Endometriosis

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What is Endometriosis?

Endometriosis is a common condition that occur in women. During a menstrual period, the endometrium or lining of the uterus is shed through the vagina. Endometriosis is where fragments of the endometrium develop in places other than the inner lining of the uterus. This misplaced tissue is commonly found on the ovaries or the tissue lining the pelvis (peritoneum). These tissues may also be found on the uterus, bowel, bladder, utero-sacral ligaments (bands of tissue at the back of the uterus that hold the uterus in place) and in the Pouch of Douglas (the area between the uterus and the bowel).The misplaced tissue implants itself onto the surface of the tissue or organ where it has been deposited and begins to grow and function.

These implants (aka patches or deposits) respond to the hormones of the menstrual cycle in the same way as does the lining of the uterus (endometrium). Like the endometrium, the implants thicken and well with blood in order to prepare for a possible pregnancy. When pregnancy does not occur, the implants break down along with the endometrium causing the period. Unlike the lining of the uterus, the blood from the implants cannot escape from the body during a period, so it bleeds directly onto the surface of the surrounding organs and tissues. This causes irritation which leads to inflammation, scarring and, sometimes, the development of adhesions between organs so that they stick together. On the ovary, the patches can increase in size and burrow in to form cysts, known as chocolate cysts or endometriomas.

Mild forms of endometriosis are common in women between the ages of 25 and 40. It can also occur in younger women and in rare cases it can persist after menopause. While it may not require treatment, the condition can make it difficult for a woman to become pregnant

What are the symptoms?

As women's menstrual cycles vary, there are a wide variety of signs and symptoms in women with endometriosis. The type, number and severity of symptoms experienced vary from woman to woman. Some women experience many symptoms which may be debilitating at times. Others experience no symptoms, or only discover that they have endometriosis because they cannot fall pregnant, or it is found at an operation performed for another cause. The symptoms experienced and their severity are not necessarily related to the severity of the condition but are often more closely related to the location of the implants. In many cases, endometriosis has no symptoms however when symptoms are present, they include:

Pain
Pain is the most common symptom experienced by women with endometriosis.  It may occur in any of the following forms:

  • Period pain - immediately before and during the period
  • Pain during or after sex
  • Abdominal, back and/or pelvic pain
  • Pain with opening bowels, passing wind or urinating
  • Ovulation pain, including thigh or leg pain

Bleeding

  • Heavy bleeding, with or without clots
  • Irregular bleeding with or without a regular cycle
  • Prolonged bleeding
  • Premenstrual spotting

Other symptoms may include:

  • Pain with intercourse
  • Bowel or bladder symptoms, including pain/bleeding from bladder or bowel
  • Irregular bowel habits e.g. constipation, diarrhoea
  • Increase in urinary frequency or change in your normal function
  • Infertility
  • Premenstrual symptoms
  • Tiredness
  • Mood changes
  • Bloating
What causes it?

The exact cause of endometriosis is unknown. Some believe that pieces of the endometrium travel back through the fallopian tubes and into the pelvic cavity, the space inside the pelvis that holds the reproductive organs. Tiny pieces of tissue may lodge on surfaces of the reproductive organs. During menstruation, the tissue bleeds and the surrounding tissue may become inflamed. Over time, scar tissue and cysts can form.

How is it diagnosed?

Endometriosis is diagnosed using a laparoscopic procedure under general anaesthesia. During this, a small telescope is inserted through a very small incision in the abdomen so that endometrial implants can be found. Many times, these implants will undergo a biopsy in order to confirm the diagnosis. After the diagnosis is confirmed, the doctor will attempt to remove the implants during surgery.

How is it treated?

Treatment of endometriosis depends on your symptoms, how severe it is, how severe the condition is at laparoscopy. The treatment can be medications or surgery. Medications can be for simple pain relief or treatment with hormones to slow down the growth of endometriosis.

Medications

Non steroidal anti-inflammatory drugs - Simple analgesics like non steroidal anti-inflammatory drugs may be used for pain relief. However these medications do not treat endometriosis itself. 

Oral contraceptive pills – These birth control pills are often prescribed to women to regulate their periods, make the bleeding lighter and relieve the pain. Sometimes, the pills are prescribed in such a way that the woman gets no periods and in the process treats endometriosis.

Gonadotropin-releasing hormones (GNRH) – GNRH is a powerful medication that works by shutting down the ovary temporarily. This causes a short period of “Menopause”. During this time, the endometriotic spots are expected to shrink and die away. This can be given as an injection or a nasal spray. As the medication causes “menopause”, there are side effects associated with it. Some of them are hot flushes, night sweats, vaginal dryness and sometimes loss of bone mineral density.
Progesterone – This hormone helps by acting against oestrogen, responsible for endometriosis. It can be taken as a tablet or can be given as an injection. Usually women don’t get any periods while on the treatment but there is a small possibility of irregular spotting. The side effects are weight gain, mood changes and bloating sensation.

Surgery

Surgery is performed if the symptoms are severe or the woman wishes to achieve pregnancy. Surgery involves doing a laparoscopy and removing the endometriotic spots either by cutting it out or burning them using electrical energy. Most women feel relief from their symptoms after the surgery. There is a possibility that symptoms might return back after a period of time. This symptom free period depends on the severity of endometriosis.

Sometimes, the symptoms are so severe the woman might need a hysterectomy to remove the uterus along with your ovaries. As this causes menopause, this is only recommended after other modalities of treatment have been tried.

As with any surgery, these surgeries are not without any risks. Your doctor will be able to discuss the details of suitability of the surgery and the risks associated with it.

REMEMBER endometriosis is a common condition and treatments are available. Seek help.