Endometriosis is a pathological condition in which tissue similar to the endometrium of the uterus is also found in other parts of the body, even in the brain. Women of reproductive age are predominantly affected, and although common, the condition of endometriosis does not always imply the presence of endometrium in distant structures. Each case is often individual and according to it – and the therapeutic approach.

The month of March is dedicated to fighting endometriosis, more popularly known as Endomarch. The initiative is global and encompasses over 100 organizations in over 60 countries. EndoMarch Bulgaria Foundation is an ambassador of the global movement EndoMarch Worldwide in support of the nearly 200 million women worldwide suffering from endometriosis. Dr. Dorian Bosev – Obstetrician and Gynecologist at the Hospital “Maichin Dom” is the Chairman of the Foundation with 25 years of experience and numerous awards. In 2008, Dr. Bosev completed his fellowship at the Center for Minimally Invasive and Robotic Special Surgery at Stanford University. He was awarded the CARLO ROMANINI Award by the American Association of Gynecologic Laparoscopy (AAGL) for excellence in the endoscopic treatment of endometriosis. He returns to Bulgaria to pass on his experience and give many Bulgarian women the chance to do their best in the context of this pathology. Even to be completely cured.

I talk to Dr Bosev about the nature of endometriosis, therapeutic solutions, prognosis and the risk of infertility.

Dr. Bosev, what is endometriosis?

Endometriosis is a chronic inflammatory disease that affects women of reproductive age. Approximately 10-15% of all women have endometriosis, or 1 in 10 women suffer from this disease.

The disease is characterized by the presence of endometrium – the tissue that covers the uterine cavity – outside the cavity.

During the monthly cycle, the endometrium prepares to become pregnant and when this does not happen, this tissue is thrown out through menstruation. When there is this same tissue, or tissue similar to it, somewhere else in the body, it undergoes exactly the same changes as the endometrium in the uterus, only there is nowhere for it to be expelled and this leads to an inflammatory reaction, adhesions and a build-up of tissue in that location.

By its nature, endometriosis is a benign disease, but at the same time it is also invasive, that is, the earlier it is diagnosed, the earlier it will be treated, hindering its development.

How do endometrial cells from the uterus reach neighboring, and even very distant organs?

There are different theories about how endometriosis occurs. One of them is related to retrograde menstruation. This is a phenomenon in which there is reflux of menstrual blood from the fallopian tubes to the peritoneal cavity. When it enters the abdominal cavity, endometriosis can spread adjacent to all organs in the cavity, as well as to the liver, diaphragm, and through it to the lung.

Another theory, called metaplastic, associates the ability of parietal epithelium to differentiate into endometrial under the action of growth factors and cytokines. Endometrial cells can “move” by a blood or lymphatic route outside the uterus. This theory is called metastatic. There is also a hormonal one, which is associated with elevated levels of estrogen and low levels of progesterone. Since it was mentioned that endometriosis is an inflammatory disease, there are increased levels of specific interleukins in the body that activate macrophages and lead to a systemic inflammatory response. This theory is the immunological one.

Does the disease have symptoms or is it discovered accidentally?

Of course, there may be a pronounced clinical picture, but in most cases, patients may not have any complaints. The most common symptoms of endometriosis are associated with painful and heavy menstruation, pain during urination, pain during intercourse, chronic pelvic pain. In practice, the symptoms depend on where the endometriosis is positioned and the symptoms of the disease are determined from there.

Are there risk factors or risk groups for the onset of endometriosis?

There are a variety of factors, but these are most often women whose menstruation is longer than 7 days; women whose cycle is shorter than 28 days; women of reproductive age; but mostly women between 30 and 40 years of age.

Of course, endometriosis can also be found in very young girls, even under the age of 10-12. Other risk groups are women who have not given birth. There may also be family burdens. The factors can be the most diverse, but are not strictly specific.

Is reproductive health related to endometriosis?

There is, and it is significant. Between 30 and 50% of women who suffer from endometriosis have reproductive problems, because in women who have endometrial cysts, ovarian reserve and anti-Müllerian hormone are actually reduced. When the cysts are larger, this reduction is greater, and it becomes even greater when the cysts are bilateral.

On the other hand, endometriosis leads to adhesions that can prevent the movement of sperm through the fallopian tube or vice versa – when we have a fertilized egg, it cannot return to the uterus and implant. The receptivity of the uterus itself is also reduced, and apart from this, endometriosis can lead to hormonal and autoimmune diseases that interfere with fertility.

What benefits does early detection of endometriosis bring to patients?

Earlier detection leads to better treatment because the disease is not as invasive when it is detected earlier, and we will cure it more easily.

Depending on where the endometriosis is located, it enters the tissues, infiltrates them, and can develop from a superficial form to a deep endometriosis.

Is endometriosis detected during a routine ultrasound examination? What should we advise women from risk groups?

In order to be able to detect this disease earlier and as protection, it is important for women to have regular preventive annual examinations, but it is also important to know the symptoms. A lot of doctors don’t think about this disease, but one sees what they know… It is very important that we doctors always think about endometriosis because it is a serious disease with potentially serious consequences.

Can the symptoms of endometriosis be confused with another condition and be neglected?

It is very important where the endometriosis is. It is a multifaceted disease depending on where it is located. There is no organ in the human body that is immune to endometriosis. It is most often found in the small pelvis, covers ovaries, fallopian tubes, uterus. But it can involve the bladder, giving the mentioned symptoms when urinating. It is possible to affect the ureter and this leads to urinary retention, even to the loss of kidney function.

The clinical picture will appear depending on where the endometriosis is. As I already mentioned, endometriosis can be present in the liver, diaphragm, lung, even the brain.

Is endometriosis curable?

Unfortunately, it is not always curable. The goal is, when treated, to leave no residual disease.

And how is it treated?

There are two methods. Medication, which is more symptomatic, includes non-steroidal anti-inflammatory drugs or hormone therapy, which again does not treat the problem in depth. We can say that the gold standard for the treatment of endometriosis is surgical treatment, and in particular, laparoscopic minimally invasive treatment, not because it is a panacea, but because it has many advantages: faster recovery, less need for analgesics, faster the patient returns to his normal lifestyle, fewer infectious complications and fewer adhesions.

With this method, the great advantage for the doctor and, respectively, for the patient, is that he sees better, and whoever sees better, diagnoses better and treats better. In practice, with the laparoscope we can see lesions that the naked eye would never notice. Thus, after the intervention, the probability of having residual disease decreases dramatically. These data are supported by a number of studies that show that after adequate laparoscopic treatment, recurrences decrease, the number of spontaneous pregnancies increases and pain symptoms are affected extremely well.

It is generally accepted that endometriosis recurs. Is this true?