What is endometriosis?

Endometriosis is a very common gynaecological condition that affects about 10% of women of reproductive age. It is characterized by the presence of tissue from the lining of the womb (called endometrial tissue, hence the name endometriosis) outside the cavity of the womb. Although, endometriosis is most commonly found in the pelvis, lesions have been found in many different parts of the body such as the lungs, the brain, the skin and the external genitalia.

What causes endometriosis?

The real cause of endometriosis is unknown. The most widely accepted theory is the retrograde menstruation theory. It is believed that cells from the lining of the womb reach the pelvis during menstruation due to the passage of the menstrual blood through the fallopian tubes into the pelvis. Although, in the majority of women these cells die, in some women they continue to grow to form deposits of endometriosis.

Types of endometriosis

Three distinct types of pelvic endometriosis can be distinguished including superficial deposits, deep-seated lesions (called nodules) and cysts on the ovaries (called endometriomas or chocolate cysts). The disease varies in severity from few superficial deposits to an extensive disease involving all the organs in the pelvis. It is frequently associated with the formation of bands of scar tissue called adhesions. The disease could also involve non-gynaecological organs such as bowel, bladder and ureter.

How does endometriosis present?

The manifestations of endometriosis vary greatly between different women and the severity of the symptoms does not reflect the extent of the disease. About 20% of patients with very severe disease are completely free from any symptoms. On the other hand women with mild disease could suffer from severe pains.

Endometriosis usually presents with two main symptoms including pain and infertility. The pain is typically cyclical i.e. occurs around the time of the period (called dysmenorrhoea). It usually starts several days before the period as a dull ache then worsens with the start of the menstrual flow and gradually eases of toward the end of the period. The pain can be severe, agonizing and not responding to strong painkillers to an extent that disrupts the patient's life. This pattern of pain should be distinguished from the normal period pain, which is a cramping central lower abdominal pain that associates the beginning of the period and lasts only for one day. Unlike the endometriosis, period pain responds will to simple painkillers.

Endometriosis can also cause other patterns of pain such as consent pelvic pain and sharp stabbing pain during intercourse. Other symptoms include painful defecation or urination and passage of blood with stools or urine around time of the period.

How is endometriosis diagnosed?

Careful assessment of the pattern of pain and other symptoms together with laparoscopy (camera inspection of the pelvis) are the key to establishing an accurate diagnosis of endometriosis. Clinical examination will not detect the disease in the majority of cases and an ultrasound scan can be helpful only in detecting Chocolate cysts. In other words a normal examination and scan do not exclude endometriosis.

How is endometriosis treated?

Several management options are available for endometriosis and the choice depends on several factors including age, fertility, nature and severity of the presenting symptoms and severity of the disease. Treatment options include painkillers, hormonal treatment and surgery. Women with extensive endometriosis who are seeking fertility treatment may require IVF.

Commonly used hormonal treatments include the combined oral contraceptive pill (COCP), progestogens and Gonadotrophin-releasing hormone antagonists. Most of these drugs are equally effective in suppressing the disease and alleviating the pain. The choice of treatment is largely dependent on the side effects of the hormones. There is a relatively high recurrence rate of symptoms after stopping the treatment. There is no rule for hormonal therapy in women seeking fertility treatment.

Surgery is usually performed via the laparoscope (keyhole surgery) and involves removal of all deposits of endometriosis either by cutting them out or by ablating them with electrical cautery or laser. More advanced cases of endometriosis requires a major surgical procedure to remove deep endometriosis deposits and may include hysterectomy, bowel or urinary surgery. Surgery is generally effective and removes pain in about 75% of cases, although the disease can recur in 20% of women within 5 years after the operation. Surgical treatment is more suitable for women trying to conceive as it doubles their chance of conception.

Saad Amer

Saad Amer MSc., FRCOG, MD
Consultant Gynaecologist

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