Re: Endometriosis

Dear Editor,

Good Day. Vanakkam. I read with interest the interesting article on Endometriosis.

Endometriosis, Infertility and Dysmenorrhea – Are they all associated conditions or are they really causally related?

Endometriosis is an estrogen dependent, menstruation led condition occurring in women who are immunologically prone and genetically predisposed. Menstruation and presence of endogenous or exogenous estrogen is a priori for the condition to develop.

I have been in the field of Obstetrics and Gynecology for the last 45 years and full time in Infertility for the last 37 years. I am yet to see a true case of Pre pubertal Endometriosis. If it does exist it must be anecdotal.

We really don’t need so many theories for Endometriosis. All menstruating women with open fallopian tubes will have Retrograde menstruation and this occurrence is good enough to explain all cases of Endometriosis in all sites (1)

Early diagnosis of Endometriosis is often talked about these days. What purpose will early diagnosis serve? (2) Currently Laparoscopy and biopsy is the gold standard and it does not have 100% positive predictive or 100% negative predictive value. Diagnosis does not alter the management. Drugs for Endometriosis have significant side effects and they only ameliorate and not cure the condition.

Pregnancy ameliorates the condition and Menopause, both natural and medical or surgical menopause cures the condition. Under all other circumstances, treatment is at best symptomatic and is not curative and has a very high recurrence rate.

It is not clear if Endometriosis leads to Infertility or Infertility leads to Endometriosis or are they both associated conditions with no causal relationship. (3) The extent of disease bears no relationship to the occurrence of Infertility. Medical treatment has no role to play in the management of Infertility associated with Endometriosis and surgical treatment leads to diminution of Ovarian Reserve and Adhesions.

Dysmenorrhea is another common symptom in some women with Endometriosis. The anatomical extent of the disease has no bearing to the severity of Dysmenorrhea. Patients with extensive disease and even Frozen Pelvis remain asymptomatic, while patients with minimal Endometriosis have severe Dysmenorrhea raising again the concern if Endometriosis and Dysmenorrhea are causally related or are they merely associated conditions.

Endometriosis remains a gynecological enigma. The best we can state at this time is: Treat the symptom, Infertility or Pain as early as possible. New Tests for Endometriosis are legerdemain and serve no useful purpose. Regardless of the label, infertility and dysmenorrhea require treatment on their own merit and labeling as Endometriosis does not alter management. Obstruction due to Endometriosis of course requires surgical intervention.

1. Etiology of Endometriosis – Simplified
Surya P, Pandiyan Natarajan
Chettinad Health City Medical Journal 2017; 6(1): 2 -3
https://www.chcmj.ac.in/pdf/vol6_no1/etiology.pdf

2. Early Diagnosis of Endometriosis – Quo Vadis?
Pandiyan N, Surya P, Shah Dupesh Khan, Radha Pandiyan
Chettinad Health City Medical Journal 2015; 4(2): 68 – 69
https://www.chcmj.ac.in/pdf/vol4_no2/Early.pdf

3. Infertility (Non Conception) with Regular Menstruation Predisposes to
Endometriosis – A Hypothesis
Pandiyan N, Surya P, Radha Pandiyan
Chettinad Health City Medical Journal 2017; 6(3): 114 – 116
https://www.chcmj.ac.in/pdf/vol6_no3/infertility.pdf

Namaste.
Pandiyan.

Professor Dr Pandiyan Natarajan,
Chief Consultant in Andrology and Reproductive Sciences.
Apollo 24/7, NOVA IVF FERTILITY,
Chettinad Super Speciality Hospital ( Retired)
Professor Emeritus, The Tamil Nadu Dr MGR Medical University