of the uterus may be beneficial as part of the treatment, if the uterus itself is affected by adenomyosis. However, this should only be done in combination with removal of the endometriosis by excision. If endometriosis is not also removed at the time of hysterectomy, pain may persist.

Presacral neurectomy may be performed where the nerves to the uterus are cut. However, this technique is not usually used due to the high incidence of associated complications including presacral hematoma and irreversible problems with urination and constipation.

In general, the diagnosis of endometriosis is confirmed during surgery, at which time ablative steps can be taken. Surgical removal of endometriosis may be used to treat those whose symptoms are not manageable with other treatments. In younger individuals, some surgical treatment attempts to remove endometriotic tissue and preserve the ovaries without damaging normal tissue.

On Laparoscopic diagnosis-endometriotic cyst is ruptured and  cyst wall fulgurized. (A procedure that uses heat from an electric current to destroy abnormal tissue, such as a tumor or other lesion.)

If patient is interested in child bearing, she should be counselled regarding artificial reproductive techniques (ART) as endometriosis destroys ovarian tissue.

Radical surgery may rarely be neccessary in very severe form of disease, in case of patient no longer desires child bearing

Oophorectomy : Removal of ovaries

Hysterectomy :(removal of the uterus)

Pseudopregnancy : (high-dose estrogen–progestogen therapy

Progesteron : monotherapy dominated the treatment of endometriosis 

Danazol : was first described for endometriosis

Oral GnRH antagonists such as elagolix were introduced for the treatment of endometriosis 

Risks and safety of pelvic surgery

Risk of developing complications following surgery depend on the type of the lesion that has undergone surgery. 55% to 100% of individuals develop adhesions  following pelvic surgery, which can result in infertility, chronic abdominal and pelvic pain, and difficult reoperative surgery. Trehan's temporary ovarian suspension, a technique in which the ovaries are suspended for a week after surgery, may be used to reduce the incidence of adhesions after endometriosis surgery. Removal of cysts on the ovary without removing the ovary is a safe procedure.

Recurrence

The underlying process that causes endometriosis may not cease after a surgical or medical intervention. A study has shown that dysmenorrhea recurs at a rate of 30 percent within a year following laparoscopic surgery. Resurgence of lesions tend to appear in the same location if the lesions were not completely removed during surgery. It has been shown that laser ablation resulted in higher and earlier recurrence rates when compared with endometrioma cystectomy; and recurrence after repetitive laparoscopy was similar to that after the first surgery. Endometriosis can come back after hysterectomy and bilateral salpingo-oophorectomy. It has 10% recurrent rate.

Endometriosis recurrence following conservative surgery is estimated as 21.5% at 2 years and 40-50% at 5 years.

Recurrence rate for DIE after surgery is less than 1%

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