Endometriosis: Classification, pathophysiology, and treatment options

The human endometrium is a complex hormone-target tissue consisting of two layers: the lower basalis, and the upper functionalis. The latter of the two goes through a cycle of thickening and shedding without residual scarring or loss of function. This cycle, known as the menstrual cycle, occurs on a monthly basis in most of healthy reproductive-age women. It is, however, associated with a number of reproductive diseases, endometriosis being one of them. Endometriosis is defined as the presence of endometrium at ectopic sites within the peritoneum or, more rarely, other locations outside the abdominal area. It affects around 6-10% of reproductive-age women in the world and causes debilitating pain, heavy menstrual bleeding, pain during penetrative sex, and infertility. The etiology of the disease is not yet fully understood but the generally accepted theory is that the endometriotic lesions originate from viable eutopic endometrial cells that flow back into the peritoneum through the process of retrograde menstruation. Endometriosis is usually classified into four stages: minimal, mild, moderate, and severe, though it is important to note that the presentation of symptoms does not necessarily correspond to the disease progression. The immune system plays an important role in supporting the viability and growth of ectopic endometriotic tissue, all the while promoting chronic inflammation at the lesion sites, which causes prolonged pain. There is no definitive cure for endometriosis, but there are several options for symptom management, including laparoscopy, hormonal therapy, the use of NSAIDs, dietary changes, exercise, and, in cases when all conservative treatments fail, hysterectomy.