Endometriosis

The Inside Story

Endometriosis is a gynecological condition where tissue from the lining of the uterus (endometrium) is found outside the uterus. It is often found in the pelvic and lower abdominal cavity, and rarely, in other areas of the body.

What Are the Symptoms of Endometriosis?

Many women with endometriosis have no symptoms or signs. Those that do often have a wide range of presentations, and often the degree of symptoms doesn’t relate to the severity of the disease. That is to say, one may have very mild symptoms but could have very extensive disease found at surgery or imaging, and vice versa.

Some common symptoms include:

Painful Periods
This pain may start before the period, and often can last the whole duration of the period. It is usually more severe than normal period cramps. Other menstrual symptoms can occur, such as irregular or heavy periods.

Painful Intercourse
Often this pain is felt deep inside during penetration, although occasionally superficially and on the outer part of the vagina as well.

Reduced Fertility
This could be due to deposits of endometriosis affecting the normal pelvic anatomy, resulting in obstruction of the fallopian tubes or damage to the ovary from large endometriosis deposits, leading to ovarian cysts. Up to 30% to 50% of women with endometriosis may experience some degree of infertility.

Other Symptoms
Some women may experience pain or bleeding on passing urine or feces, pain at other times of the month not related to menses (often due to internal scarring or adhesions) and chronic pelvic pain.

Who Is at Risk of Endometriosis?

Endometriosis can affect any woman. However, it typically presents during the reproductive years, as it is dependent on oestrogen, the female hormone. Oestrogen levels fall after the menopause.

It has been estimated that endometriosis occurs in about 10% of women. However, this number may be much higher as many women have mild or no symptoms and are never diagnosed.

Sometimes it runs in the families, and daughters or sisters of women with endometriosis are at a higher risk of developing endometriosis themselves.

What Causes Endometriosis?

The exact cause of endometriosis is not known, and it is a condition likely to be contributed to by multiple factors.

The most widely accepted theory is that of retrograde menstruation, where cells from the lining of the uterus (endometrium) spill backwards along the fallopian tube to enter the pelvic cavity. These cells survive and continue to multiply and divide with the help of oestrogen, and form sticky patches of endometriotic deposits which often cause internal organs to be ‘stuck’ to one another – for example, endometriosis can cause the bowels or bladder to be stuck to the uterus or ovaries. Large clumps of these deposits can sometimes form into cysts on the ovary filled with dark, altered blood. These are known as ‘chocolate’ or ‘endometriotic’ cysts.

How Do We Diagnose Endometriosis?

If you encounter the symptoms mentioned above, you should see a gynaecologist for a proper assessment. Usually, a health history and physical examination may lead to a suspicion of endometriosis. Investigations such as ultrasound scans may be helpful in picking up large cysts or deposits caused by endometriosis. Laparoscopy, or keyhole surgery, a minimally invasive surgical procedure where a camera is used to look inside the abdominal cavity, is the most confirmatory way to diagnose endometriosis, as the lesions can be visualised directly, and also can be sent for examination under the microscope.

How Do We Manage Endometriosis?

If endometriosis is left untreated, it can get worse in about four out of 10 cases. This can sometimes lead to the progression of symptoms, persistent difficulty with getting pregnant or even complications such as bowel obstruction. There is no known cure for endometriosis.

Treatment is usually directed towards relieving pain and improving fertility, if desired.

Painkillers
Paracetamol and anti-inflammatory medications are often used in relief of cyclical pain caused by endometriosis. Stronger painkillers are occasionally required.

Hormonal Treatments
There are several options of hormonal treatments for endometriosis.

• The combined oral contraceptive pill is useful for reducing the menstrual pain associated with endometriosis, and possibly also the pain which occurs during intercourse.
• Progesterone/progestin hormone tablets counteract the effect of oestrogen and inhibit the growth of the endometrium. One example of a progestin used in the treatment of endometriosis-related pain is Dienogest.
• Progestogen releasing intrauterine system is a small plastic device inserted into the uterus. It is used for contraception, and is useful for reducing pain related to endometriosis and also greatly reduces the volume of periods. An example of this is the Levonorgestrel-Releasing Intrauterine System.
• GnRH (Gonadotrophin Releasing Hormone) analogues work by greatly reducing the amount of oestrogen made in the ovaries. While effective in reducing symptoms from endometriosis, they are associated with some menopausal side effects and overtime may lead to osteoporosis. It may be necessary to ‘add back’ hormones during therapy to reduce these side effects.

Surgery
Laparoscopy, as earlier described, can not only be used to diagnose, but also to treat problems caused by endometriosis. This form of minimally invasive surgery can be used to remove cysts caused by endometriosis, separate pelvic organs which may be ‘stuck’ together due to endometriosis, and be used to restore normal pelvic anatomy as much as possible. Surgery can not only relieve symptoms but also help to increase the chance of pregnancy if infertility is present.

For women who have completed their families and if other treatments have been unsuccessful, removal of the uterus and ovaries may also be an option. Often, this can also be achieved via laparoscopy.

To Sum it Up...
Endometriosis is a condition that can affect all women of childbearing age. It can lead to a wide variety of presentations and problems, and treatment should be individualised to meet each patient’s need. Even after treatment, endometriosis can still recur. Thanks to recent advances in medicine and surgery, there now exist new and effective ways to approach and treat endometriosis. If you suspect that you might have pain from endometriosis or difficulty conceiving, please do seek assistance from a gynaecologist early for a full assessment.