April 27, 2020
Author Name: Dr.Mamatha C.V. || Mentor Name: Dr.Ramesh Gaikwad on April 27, 2020
Pregnancy and Endometriosis –
Pregnancy provided immense benefits in the endometriosis symptoms especially in last trimester of pregnancy. Some ladies experience worsening of symptoms during the first trimester.
Beneficial effects are due to progesterone effect. Progesterone suppresses the growth and development of endometriotic lesion because of no menstruation causing lesion to be inactive. Symptoms may worsen in early pregnancy due to rapid increase in the size of the uterus which will cause pulling and stretching of the tissues and also adhesions, which is already scarred by endometriotic lesions.
Increased levels of estrogen produced during pregnancy may stimulate the growth of endometriotic lesions which may worsen the symptoms. Majority of the ladies beneficial effects of pregnancy are only temporary. Many women will experience recurrence of disease once resuming their menstruation or after few years.
Breast Feeding – Many women are able to lengthen the remission of their endometriosis symptoms after pregnancy due to breastfeeding. Regular breastfeeding inhibits the release of estrogen by ovaries which suppress the ovulation and growth and development of endometriosis.
Myth that pregnancy can cure endometriosis is disappearing. In reality pregnancy is like hormonal drug treatment. Pregnancy may temporarily suppress the symptoms of endometriosis but will not cure. Symptoms will recur after birth.
In past few years pregnancy is considered as therapeutic period of relief of painful symptoms of endometriosis.
In 1921 Sampson first identified the regression of endometriotic lesions during pregnancy. After that all the doctors recommended women to conceive in order to reduce the advancement of the symptoms. Lack of symptoms before menarche and after menopause additionally supported this theory that pregnancy was helpful. Progesterone induces endometrial atrophy and endometriotic lesions which shows cyclical changes such as endometrial growth and luteal phase transformation in the entire menstrual cycle.
Progesterone levels are greatly increased in pregnancy which is in favour of the regression of endometriotic lesions, using this the theory pseudo pregnancy is established.
Progesterone is established for therapeutic treatment against endometriosis and continues to be part of therapeutic strategy even today.
Apart from this, endometriosis can cause severe complications in the event of pregnancy such as rupture of lesions leading to intra-abdominal bleeding.
Hence learning the effect of pregnancy on the development of endometriosis is critical to ensure the benefits and adverse effects in counseling the women with endometriosis. This is specifically important as a co-occurrence of endometriosis and pregnancy becomes more dominant due to rise in success rates of latest assisted reproductive technologies.
Knowing the effects of endometriosis is challenging. Use of transvaginal scan which leads to high detection rates of endometriosis in pregnancy, ultrasound evaluation of ovaries is not a part of routine antenatal tests and USG does not allow dependable checking of non-ovarian endometriotic lesions. Retrospective studies are often biased as symptomatic lesions are more likely to be evaluated and reported than lesions which do not have symptoms. Certain studies include systematic study of endometriotic lesions during pregnancy and mostly that is post the years after the pregnancy. Additionally studies are mixed with regards to times and methods of examination (clinical USG, MRI, laparoscopic surgeries and histo pathological examination), different types of endometriotic lesions investigated (lesions in ovary, non-ovarian lesions, exact locations), information of lesions collected (size, number and structure) other limitations and logical approach. Lastly most of the data studies are small, old. Often the data is extracted retrospectively from databases designed for different purposes.
Not only the data on endometriotic lesions during pregnancy sparse, but factors potentially influencing the development of endometriosis are also even more difficult to evaluate. Few studies that are available support regression more often in second or third than in the first trimester or the lactation period.
HPE studies of endometriotic lesions during pregnancy shows that they may grow aggressively during this time. Which makes the differentiation from malignant tumors difficult. Expansion of endometriotic lesions and suspicious sono-morphological appearance is obviously the reason for surgery during pregnancy. Such changes are due to decidualization. This has reported upto seventy seven percentage of chocolate cysts and to similar endometriosis in other sites which is tough to diagnose and monitor during pregnancy.
Decidualization lesions has reduced ability to spread and it is first step towards regression, this hypothetically has a benefit on endometriosis.
However, on conclusion pregnancy supports to reduce the symptoms of the disease but only pregnancy cannot cure the disease. At the same time endometriosis-related pain will lead to surgical intervention during pregnancy.
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