Deep Infiltrating Endometriosis: Symptoms, Diagnosis, and Treatment

Endometriosis is a chronic condition affecting millions of women worldwide. 

Among its various forms, Deep Infiltrating Endometriosis (DIE) stands out as one of the most severe manifestations. 

DIE involves the abnormal growth of Endometrial-like tissue outside the uterus, infiltrating deeply into
surrounding organs such as the urinary tract, bowel, and pelvic structures. 

This condition can cause debilitating symptoms and significantly impact a person’s quality of life.

This article will dive into Deep Infiltrating Endometriosis, covering its symptoms, causes, complications, diagnosis, and treatment options.

Deep Infiltrating Endometriosis symptoms

The symptoms of Deep Infiltrating Endometriosis can vary in severity and may include:

• Dyspareunia
• Dysmenorrhea
• Chronic pelvic pain
• Pelvic tenderness
• Urinary symptoms (frequency, urgency, dysuria, haematuria)
• Asymptomatic, colicky flank pain, Haematuria
• Dyschezia 
• Diarrhea 
• Constipation
• Intestinal cramping
• Painful defecation
• Abdominal bloating

Causes

The cause of Deep Infiltrating Endometriosis remains uncertain, although certain risk factors have been identified. 

Deep Infiltrating Endometriosis tends to occur more frequently in women who:

• Are married
• Are older
• Have siblings
• Have had previous pregnancies
• Have undergone uterine surgery in the past
• Experience menstrual and ovulatory disorders
• Feel pain during deep vaginal penetration (deep Dyspareunia)
• Experience high levels of stress
• Have digestive symptoms during their periods
• Have a family history of Endometriosis
• Use oral contraceptives

Diagnosis

Diagnosing Deep Infiltrating Endometriosis can be challenging due to its diverse symptoms and the variability of its presentation. 

There are several ways to diagnose Endometriosis. 

One common method is pelvic ultrasound, which can detect Endometriosis in the rectum and lower sigmoid colon. 

This test is preferred because it’s affordable, doesn’t require surgery, and is available in most hospitals. 

However, ultrasound has its limitations. 

It may not detect Endometriosis in higher parts of the gastrointestinal tract, and technicians need special training to identify Endometriosis lesions accurately.

Another option is rectal ultrasound, but it’s not as commonly used because it can be uncomfortable for patients and doesn’t provide clear views of higher areas in the pelvis. 

CAT scans and pelvic MRIs are also commonly used. 

While MRIs are more expensive, they may have better resolution for detecting Endometriosis and don’t expose patients to radiation. 

Colonoscopy is sometimes used, but it’s rare because Endometriosis typically doesn’t grow throughout the entire gastrointestinal tract.

Treatment for Deep Infiltrating Endometriosis

Managing Deep Infiltrating Endometriosis aims to alleviate symptoms, improve quality of life, and preserve fertility when possible. 

Available treatments include Progestogens, Combined Oral Contraceptives (COCs), Danazol, Gonadotropin-releasing Hormone (GnRH) analogs, and Aromatase Inhibitors. 

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Maintaining a healthy lifestyle, including a diet rich in vegetables and omega-3 fatty acids while reducing intake of red meat, coffee, and alcohol, can enhance the benefits of medical therapy. 

Additionally, certain substances targeting mastocyte function and inflammation have shown promise, especially for women unable to use hormone therapy or those aiming to conceive.

Treatment options may include:

Progestogens and Combined Oral Contraceptives

Progestogens and COCs are particularly effective in managing symptoms associated with Deep Infiltrating Endometriosis. 

Norethisterone Acetate (NETA) and Dienogest have shown positive effects in improving intestinal symptoms and reducing the size of endometriotic nodules.

Dienogest, specifically, has been successful in managing rectovaginal or bowel Endometriosis, leading to a reduction in pain and nodule size. 

COCs, while effective in decreasing nerve fiber density in Endometriosis lesions, may have additional side effects and contraindications compared to Progestogens. 

Therefore, Progestins are often recommended as the first-line medical therapy according to guidelines.

Gonadotropin-Releasing Hormone Analogues

GnRH agonists play a significant role in Endometriosis treatment, demonstrating remarkable results in managing symptoms. 

However, some studies have shown a high recurrence rate of symptoms after treatment cessation. 

GnRH antagonists, such as Elagolix, offer advantages over GnRH agonists due to their oral formulation and lower incidence of adverse events.

Danazol and Aromatase Inhibitors

Danazol suppresses Luteinizing Hormone (LH) and steroidogenesis, providing pain relief similar to GnRH agonists. However, its hyperandrogenic side effects are common. 

Aromatase inhibitors (AIs) inhibit Estrogen secretion in Endometriosis implants and have been studied for pain management. 

However, their use is considered experimental and should be reserved for refractory cases or within the context of clinical trials.

Other medical treatments

Selective Progesterone Receptor Modulators (SPRMs) and Selective Estrogen Receptor Modulators (SERMs), have shown promising effects in animal studies, but their effectiveness in humans is yet to be established.

Additionally, drugs targeting angiogenic and proinflammatory factors have been investigated for Endometriosis treatment, but clinical evidence of their efficacy and safety is lacking.

Surgical treatment

Surgical treatment of Deep Infiltrating Endometriosis is indicated for patients unresponsive to medical therapy and experiencing severe symptoms. 

The goal of surgery is complete eradication of Endometriosis lesions while preserving organ function. 

A multidisciplinary approach involving colorectal surgeons and urologists is often necessary to minimize complications and ensure optimal outcomes for Endometriosis surgery.

Conclusion

Deep Infiltrating Endometriosis (DIE) is a severe form of Endometriosis where endometrial-like tissue grows outside the uterus and invades surrounding organs. 

It causes debilitating symptoms like pelvic pain, urinary problems, and bowel issues.

Diagnosing DIE can be challenging and involves various tests like pelvic ultrasound, MRI, and sometimes colonoscopy.

Treatment options aim to manage symptoms and improve quality of life. 

In severe cases, this may involve hormonal therapies, pain medications, and surgery.

While the cause of DIE remains unknown, early diagnosis and treatment are crucial for managing symptoms and improving the well-being of affected individuals.

Frequently Asked Questions

• brighamandwomens.org
• ncbi.nlm.nih.gov