[Epidemiological and anatomopathological profile of endometriosis in Dakar: retrospective study over a period of 20 years]

INTRODUCTION

Endometriosis is a gynecological pathology defined by the presence and abnormal development of endometrial tissue outside the uterine cavity. Our objective was to draw up an epidemiological profile and to describe the anatomical clinical forms of endometriosis in Dakar.

PATIENTS AND METHODS

This is a retrospective study of all cases of external and internal endometriosis diagnosed in an anatomy and pathology laboratory in Dakar over a period of twenty (20) years. The study parameters were collected from anonymous data sheets. Data entry and analysis were performed using version 22 of the EPI INFO and SPSS software.

RESULTS

Our study involved 104 female patients. The mean age was 47.3±10.0. Among the patients with an adenomyosis condition, the mean age was 49.8 years. Patients with an external endometriosis condition had a mean age of 37.6 years. The location of the endometriosis was statistically correlated with the age of patients and with parity. Anatomically and pathologically, the surgical specimen 89.4% (n=93) was the main type of sampling that was found. The uterine body was the main location of the pathology, with 78.9% (n=82), followed by the umbilical location with 9.6% (n=10). Leiomyomas 44.07% (n=26) were the main associated lesions.

CONCLUSION

Endometriosis is a gynecological pathology that is unfortunately not well known, and which is under diagnosed in Senegal.

[Adenomyosis pathophysiology: An unresolved enigma]

Adenomyosis is a chronic benign uterine disease characterized by the presence of endometrial glands and stroma within the myometrium. It is a heterogeneous disease, presenting various clinical forms, depending on the location of the ectopic lesions within the myometrium. Adenomyosis can be responsible for several symptoms such as dysmenorrhea, abnormal uterine bleeding and/or infertility. Its pathophysiology is a real conundrum and several theories have been proposed: development of adenomyosis lesion could initiate de novo from Mullerian rests or from stem cells. Moreover, multiple factors could be involved in initiating lesions, including specific hormonal, immune and/or genetic changes. The objective of this review is to provide an update on adenomyosis pathophysiology, in particular on the various theories proposed concerning the invasion of the myometrium by endometrial cells and the inducing mechanisms, and to study the link between the physiopathology, the symptoms and the medical treatments.

[Endometriosis and adenomyosis]

Diffuse adenomyosis, focal adenomyosis, ovarian endometrioma, superficial endometriosis and deep infiltrating adenomyosis are all defined by the presence of an endometrioid tissue in an ectopic location that is at distance from the endometrium. Although frequently associated, these lesions represent different clinico-pathological entities that the pathologist should recognized. Herein, we review the clinical and pathological features of these entities, as well as related current physiopathological understandings and differential diagnoses that could be raised by some morphological variants. The statistical association between endometriosis and several ovarian tumors, mainly endometrioid and clear cell carcinomas and seromucinous borderline tumors is well established and we present some molecular and morphological features that support this transformation potential.

[Performances and place of sonography in the diagnostic of endometriosis: CNGOF-HAS Endometriosis Guidelines]

Endometriosis is difficult to diagnose clinically. Transvaginal sonography (TVS) is a procedure that is known to be operator-dependent, which mean that published evidences has to be balanced with the level of the sonographer that produced the data. The objective of this publication was to assess the performances of the sonography in the diagnosis of endometriosis in order to establish the French national recommendations. We searched the MEDLINE database for publication from January 2000 to September 2017 using keywords associated with endometriosis and sonography. Eighty-four trial and reviews published in English or French were included. Ovarian endometrioma can usually be diagnosed by a non-expert sonographer, especially when its aspect is typical. In case of an ovarian cyst with atypical presentation, it is recommended to control the sonography by a referent or to perform an MRI. In menopaused women, any ovarian cyst should be considered as a cancer until proven otherwise. In the diagnosis of posterior deep invasive endometriosis (DIE), TVS with sensitivity and specificity of 96 and 99% respectively, seems at least equivalent if not superior to MRI. However, these performances are related to expert sonographers. To reach sufficient efficiency in posterior DIE, the estimated learning curve for a sonographer is 44 cases. When posterior DIE is suspected, we recommend proposing a TVS "performed by an expert" or a MRI "at least interpreted by an expert". In anterior DIE, TVS has a good specificity (100%), but its sensitivity is poor in the literature (64%). TVS is therefore not able to eliminate the diagnosis. However a renal ultrasound should be proposed each time a urinary endometriosis is confirmed, and should be considered whenever posterior DIE is diagnosed especially the lesion is superior to 3cm.

[An update on adenomyosis and implantation]

Adenomyosis is an enigmatic disease whose impact on implantation and fertility outcome is still controversial. A negative effect on IVF outcome was already observed, but it is mainly explained by an increase in early spontaneous miscarriages. We reviewed scientific data in order to bring relevant information about adenomyosis and endometrial receptivity for patient counselling and to precise if screening of adenomyosis is indicated before IVF treatment.

[Treatment of adenomyosis (excluding pregnancy project)]

In this review we aimed to update the possibilities of adenomyosis treatment in women excluding those with a desire for pregnancy. Adenomyosis is defined as the presence of endometrial tissue within the myometrium and frequently underestimated. Over the last decades, its pathophysiology has been better known. The diagnosis is essentially based on clinical symptoms like menorrhagia and dysmenorrhea. Transvaginal ultrasound and magnetic resonance imaging are the main tools of the radiologic diagnosis. However, the definitive diagnosis is histological. The most effective treatment remains hysterectomy; however it is expensive, radical and at risk of morbidity compared with medical or surgical conservative management. The literature has reported several series of patients undergoing various treatments, thus allowing different therapeutic options. The levonorgestrel-releasing intrauterine device showed its efficacy alone or in combination with hysteroscopic treatment. Oral progestins, GnRH agonists are useful at short term or in preoperative condition. Some conservative treatments like focused ultrasound therapies or uterus-sparing operative treatment stay under evaluation and seems to be effective. Embolization has been the subject of several studies and must be outlined. Furthermore, several molecules, such as modulators of progesterone receptors and the aromatase inhibitors have been recently studied and are perhaps future treatments.

[Conservative treatment of a compressive adenomyosis: report of a case]

Adenomyosis is frequent, mostly asymptomatic. A hypertrophy of the smooth muscular cells around ectopic endometrial glands might induce a compressive syndrome. We report the case of an embolization of a voluminous adenomyosic uterus which has triggered venous iliac's compression in patient refusing surgery. This treatment was efficient in reduction of uterin volume, without recurrence after three years. MR imaging is the exam of choice particularly when diagnosis is still uncertain and allows a non-invasive and good evaluation, and follow-up. Embolization is not actually recommended. But, it appears to be efficient, relatively safe and contributes to the conservation of fertility.