Question

1. Compare the hormonal controls of the male reproductive cycle with the hormonal controls of the female reproductive cycle. How are they the same? How are they different?
2. What is this condition called?
3. What causes it?
4. What is ectopic endometrial tissue?
5. What is the rationale for using danazol, a gonadotropin inhibitor?
6. Why do you think oral contraceptives could also be used as a treatment?
7. Is surgical treatment an option, why? Why not?

Case Study

A 26-year-old female complained of severe, dull, aching pain, and cramping in the lower abdomen. There were no other physical findings. A laparoscopy revealed the presence of ectopic endometrial tissue on the uterine wall and ovaries. Danazol (a synthetic androgen and inhibitor of gonadotropins), 600 mg/day, was prescribed for up to nine months to inhibit ovulation, suppress the growth of the abnormal endometrial tissue, and achieve appreciable symptomatic relief, with a 30% possibility of conception after the withdrawal of the therapy.

Answer 1

1. The patient is suffering from endometriosis as she has ectopic endometrial tissues present on uterine wall and ovaries. Endometrium is the innermost lining of the uterus to which embryo attached during pregnancy. In endometriosis, the uterine endometrial tissue lodges out of the uterus into the pelvic cavity via the fallopian tube. Hence, it can be present on walls of uterus as well as ovaries.

2. It can be caused by retrograde movement of endometrial tissue from the uterus via the fallopian tubes into the pelvic cavity. Normally, there are no blood vessels that join the ovaries with fallopian tube. If reverse flow occurs, endometrial tissue can flow back and lodge into the ovaries. Hormonal imbalances are other reason why endometrial tissue can lodge into pelvic cavity. Hormonal imbalances causes increased bleeding during menses. The endometrial tissue that is present in the menstrual blood can enter the pelvic cavity and lodge on uterine walls.

3. Ectopic endometrial tissue is endometrial tissue that is present in any other site in pelvic cavity or reproductive tissues other than its normal location in the uterus. Normally, endometrium lines the innermost region of uterus and is in contact with the uterine lumen. If it is present in pelvic cavity, ovaries, uterine walls etc, it becomes ectopic endometrial tissue.

4. Danazol is an inhibitor of gonadotropin. It inhibits the release of GnRH from the hypothalamus. GnRH is known to induce FSH and LH secretion from anterior pituitary. FSH stimulates the ovarian follicle growth. LH is involved in ovulation and corpus luteum formation. Corpus luteum procures progesterone. FSH induces estrogen secretion in ovaries. Estrogen and progesterone create menstrual imbalances that cause endometriosis. Thus, Danazol will inhibit estrogen and progesterone release, thereby causing ectopic endometrial tissues from growing and vascularization. This reduces endometriosis related pain and bleeding.

5. Oral contraceptives contain estrogen and progesterone. They are known to prevent menstruation in women as menstruation only occurs when the levels of these hormones decline in circulation. As hormones will always be present due to oral contraceptive use, menstruation doesn’t set it. Ectopic endometrial tissues also behave as normal endometrium and will be sloughed off during menses causing bleeding. Pain is associated with menstrual bleeding in endometriosis. As menstruation is prevented, oral contraceptives will prevent endometriosis related pain. However, it does not cure endometriosis.

6. Surgery can be considered to remove the ectopically lodged endometrial tissues during endometriosis. However, it is not possible to completely remove the tissue and hence is done only severe cases that do not respond to drugs. It can help to alleviate pain. Abdominal surgery can be performed by laparoscopy or in rare cases total hysterectomy can be performed.