Endometriosis

Endometriosis is a condition wherein tissue lining the inner layer of the womb (endometrium) if found outside the womb. Endometriosis is commonly seen in young women who are in reproductive age group. It’s usually seen in the pelvis (lower part of the tummy), mainly on the ovaries. Endometriosis is a common non-cancerous condition, affecting around 1 in 10 women. Endometriosis is a chronic debilitating conditions and sometimes difficult to diagnose and treat.

What are the causes?

  • Exact cause why some women develop endometriosis is not known. There are several hypothesis, but none of them has been entirely proven. The most commonly accepted theory is retrograde menstruation. During  normal menstruation the menstrual bleeding comes out of the cervix, sometime for unknown reasons some of menstrual blood falls in the abdominal cavity through the fallopian tubes. These endometrial cells present in the menstrual blood will adhere to the peritoneal lining and develop into endometriotic lesions. It has been shown that the hormone called oestrogen is crucial in this process. Hence, most of the medical treatments for endometriosis attempt to lower oestrogen levels in the body in order to relieve your symptoms. 

  • It has postulated that endometriosis is a genetic disease, since some families have more patients with endometriosis compared to other families, so you are likely to develop endometriosis if your mom or sister has had it. 

Common site where endometriosis deposits are seen: 

  1. On the ovaries: when endometriotic glands sit on the ovaries they form cysts known as endometriomas or ‘chocolate cysts’ (that’s because the content of this cyst looks like chocolate sauce.

  2. On or in the fallopian tubes: endometrial glands escapes through the fallopian tube and falls on the ovary, hence fallopian tubes and ovaries are common sites.

  3. On the peritoneum (peritoneum is the lining of the pelvis & abdomen), endometriosis on the peritoneum causes adhesions of internal organs.

  4. On or behind the womb and between the vagina and the rectum. 

What are the symptoms?

  • Pain during periods (dysmenorrhoea), most women complain that over the years severity of pain during menstruation is increasing.

  • Persistent pelvic pain.

  • Pain during sexual intercourse (dyspareunia), mainly with deep penetration.

  • Sometime when there is endometriosis deposits on the bowel you can have pain with your bowel movements, pain while passing urine and these symptoms can be sever during your menstruation and can repeat every month.

  • If you have endometriosis of ovary which has formed a cyst, then sometimes this cyst can twist (torsion) or rupture and you be in sever pain with vomiting.

  • Sometimes it can cause infertility.

  • Cyclical bleeding per-rectal during menstruation.

What test will be required for diagnosis?

1. Physical examination:

  • Your doctor will need to do a thorough physical examination, which includes feeling your tummy and an internal examination to check the position of uterus because of endometriosis leads to fixing the uterus to the rectum. 

2. Ultrasound:

  • An ultrasound will help your doctor to look for ovarian cysts.

3. CT / MRI scan may be required sometimes

4. Diagnostic laparoscopy: To make accurate diagnosis and the severity of endometriosis, laparoscopy (passing telescope into you tummy) is almost always necessary.

What are the treatment options?

  • Endometriosis is a chronic disease to treat. There is no permanent cure for endometriosis, but the symptoms can be reduced with the right treatment. Before you start your treatment, please discuss your options with your doctor and ask any questions you may have. We will be happy to explain the different options and answer your questions. 

  • Women with endometriosis have either chronic pain, fertility issues (infertility)or they may have both. Treatment of endometriosis focuses on reducing pain due to endometriosis or and resolving fertility issues, so a patient can get pregnant naturally or through fertility treatments. 

  • Endometriosis treatment is mainly medical treatment or sometimes you may be advised surgical treatment. 

  • Depending on the patient symptoms, the treatment will be different. We will take several factors into consideration when prescribing medical treatment or advising surgical treatment, these factors include: 

  1. The preferences of the woman – has fertility issues or not

  2. The type and severity of disease 

  3. Type of pain symptoms 

  4. The wish to become pregnant immediately or at a later stage 

  5. The age of the woman 

  • This means that no two women with endometriosis will receive same treatments. 

  • What’s important to remember is that medical treatment works only when the medications are taken as prescribed. You also need to remember that once you stop medical treatment the symptoms may recur, so

Medical Management:

1. Pain-relieving medication: Nonsteroidal anti-inflammatory drugs (NSAIDs): NSAIDs, such as mefenamic acid or ibuprofen, help reduce menstrual blood loss. NSAIDs also has the added benefit of relieving painful menstrual cramps (dysmenorrhea).

2. To decrease bleeding: Tranexamic acid: Tranexamic acid is a antifibrinolytics group of medications that helps reduce menstrual blood loss and only needs to be taken at the time of the bleeding.

3. Hormonal treatment: Hormonal treatment: since endometriosis is hormone dependent, the important step in management is hormonal treatment and there are different types of regimens  that may be offered to you depending on your symptoms. Aim of giving hormonal treatment is to reduce or stop your ovulation (release of egg from your ovary), by doing so there is a chance that your endometriosis will shrink in size and relieve you of symptoms. Important for you to know is that such hormonal treatment when taken will also prevent you from becoming pregnant.

  • Oral contraceptive pills (OCP): apart from providing birth control, oral contraceptives can also help regulate menstrual cycles and reduce excessive or prolonged menstrual bleeding. This is generally taken for 21 days and repeated cyclically.

  • Hormonal Intrauterine Device (IUD): Mirena this IUD releases a type of progestin called levonorgestrel into the uterus and makes the uterine lining thin and thus decreases menstrual blood flow and cramping. This device also acts as contraceptive method like Copper-T.

  • GnRHa (gonadotrophin-releasing hormone agonists): which are given as injections or a nasal spray. This medication is very effective, this medication causes medical menopause and thus can cause menopausal symptoms. 

It's important to note that medical management is  for temporary relief and symptoms of endometriosis can flare after stopping the medications. 

Surgical Management:

  • Surgery can treat by removing the areas of endometriosis. The surgery recommended will depend on extent of the endometriosis. Success rates for surgery may vary and sometimes you may need repeat surgery. Your gynaecologist should discuss the options with you fully.

Possible route of operations include:

  1. Robotic or Laparoscopic surgery (key hole): patches of endometriosis can be destroyed or removed. Sometimes for severe cases removing endometriotic cysts from ovaries or removal of ovaries with or without performing a hysterectomy (removing the womb). In some situations such as sever endometriosis surgery may be planned with colorectal surgeon to remove the deep endometriosis sitting on the rectum. 

  2. Laparotomy (open surgery): when key hole surgery is not possible then you may be offered open surgery. 

Note: endometriosis is chronic debilitating disease which can hamper your quality of life and curing endometriosis can be challenging sometimes. 

Role of endometriosis and cancer

Some studies have shown that there is slight increase in incidence of ovarian caner, endometriosis is identified in 17% of ovarian cancers but there are no strong evidence. To know more about it talk to your doctor.

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