Understanding the Complex Nature of Endometriosis

Endometriosis is defined as the presence of endometrium-like tissue outside the uterus. However, this definition does not encompass the complex symptomatic, pathobiologic, and multisystemic nature of the disorder. 1/15 pic.twitter.com/qfQGo2qKAb

— NEJM (@NEJM) March 8, 2023

Endometriosis is estimated to affect 10% of reproductive-age women, which extrapolates to approximately 190 million women worldwide. However, the true prevalence of endometriosis is uncertain. 2/15

— NEJM (@NEJM) March 8, 2023

Presentations of endometriosis range from superficial peritoneal lesions of varying color, to cysts in the ovaries (endometrioma), to nodules with a depth of penetration exceeding 5 mm, to extrapelvic lesions. 3/15 pic.twitter.com/852nqfUBub

— NEJM (@NEJM) March 8, 2023

More severe endometriosis, according to the widely used, revised American Society of Reproductive Medicine (rASRM) staging classification (stages I through IV), does not correlate with symptoms, treatment response, or prognosis. 4/15 pic.twitter.com/3CsGnkRzrL

— NEJM (@NEJM) March 8, 2023

Although the natural history of endometriosis is unknown, subphenotypes of lesions may vary across the life course. However, no robust evidence supports an ordered progression of endometriotic lesions. 5/15

— NEJM (@NEJM) March 8, 2023

The development of endometriosis involves interacting endocrine, immunologic, proinflammatory, and proangiogenic processes. 6/15

— NEJM (@NEJM) March 8, 2023

Whether these factors are pathogenic (causal) or merely represent a feature of the pathophysiological process typically measured years after symptom onset remains uncertain. 7/15 pic.twitter.com/ZxQPEkm2O3

— NEJM (@NEJM) March 8, 2023

Endometriosis remains difficult to diagnose. No biomarkers to detect or rule out endometriosis are available. 8/15

— NEJM (@NEJM) March 8, 2023

The predominantly intraabdominal location of the lesions, plus their small size, means that laparoscopic visualization (ideally with histologic verification) remains the standard for diagnosis of the disease. 9/15 pic.twitter.com/6dM2L8z1Mz

— NEJM (@NEJM) March 8, 2023

However, endometriomas can be identified reliably by transvaginal ultrasonography or MRI, with more than 90% sensitivity and specificity. 10/15

— NEJM (@NEJM) March 8, 2023

In choosing treatment for endometriosis, it is crucial to consider the patient’s predominant symptoms and preferences, side-effect profile, and age, as well as the extent and location of disease, previous treatment, and costs. 11/15

— NEJM (@NEJM) March 8, 2023

Management of endometriosis requires multidisciplinary expertise. Approximately 50% of women with endometriosis have recurrent symptoms over a period of 5 years, irrespective of the treatment approach. 12/15

— NEJM (@NEJM) March 8, 2023

Given the high prevalence of endometriosis, the cumulative effect of the disease on health and well-being across the life course, and the high associated economic costs, improvements in awareness, education, and action are long overdue. 13/15

— NEJM (@NEJM) March 8, 2023

Progress can be achieved only through sufficiently powered, collaborative, multidisciplinary research, facilitated by funding bodies by means of the prioritization of endometriosis as an important public health issue. 14/15

— NEJM (@NEJM) March 8, 2023