The Everywoman Cliniq

Endometriosis

EndometriosisEndometriosis affects about 10% women during their "reproductive years" (that's the years between starting the menstrual period and menopause). Approximately 176 million women over the world suffer from endometriosis.

Endometriosis is a condition where tissue similar to the lining of the uterus (the endometrial stroma and glands, which should only be located inside the uterus) is found elsewhere in the body.

Endometriosis lesions can be found anywhere in the pelvic cavity: on the ovaries, the fallopian tubes, and on the pelvic sidewall. Other common sites include the uterosacral ligaments, the cul-de-sac, the Pouch of Douglas, and in the rectal-vaginal septum.

It can also be found in caecarian-section scars, laparoscopy or laparotomy scars, and on the bladder, bowel, intestines, colon, appendix, and rectum. Rarely, endometriosis has been found inside the vagina, inside the bladder, on the skin, even in the lung, spine, and brain.

Q.   What are the symptoms of endometriosis ?

Ans: Progressively increasing dysmenorrhea (periods pains or menstrual cramping) may be a symptom of endometriosis. These are caused by contractions of uterine muscle initiated by prostaglandins released from the endometrial tissue. A puzzling feature of endometriosis is that the degree of pain it causes is not related to the extent of the disease. Some women with extensive disease feel no pain at all. A woman with endometriosis may notice that as the disease progresses her periods become more painful or that the pain begins earlier or lasts longer.

Endometriosis can cause pain during intercourse, a condition known as dyspareunia. The thrusting motion of the penis can produce pain in an ovary bound by scar tissue to the top of the vagina or in a tender nodule of endometriosis. Most women who have endometriosis report no bleeding irregularities. Occasionally, however, the disease is accompanied by vaginal bleeding at irregular intervals; or by premenstrual spotting.

Symptoms of endometriosis:

The most common symptom of endometriosis is pelvic pain, mostly in the abdomen, lower back and pelvic areas. The pain often correlates to the menstrual cycle. Sometimes woman with endometriosis may also experience pain at other times during her monthly cycle.

For many women, but not everyone, the pain of endometriosis can unfortunately be so severe and debilitating that it impacts on her life significant ways.

Pain may be felt:

  • before/during/after menstruation
  • during ovulation
  • in the bowel during menstruation
  • when passing urine
  • during or after sexual intercourse
  • in the lower back region

Other symptoms may include:

  • diarrhoea or constipation (particularly during menstruation)
  • abdominal bloating (during menstruation)
  • heavy or irregular bleeding
  • Intestinal pain
  • Fatigue
  • Infertility

The other well known symptom associated with endometriosis is infertility. It is estimated that 30-40% of women with endometriosis are subfertile.

What Causes It?:

The cause is unknown, but theories include:

  • Abnormal functioning of the immune system
  • Retrograde (or reflux) menstruation, in which some menstrual blood flows backward through the fallopian tubes
  • Genetic or heredity factors (the risk of endometriosis is 10 fold higher among women who have a first degree relative with endometriosis)
  • Some studies suggest that being overweight during late childhood is associated with the development of endometriosis
  • Stress

What causes endometriosis?
Several different hypotheses have been put forward as to what causes endometriosis. Unfortunately, none of these theories have ever been entirely proven, nor do they fully explain all the mechanisms associated with the development of the disease. Thus, the cause of endometriosis remains unknown.

Most researchers, however, agree that endometriosis is exacerbated by oestrogen. Subsequently, most of the current treatments for endometriosis attempt to temper oestrogen production in a woman's body in order to relieve her of symptoms. At the moment there are notreatments, which fully cure endometriosis.

Several theories have become more accepted, and reality is that it may be a combination of factors, which make some women develop endometriosis.

Metaplasia:
Metaplasia means to change from one normal type of tissue to another normal type of tissue. It has been proposed by some that endometrial tissue has the ability in some cases to replace other types of tissues outside the uterus.

Some researchers believe this happens in the embryo, when the uterus is first forming. Others believe that some adult cells retain the ability they had in the embryonic stage to transform into reproductive tissue.

Genetic predisposition
Studies have shown that first-degree relatives of women with this disease are more likely to develop endometriosis. And when there is a hereditary link, the disease tends to be worse in the next generation.

An ongoing worldwide study called the International Endogene study is conducting research based on the blood samples from sisters with endometriosis in hopes of isolating an endometriosis gene.

Lymphatic or vascular distribution
Endometrial fragments may travel through blood vessels or the lymphatic system to other parts of the body. This may explain how endometriosis ends up in distant sites, such as the lung, brain, skin, or eye.

Immune system dysfunctions
Some women with endometriosis appear to display certain immunologic defects or dysfunctions. Whether this is a cause or effect of the disease remains unknown.

Environmental influences
Some studies have pointed to environmental factors as contributors to the development of endometriosis, specifically related to the way toxins in the environment have an effect on the reproductive hormones and immune system response, though this theory has not been proven and remains controversial.

Endometriosis Treatments:

Endometriosis is a common problem which affects young women in the reproductive age group. In this, the tissue which lines the womb (endometrium) is found growing in abnormal locations such as the ovaries or around the uterus.

Every time the patient has her menses, there is also bleeding inside this. As a result thick dark blood accumulates in the ovaries (endometrium cyst) and there are blood spots all over the pelvis which cause the intestines tubes and ovaries to stick to each other.

Endometriosis can cause severe pain before or during periods, also heavy or abnormal bleeding. As it damages tubes and ovaries, it often causes infertility (inability to conceive). The condition always worsens with time and in severe cases can result in total damage to all pelvic organs causing a frozen pelvis.

The diagnosis is made by history, examination and sonography. Sometimes a laparoscopy (Key hole surgery) may be required to diagnose and treat endometriosis at the same time.

The treatment is essentially surgical. Nowadays, 2-3 visual cuts on the stomach wall are used to introduce a camera and operating instruments inside the pelvis and the endometriotic areas are removed and burnt using current or laser.

Despite surgical removal, there is a possibility of recurrence of endometriosis, and the same patient needs multiple surgeries within a few years.

Medical treatment is used to create ‘artificial menopause’ as when there are no periods, the endometriosis subsides. This can be done using continuous hormone tablets or once a month injections. However this form of treatment is temporary.

Young patients with endometriosis who want to have a baby may require specialized treatment like IUI or IVF (Test tube baby). If the patient is older and has had repeated surgery, a total hysterectomy with oophoorectomy (removing uterus and ovary) is the final solution.

Diagnosing Endometriosis:

There is no simple test that can be used to diagnose endometriosis, which may be why there is a diagnostic delay of up to 12 years in some healthcare settings.

At present the only reliable way to definitively diagnose endometriosis is by performing a laparoscopy and to take a biopsy of the tissue. This is what is known as "the gold standard".However, this is an expensive, invasive proceduce. Furthermore, if the surgeon is not a specialist in endometriosis s/he may not recognise the disease, which can result in a "negative"result (ie. you may be told that you have not got endometriosis, even if you do, because the surgeon was unable to visually recognise the disease, and if no biopsy was taken). And, not everyone want to have surgery.

This makes diagnosing endometriosis a challenge, and therefore an experienced gynaecologist should be able to recognise symptoms suggestive of endometriosis through talking with the woman and obtain a history of her symptoms. For this to be effective, it is important that the woman is honest with her physician about all of her symptoms and the pattern of these.

To aid you in your preparation for this consultation you may wish to use the questionnaire: your first consultation. It lists a number of questions your doctor may ask you - and will help him/her in determining whether your symptoms may be due to endometriosis (not all pelvic pain, nor fertility issues, are caused by endometriosis).

There are other tests, which the gynaecologist may perform. These include ultrasound, MRI scans, CA125, and gynaecological examinations. None of these can definitively confirm endometriosis (though they can be suggestive of the disease), nor can they definitively dismiss the presence of endometriotic lesions/cysts.

The fact that there is no non-invasive, definitive diagnostic method for endometriosis is as frustrating for clinicians as it is for women with the disease.

Recently there has been a lot of hype about a new non-invasive test for endometriosis. This is based on promising research in deteching nerve-fibres in the endometrium of women with endometriois. However, this research has not been validated, and there is not yet a test on the market.

Endometriosis and Infertility

Endometriosis, a cause of female infertility, is a condition in which endometrial tissue, the tissue that lines the inside of the uterus, grows outside the uterus and attaches to other organs in the abdominal cavity such as the ovaries and fallopian tubes. Endometriosis is a progressive disease that tends to get worse over time and can reoccur after treatment. Symptoms include painful menstrual periods, abnormal menstrual bleeding and pain during or after sexual intercourse.

The endometrial tissue outside your uterus responds to your menstrual cycle hormones the same way the tissue inside your uterus responds - it swells and thickens, then sheds to mark the beginning of the next cycle. The blood that is shed from the endometrial tissue in your abdominal cavity has no place to go, resulting in pools of blood causing an inflammation that forms scar tissue. The scar tissue can block the fallopian tubes or interfere with ovulation. Another result of endometriosis is the formation of ovarian cysts called endometrioma that may also interfere with ovulation.

The cause of endometriosis is unknown though there are a few theories that suggest possible causes. One theory suggests that during menstruation, some of the menstrual tissue backs up through the fallopian tubes into the abdomen where it implants and grows. Another theory indicates that it is a genetic birth abnormality in which endometrial cells develop outside the uterus during fetal development.

A laparoscopy, an outpatient surgical procedure, is necessary to confirm a diagnosis of endometriosis after a medical history review and pelvic exam. After the initial diagnosis, your physician will classify your condition as stage 1 (minimal), stage 2 (mild), stage 3 (moderate) or stage 4 (extensive) based on the amount of scarring and diseased tissue found. Based on the stage of endometriosis, your physician will determine the best treatment plan for you which may include medication or surgery, or a combination of both.

How is IVF used for treating endometriosis ?

IVF

Treatment cannot "cure" endometriosis - but it can control it. If an infertile woman with endometriosis fails to conceive even after surgical treatment, the next option is superovulation with intrauterine insemination, since the fallopian tubes in these patients are usually open. If this fails, then IVF ( in vitro fertilization ) can be very useful. However, the ovarian response in some of these patients can be poor, especially if they have large chocolate cysts, or have had surgery for these cysts. Fertilization rates in some patients with endometriosis can be a little lower than for other patients, perhaps because of an intrinsic oocyte abnormality.

FAQ

Q.1.   What is endometriosis?

Ans: Endometriosis is a condition where tissue similar to the lining of the uterus is also found elsewhere in the body, mainly in the abdominal cavity.

Q.2.   Who gets endometriosis?

Ans: Endometriosis typically affects women during their menstruating years. Symptoms can start with or after the first menstruation and, for most women, the disease is rarely found after the menopause.

Q.3.   What are the symptoms of endometriosis?

Ans: The most common symptom of endometriosis is pelvic pain. The pain is often with menstruation, however a woman with endometriosis may also experience pain at other times during her monthly cycle. Another symptoms is infertility, and some women with endometriosis also experience severe fatigue.

Q.4.   How is endometriosis diagnosed?

Ans: The only way to diagnose endometriosis for sure is during alaparoscopy, which is a surgical procedure. However, many physicians are able to "diagnose" endometriosis based on a woman's symptoms and start treatment on that basis.

Q.5.   Is there a cure for endometriosis?

Ans: No. But it can be treated, and for many women it is possible to manage their symptoms through a combination of long term treatments.

Q.6.   Where do I find someone who specialises in endometriosis?

Ans: Most national or local support groups will be able to advise you where to find specialist help. Also read our article on how to find a centre which specialises in treating endometriosis and the questions you need to ask your physician before you decide on the right treatment for you.

Q.7.   Is endometriosis a sexually transmitted disease or infectious?

Ans: No. Endometriosis cannot be transferred from one human being to another. The cause of endometriosis is not yet known, but it is not an infectious disease.

Q.8.   Is endometriosis inherited?

Ans: No. Endometriosis cannot be transferred from one human being to another. The cause of endometriosis is not yet known, but it is not an infectious disease.

Q.9.   Will I be able to have children?

Ans: It is estimated that 30-40% of women with endometriosis may have difficulties in becoming pregnant (but this means that 60-70% will have no problems!). If fertility is a great wish, then please discuss your symptoms with your physician so that together you can develop the best treatment plan for you.

Q.10.   Will a hysterectomy cure endometriosis?

Ans: Some women chose, as a last resort to have a hysterectomy. However, this does not guarantee complete pain relief. If you opt for a hysterectomy it is important that all the endometriosis is removed at the same time.

Q.11.   Will pregnancy cure endometriosis?

Ans: No. Some women find that their pain symptoms are reduced during pregnancy, but this is not the case for everyone. In most cases, endometriosis will return after giving birth and stopping breast

Q.12.   Is endometriosis cancer?

Ans: No. Endometriosis cysts are sometimes referred to as "beningn tumours", because they may "behave similarly" to cancer, but endometriosis is not the same disease. In very rare cases, endometriotic implants has lead to cancer, but this is very very rare. Some research suggests that some women with endometriosis may be at a slightly higher risk of developing certain cancers but this is still controversial.

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