Endometriosis Treatment Program

Endometriosis is a chronic, estrogen-dependent gynecological condition characterized by the presence of endometrial-like tissue outside the uterine cavity, typically involving the ovaries, pelvic peritoneum, fallopian tubes, and other pelvic structures. These ectopic lesions respond to the menstrual cycle, leading to cyclical inflammation, scarring, and adhesions.  

Endometriosis affects an estimated 10% of reproductive-aged women globally and is a leading cause of pelvic pain, infertility, and diminished quality of life. Despite its prevalence, endometriosis is often underdiagnosed due to the variability of symptoms and the need for surgical confirmation in some cases. 

Why Cuba 

In Cuba, the management of endometriosis is based on symptom relief, preservation of reproductive function, and the prevention of long-term complications such as chronic pelvic pain, infertility, and pelvic organ damage. Care is delivered within a structured and evidence-based clinical pathway, where each patient undergoes a comprehensive gynecological assessment to evaluate the extent and severity of endometrial implants, the presence of deep infiltrating lesions, coexisting pelvic pathologies, fertility goals, prior treatment response, and overall health status. 

Cuban gynecology teams utilize modern diagnostic imaging and laparoscopic techniques to support precise diagnosis and individualized care planning. The healthcare system places strong emphasis on personalized and affordable care, integrating both conservative hormonal therapy and minimally invasive surgical options to maximize outcomes and maintain quality of life. 

Causes of Endometriosis 

 The exact cause of endometriosis remains unclear, but several theories have been proposed, including:  

• Retrograde Menstruation: Menstrual blood flows backward through the fallopian tubes into the pelvic cavity. 

• Coelomic Metaplasia: Transformation of peritoneal cells into endometrial-like cells. 

• Immune System Dysfunction: Impaired immune response allows endometrial cells to implant and grow outside the uterus. 

• Genetic Predisposition: Family history increases risk. 

• Lymphatic or Vascular Spread: Endometrial tissue may spread through blood or lymphatic channels. 

While these mechanisms may contribute to disease onset, endometriosis is likely multifactorial, involving genetic, hormonal, immunological, and environmental influences. 

Types and Classification  

Endometriosis is classified based on location, depth of invasion, and severity of disease. Accurate classification is essential for treatment planning and fertility counseling. 

Superficial Peritoneal Endometriosis 

• Lesions are found on the surface of pelvic organs or peritoneum. 
• Often early-stage and may cause less distortion of anatomy. 

Ovarian Endometrioma 

• Cystic masses (“chocolate cysts”) filled with old blood, found within the ovaries. 
• Often associated with moderate to severe disease. 

Deep Infiltrating Endometriosis (DIE) 

• Lesions invade more than 5 mm beneath the peritoneal surface. 
• May involve the uterosacral ligaments, rectovaginal septum, bowel, or bladder. 
• Typically associated with severe pain and organ dysfunction. 

Stages of Endometriosis 

Endometriosis is clinically staged from Stage I (Minimal) to Stage IV (Severe) based on the size, depth, location, and number of endometrial implants, as well as the presence and severity of adhesions. This staging system helps guide treatment decisions and provides insight into potential reproductive impact, although symptom severity does not always correlate with stage.  

Stage I – Minimal 

• Few isolated endometrial implants on the peritoneum or ovaries. 
• Lesions are superficial, measuring just a few millimeters. 
• No significant adhesions or anatomical distortion. 
• Often discovered incidentally during evaluation for other issues. 

Stage II – Mild 

• Increased number of implants compared to Stage I. 
• Lesions may be deeper and measure larger in size. 
• Minimal scarring or filmy adhesions may be present on the ovaries or surrounding pelvic tissues. 
• Uterine and pelvic anatomy usually remains unaffected. 
• May begin to impact fertility in some patients. 

Stage III – Moderate 

• Presence of both superficial and deep implants. 
• Endometriomas (ovarian cysts) may be present, usually measuring under 4 cm. 
• Adhesions may be more dense or fibrous, involving the ovaries, fallopian tubes, or posterior uterus. 
• Pelvic anatomy may be partially distorted. 
• Frequently associated with moderate pelvic pain and infertility. 

Stage IV – Severe 

• Numerous deep implants and large endometriomas (typically >4 cm). 
• Extensive dense adhesions binding pelvic organs together (e.g., ovaries to the uterus or bowel). 
• Severe distortion of pelvic anatomy, including involvement of the bowel, bladder, or ureters. 
• Strongly associated with infertility and debilitating pain. 
• May require multi-disciplinary surgical management, especially when involving organs outside the reproductive tract. 

Symptoms of Endometriosis 

Symptoms can vary widely and do not always correlate with disease severity. Common manifestations include:  

• Dysmenorrhea (painful menstruation) 
• Chronic pelvic pain 
• Dyspareunia (pain during intercourse) 
• Infertility 
• Heavy or irregular menstrual bleeding 
• Painful bowel movements or urination, especially during menstruation 
• Fatigue, gastrointestinal symptoms, or lower back pain 

Many women experience delayed diagnosis—often years—due to normalization of pain or symptom overlap with other conditions. 

Diagnosis of Endometriosis 

 Diagnosing endometriosis involves a combination of clinical evaluation, imaging, and in some cases, surgical exploration. 

Clinical Evaluation 

• Detailed medical and menstrual history 
• Pelvic examination may reveal tenderness or nodularity, especially in the posterior fornix or uterosacral ligaments. 

Imaging 

• Transvaginal Ultrasound (TVUS): Useful for identifying endometriomas and large pelvic lesions. 
• MRI: Provides better soft tissue detail and can help assess deep infiltrating disease. 
• Sonohysterography: May help evaluate uterine or adnexal involvement. 

Definitive Diagnosis 

• Laparoscopy with biopsy remains the gold standard. 
• Allows for direct visualization, staging, and histological confirmation of lesions. 

Conservative Treatment Options 

 Conservative management is typically the first line of treatment, especially in women who wish to avoid surgery or preserve fertility. 

• Hormonal therapy 
• NSAIDs for pain management. 
• Lifestyle modifications, including stress reduction and anti-inflammatory diets, may support symptom control. 
• Fertility support: Ovulation induction or intrauterine insemination (IUI) may be considered before surgical intervention in selected patients. 

Conservative treatment is often symptom-based, requiring ongoing monitoring and adjustment of therapy over time. 

 Surgical Treatment Options 

 Surgery may be indicated when: 

• Pain is severe or refractory to medical management. 
• Anatomical distortion or organ involvement is suspected (e.g., bowel, bladder, or ureteral lesions). 
• Endometriomas ≥4 cm is present. 
• Fertility is impaired and assisted reproductive technologies have failed or are not appropriate. 
• There is a need for definitive diagnosis and staging in uncertain cases. 

Surgical treatment may also be required to restore pelvic anatomy, reduce adhesions, and improve quality of life. 

Surgical procedures for endometriosis aim to excise or ablate ectopic lesions, remove adhesions, and, when necessary, resect affected organs. 

Laparoscopic Excision or Ablation (Minimally Invasive) 

• Performed through small abdominal incisions using a laparoscope for visual guidance. 
• Lesions are either excised (surgically removed) or ablated (destroyed using electrosurgical, laser, or plasma energy). 
• Offers high precision, especially for deep infiltrating endometriosis (DIE), while preserving healthy tissue. 
• Associated with fewer adhesions, less postoperative pain, and faster recovery than open surgery. 
• Preferred for patients with moderate to severe pain, those seeking fertility preservation, or when diagnosis and treatment are done simultaneously. 

Ovarian Cystectomy (Minimally Invasive) 

• Involves the surgical removal of endometriomas (chocolate cysts) while preserving surrounding functional ovarian tissue. 
• Typically performed laparoscopically, allowing for better visualization and minimal trauma to the ovary. 
• Helps relieve pain, reduces recurrence, and may improve fertility outcomes when ovarian reserve is still sufficient. 
• Requires surgical skill to avoid compromising ovarian function, especially in younger patients or those pursuing pregnancy. 

Lysis of Adhesions (Minimally Invasive or Open, Depending on Severity) 

• The process of cutting or removing fibrous bands (adhesions) that tether pelvic organs, restoring their normal position and function. 
• Can be performed laparoscopically in most cases, particularly when adhesions are limited or filmy. 
• In complex cases with dense, vascular, or bowel-involving adhesions, open surgery (laparotomy) may be necessary for safety. 
• Crucial for improving pelvic mobility, reducing pain, and increasing the chances of natural conception. 

Segmental Bowel Resection or Organ-Specific Surgery (Open or Laparoscopic, Case-Dependent) 

• Indicated in advanced endometriosis that deeply infiltrates the bowel, bladder, ureters, or other pelvic structures. 
• Requires multi-disciplinary collaboration, often with colorectal or urologic surgeons. 
• Can involve resection and anastomosis of the bowel, removal of bladder nodules, or ureterolysis/reimplantation. 
• May be performed laparoscopically in experienced centers, but open surgery is sometimes preferred for extensive disease, dense adhesions, or when multiple organs are involved. 
• Reserved for severe disease where organ function is compromised or pain is disabling.

Hysterectomy – with or without Oophorectomy (Minimally Invasive or Open) 

• Considered for women with severe, refractory symptoms who have completed childbearing or have coexisting uterine pathology (e.g., adenomyosis or fibroids). 
• May involve removal of the uterus alone or include bilateral oophorectomy (removal of ovaries) to reduce estrogen and prevent recurrence. 
• Can be performed via: 
  • Laparoscopic hysterectomy (minimally invasive) for smaller uteri and uncomplicated anatomy. 
  • Abdominal hysterectomy (open surgery) for large uteri, extensive adhesions, or complex pelvic disease. 
• While hysterectomy can provide long-term relief, it is not always curative if extra-uterine endometriosis persists, particularly without removal of both ovaries. 

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