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The deaf pain of women

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Published the 3/11/2021

On the occasion of Women's Rights Day, together with the Cortex team, we deliver this article on endometriosis, accompanied by written and oral testimonies.

Before getting down to business, it is necessary to recall how a woman works and her menstrual cycle.

Every woman with a vagina, uterus, fallopian tubes and ovaries normally has what are called menstrual cycles. A menstrual cycle is broken down over a month. During this month, the woman, her organs and hormones will go through different changes so that her body can at some point in time accommodate a future child.

Diagram of the female reproductive system

Every month, at the beginning of a cycle, oocytes are ready to be expelled, they are contained in follicles. During the first 14 days of the cycle, their size increases until one of them stands out. An oocyte is then expelled on the 14th day by one of the two ovaries. Once it reaches the auricle of the tube, it becomes an ovum. At the same time, another organ changes its appearance: the uterus. During the first 5 days, its mucous membrane which covers it will degenerate and be destroyed, it is the menstruation. After that it will rebuild and thicken its endometrial wall. After ovulation, the uterus still changes aspect and the uterine lace appears. It is under these conditions that an embryo can nestle and develop.

This synchronisation of the uterus and the ovaries is linked to the secretion of hormones from the ovaries. The concentration of hormones varies according to the period of the cycle. These include estrogen and progesterone. At the beginning of the cycle, their concentration is low, so you have your period. An increase in estrogen will then help regenerate the lining of the uterus. After ovulation on day 14, progesterone takes over.



Endometriosis, a disease that affects 6 to 10% of women.

Endometriosis is a gynecological disease that is still poorly known, yet common, affecting women of childbearing age. The formation of endometrial tissue occurs in places where it should not be present. Endometrial cells line the lining of the uterus and develop to accommodate an embryo.




Diagram of the reproductive tract of a woman with endometriosis


When a woman has endometriosis, her endometrial cells will migrate into the fallopian tubes instead of being evacuated with menstruation, and thus become lodged in the pelvic cavity.



Diagram of ruler deposits in the pelvic cavity

In some cases, these cells can also be found in different areas of the body such as the vagina, rectum and sometimes even the liver, lungs and brain. These cells, once attached to the organs, will create lesions and react to the hormone plays during the menstrual cycle. They will bleed, which can cause severe pain during (dysmenorrhea) and outside of the menstrual period. Severe fatigue may also be experienced. For some women, there is pain during urination (dysuria) and defecation (dyschesia), as well as during sexual intercourse (dyspareunia).

Endometriosis is said to be present. Because the symptoms and severity vary according to the women affected and, above all, there are asymptomatic women among them, 5 to 10% (who have no signs of the disease such as pain).

For this reason, a classification has been established by the ASRM (American Society for Reproductive Medicine) according to the location and size of the lesions observed during surgery: I (minimal), II (mild), III (moderate), IV (severe).

There are three main types of endometriosis:

- Superficial peritoneal endometriosis: this is a stage where "bits" of the endometrium will be implanted outside their area and will react according to the hormones regulating the menstrual cycle. These affected areas do not heal completely.

- Deep infiltrating endometriosis: unlike the previous case, there is no real influence of the menstrual cycle. “Pieces" of endometrium can be found in areas at the back of the uterus and vagina such as the rectal area.

- Ovarian endometriomas: brown cysts are found as a result of repeated bleeding from endometrial "pieces" in certain areas.

The cause(s) of endometriosis are still unknown, however there are several hypotheses. It is known that endometriosis reacts to hormones and is therefore hormone dependent. It is also known that the immune system plays a role during inflammation, but it is not yet known whether it is the immune system that has an impact on the disease or the other way around.

The dominant hypothesis of the causes of this disease is implantation. As explained above, this would involve endometrial cells migrating in the wrong direction, moving up the fallopian tubes and lodging in different organs, but this is unlikely to be the only explanation.

The direct consequence of endometriosis, other than pain, is infertility. In fact, it is on this occasion, during a medical check-up in order to have a child, that some women are diagnosed.


Diagnostic techniques

Routinely and as a first step, affected women are detected through palpation by a doctor or midwife. A pelvic ultrasound or even an MRI (magnetic resonance imaging) is often used afterwards. In order to confirm the diagnosis of the disease, it is necessary to take a tissue sample for a histological study (observation and study of tissue). This is done during a surgery called laparoscopy. This operation allows both to confirm the presence of the disease but also to classify it on the ASRM scale and to treat apparent lesions to relieve pain.


Scientists suspect risk factors

Nowadays, when the word is slowly getting out in many areas, the same culprits are often found in public health debates: endocrine disruptors. In the case of endometriosis, scientists are inclined to think that these endocrine disruptors play a role in the progression of the disease, but also in its onset. There is another element that may be involved in this disease: epigenetics. For readers who are not familiar with this concept, I invite you to read our article "Our impact on our genes". Basically, epigenetics illustrates the capacity of our environment to influence the expression of our genes.

These two risk factors are still not fully identified as being responsible, but several researchers are strongly interested in them.


Where are we today?

Well currently, there are two types of treatment for women with endometriosis. The drug route, which usually involves taking oral contraceptives and progestin to stop menstruation and reduce pain. However, few women seem to be able to tolerate this option because of the serious side effects, such as increased hair growth, strong mood swings, a drop in libido... This method is used to obtain long-term effects but is not compatible with a desire to have children. The second solution is surgery, which is applied in the desire to procreate but also to reduce pain.

It is important to understand after reading this article that endometriosis is still a disease that is neither understood nor properly managed. There are methods to relieve these women who suffer from it, but nothing that will allow them to be fully cured. This is why it is important to communicate and discuss this disease. Both to avoid having women who, through wandering and misunderstanding of the medical profession, feel "not legitimately ill". But also in order to involve and value the world of research which is working to find solutions.


References:

1. Alimi, Y., Iwanaga, J., Loukas, M. & Tubbs, R. S. The Clinical Anatomy of Endometriosis: A Review. Cureus 10,.

2. Bulun, S. E. et al. Endometriosis. Endocr Rev 40, 1048–1079 (2019).

3. Farquhar, C. Endometriosis. BMJ 334, 249–253 (2007).

4. Hogg, S. & Vyas, S. Endometriosis update. Obstetrics, Gynaecology & Reproductive Medicine 28, 61–69 (2018).

5. Parasar, P., Ozcan, P. & Terry, K. L. Endometriosis: Epidemiology, Diagnosis and Clinical Management. Curr Obstet Gynecol Rep 6, 34–41 (2017).

6. Raffi, F. & Amer, S. Endometriosis. Obstetrics, Gynaecology & Reproductive Medicine 21, 112–117 (2011).

7. Rafique, S. & DeCherney, A. H. MEDICAL MANAGEMENT OF ENDOMETRIOSIS. Clin Obstet Gynecol 60, 485–496 (2017).

8. Rolla, E. Endometriosis: advances and controversies in classification, pathogenesis, diagnosis, and treatment. F1000Res 8, (2019).

9. Salvat, J. Diagnostic et suivi de l’endométriose en consultation: nouveautés. Gynécologie Obstétrique & Fertilité 29, 616–623 (2001).

10. Wee-Stekly, W.-W., Kew, C. C. Y. & Chern, B. S. M. Endometriosis: A review of the diagnosis and pain management. Gynecology and Minimally Invasive Therapy 4, 106–109 (2015).

11. Endometriosis: Causes, Complications, and Treatment. Healthline https://www.healthline.com/health/endometriosis (2012).

12. Endométriose. Inserm - La science pour la santé https://www.inserm.fr/information-en-sante/dossiers-information/endometriose.

13. Endometriosis - an overview | ScienceDirect Topics. https://www.sciencedirect.com/topics/medicine-and-dentistry/endometriosis.

14. Endometriosis - an overview | ScienceDirect Topics. https://www.sciencedirect.com/topics/pharmacology-toxicology-and-pharmaceutical-science/endometriosis.

15. Qu’est ce que l’Endométriose. Association EndoFrance https://www.endofrance.org/la-maladie-endometriose/qu-est-ce-que-l-endometriose/.




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