Endometriosis is a condition that affects a significant group of women from adolescence through premenopause, and in some cases, it can occur in postmenopausal women on hormone replacement therapy and other conditions, with a strong genetic influence according to recent research. Its prevalence is even higher in women who have difficulty conceiving, reaching up to 35%. Those with a family history (mothers or sisters with endometriosis) have a six times higher risk than those without this history.
Diagnosis and Evaluation
Diagnosis is generally based on clinical symptoms, but additional tests are needed to confirm it. Gynecological ultrasounds are not very effective, so transvaginal or transrectal ultrasound is recommended to assess pelvic endometriosis. Magnetic resonance imaging (MRI) is another diagnostic tool, both with specialized preparation to map endometriosis areas for subsequent surgical laparoscopy to remove the lesions and take samples for analysis to determine the severity and extent of the disease.
Severity Assessment
The American Fertility Society (AFS) has developed a scale to assess the severity of pelvic endometriosis, which is divided into four stages: Minimal, mild, moderate, and severe.
Treatments
In uncomplicated cases, treatment is usually medical, using hormonal agents. Experimental treatments that show promising results are also being researched. When conservative treatment is not effective, more invasive treatments such as surgery, especially laparoscopy, are used. This can be complicated if the patient has had previous abdominal surgeries. For women who wish to become pregnant, a suitable medical and surgical approach is preferred. However, in other cases, such as severe cases, with no desire for pregnancy or already satisfied parity, hysterectomy with the removal of all endometriotic lesions and sometimes the removal of both ovaries may be an option.
Endometriosis in the Intestine: Frequency and Symptoms
Endometriosis can also affect areas outside the genital organs, with the intestine being one of the most common locations. Approximately 12% of women with endometriosis have intestinal involvement, with the rectosigmoid colon being the most common location (70-93%). This can cause specific symptoms such as rectal pain during menstruation, changes in bowel habits, diarrhea, and rectal bleeding. In some cases, it can present as acute intestinal obstruction. Ileocecal or appendicular endometriosis may manifest as recurrent right-sided abdominal pain, sometimes confused with acute appendicitis.
Diagnosis and Evaluation
To evaluate local involvement once endometriosis is suspected, specialized ultrasound for endometriosis and magnetic resonance imaging (MRI) are used. Overall, MRI in combination with ultrasound is often the most effective option. Laparoscopy is useful for confirming the diagnosis and performing definitive surgical treatment.
Specific Tests for Intestinal Cases
When endometriosis affects the intestine, especially the rectosigmoid colon, specific symptoms may arise, such as rectal pain during menstruation, changes in bowel habits, diarrhea, rectal bleeding, and in some cases, acute intestinal obstruction. In emergency situations, such as acute obstruction, contrast-enhanced CT can be performed. In some cases, colonoscopy or barium enema may be considered, but caution must be exercised to differentiate endometriosis from other conditions such as colorectal cancer.
Treatments
In early stages and when intestinal involvement is mild, hormonal treatment may be attempted, which appears to be effective. However, there is insufficient data on medical treatment for intestinal endometriosis in the literature, except for some isolated cases successfully treated with medications like danazol.
Regarding hormonal treatment in combination with surgery, some doctors suggest it before surgery to reduce the size of ectopic endometrial tissue, making surgery easier. Others prefer hormonal treatment after surgery, especially if radical surgery was not performed to reduce recurrence. However, the benefits of this approach are still debated and depend on the individual patient’s situation.
Surgical Treatment
Surgery for intestinal endometriosis is divided into two categories: elective surgery in diagnosed patients and emergency surgery when a clear diagnosis has not been achieved.
In elective situations, laparoscopic surgery is preferred due to its advantages. Less invasive surgical techniques are attempted, and if the patient desires to become pregnant after surgery, a more conservative approach is chosen. In the treatment of endometriosis, it is often recommended to perform bilateral hysterosalpingo-oophorectomy and removal of all endometriotic lesions, as mentioned earlier.
Treatment by Location and Extension
The approach to treating intestinal endometriosis depends on the location, extent, and depth of the lesions. Laparoscopic surgery may not always be possible, as many patients have had previous pelvic surgeries due to the same disease. Additionally, local conditions may not be ideal due to recurrent inflammation, increasing the possibility of conversion to open surgery. Wherever possible, attempts are made to locally remove endometrial implants using techniques such as excision or shaving of lesions. In more severe cases, especially in the rectosigmoid colon, where intestinal lesions are most common, intestinal resection may be required. This is usually done through laparoscopic surgery, or in exceptional cases, open surgery. The goal is to remove as much ectopic endometrial tissue as possible.
Elective Surgery vs. Emergency Surgery
Surgery for intestinal endometriosis is divided into elective surgery for previously diagnosed patients and emergency surgery when a clear diagnosis has not been achieved.
Complications and Emergency Treatment
The most common complication requiring emergency surgery is intestinal obstruction, usually in the rectosigmoid colon. Diagnosis in this situation is challenging, but a proper medical history can help suspect it. Treatment varies according to each center’s protocol. Some advocate single-stage surgery, while others suggest a two-stage approach. Intestinal perforation as a complication is very rare. As for intestinal bleeding, it is even rarer and generally resolves on its own.
Neoplastic Degeneration
Although rare, neoplastic degeneration of colorectal endometriosis must be recognized and treated more aggressively using oncological surgery principles.
Treatment Outcomes
Overall, surgical treatment outcomes are satisfactory in over 80% of women who undergo surgery, especially in relation to intestinal symptoms. Severe complications such as fistulas and abscesses are possible, and conversion from laparoscopic surgery to open surgery may be necessary in less than 2% of cases in our group. Intestinal surgery can lead to sequelae such as constipation or, in some cases, mild diarrhea.
Pregnancy Rate and Postoperative Hormonal Treatment
It is important to note that after intestinal endometriosis surgery, around 50% of women can achieve pregnancy. This emphasizes the importance of being as conservative as possible in treating female internal organs.
Despite some studies, there are no statistically robust data to support the systematic use of hormonal treatment in the postoperative period. Some studies suggest a decrease in pain recurrence after surgery, but it is not a universal recommendation. Each case should be evaluated individually.
Conclusions
Intestinal endometriosis is a relatively common disorder that affects many women with endometriosis. The most common symptoms include intestinal problems and bleeding. However, less than 1% of these patients will require intestinal resection surgery.
The rectosigmoid colon is the most affected part of the intestine in this process, with approximately 90% of cases of intestinal endometriosis. Diagnosis is made through transvaginal ultrasound and magnetic resonance imaging. Laparoscopy is the most accurate method for treatment and assessment of severity.
Medical treatment is often less effective when intestinal endometriosis is symptomatic. Contraceptives, danazol, and gonadotropin antagonists are considered the most effective.
In the hands of expert teams, laparoscopic surgery is the preferred option when possible, and rectosigmoid colon resections are often required. For women of childbearing age who wish to become pregnant, a conservative approach to internal genital organs is recommended. In other cases, removal along with intestinal surgery is advised. The fertility rate after this type of surgery can be close to 50%.
Overall, outcomes are good concerning the resolution of intestinal problems. Additional hormonal treatment is only considered in cases where surgery has not been effective. Despite the relative benignity of laparoscopic surgery, indications for surgical treatment of intestinal endometriosis should not be expanded, as the morbidity in non-expert hands