Epidemiology

Endometriosis affects approximately 10% of women of reproductive age, with higher rates among those with chronic pelvic pain (40–50%) and infertility (30–40%). Diagnosis is often delayed by 8–10 years, coinciding with peak disease years (ages 25–45). While some studies report no significant racial differences, others note lower prevalence in black African women compared to Caucasian and African American populations. The disease commonly involves pelvic organs but can occasionally affect extra-pelvic sites such as the chest and brain.

Aetiology

The exact cause of endometriosis remains unclear. The most widely accepted theory is retrograde menstruation, where endometrial cells reach the peritoneal cavity. A process occurring in most women. Other contributing factors include genetic predisposition, immune dysfunction, and environmental toxins. Hematogenous or lymphatic spread may explain extra-pelvic disease.

Symptomatology and Diagnosis

Endometriosis is underdiagnosed and undertreated, with a long interval between symptom onset and diagnosis. Common symptoms include dysmenorrhea (often severe), deep dyspareunia, infertility, dysuria, painful defecation, abdominal bloating, and constipation. Mental health issues such as anxiety and depression may also occur.

Symptoms vary depending on lesion location. For example, bladder involvement may cause cyclical hematuria, while chest lesions can result in cyclical hemoptysis. Diagnosis based solely on history is difficult due to variable presentation and mimicry of other conditions. Laparoscopy remains the gold standard for diagnosis, with histological confirmation. Non-invasive methods like transvaginal ultrasound and MRI are useful adjuncts.

Classification

Endometriosis is classified into two main subtypes:

• Superficial peritoneal endometriosis: Lesions on the peritoneal surface, often of various colors. Endometriomas (ovarian cysts with “chocolate” fluid) are common.
• Deep endometriosis: Lesions extend beyond the peritoneum, are nodular and fibrotic, and may invade pelvic organs such as the rectosigmoid, ureter, or bladder. Deep endometriosis can cause organ damage (e.g., kidney failure from ureteric obstruction, bowel obstruction), making timely diagnosis and management crucial.

Treatment

Management depends on patient age, fertility status, symptom nature and severity, previous treatments, cost, side-effect profile, and best available evidence. Treatment options are divided into lifestyle/dietary interventions, medical therapy, and surgical interventions.

Lifestyle Modifications and Behavioral Therapy

• Psychological support, cognitive-behavioral therapy, and exercise (e.g., yoga) may help manage symptoms.
• Dietary interventions, such as gluten-free diets (gluten should be avoided), fish oil (omega-3 fatty acids), vitamins, minerals, and lactic ferments, have shown benefit.

Medical Management

• Progestins: Dienogest, medroxyprogesterone acetate, and levonorgestrel intrauterine system are first-line options.
• Combined oral contraceptive pills (COCP): Useful for symptom control.
• NSAIDs: Widely used for dysmenorrhea and pelvic pain (e.g., ibuprofen, diclofenac).
• GnRH agonists/antagonists: Reserved for persistent symptoms; add-back hormonal therapy is necessary for prolonged use (>6 months).
• Aromatase inhibitors, danazol, gestrinone, SERMs, SPRMs: Considered in refractory cases.
• Non-hormonal treatments: Pentoxifylline may be considered.

Complementary Therapies

• Acupuncture: May help with pain when conventional methods fail.
• Electrotherapy: TENS is commonly used for pain management.

Surgical Treatment

• Laparoscopic surgery is preferred over laparotomy for chronic pain and infertility due to less pain, shorter hospitalization, quicker recovery, and better cosmetic results.
• Surgical options include cyst drainage and ablation, cystectomy (preferred for cysts >3cm), laser vaporization, hysterectomy with or without bilateral salpingo-oophorectomy (BSO), adhesiolysis, laparoscopic uterine nerve ablation (LUNA), and presacral neurectomy.
• Endometrioma surgery is technically demanding and may require a staged approach with interim medical suppression.

Conclusion

Endometriosis is a challenging disease to diagnose and manage, especially in sub-Saharan Africa where awareness and resources may be limited. Clinicians should maintain a high index of suspicion, utilize available diagnostic modalities, and tailor management to individual patient needs to reduce morbidity associated with delayed diagnosis.