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Endometriosis

 Endometriosis is a common and often painful condition. It is thought to affect approximately 10 per cent of women at some stage during their menstruating years. It can occur anytime, from when periods start, right up to the time of menopause.  It rarely continues to be active after menopause but occasionally, may be reactivated by hormone therapy after menopause. In rare cases, endometriosis may develop into cancer.

Endometriosis can have a major impact on quality of life with the symptoms interfering with work, relationships, family and overall health. One of the main issues is that there is often a delay in diagnosing endometriosis and some women have symptoms for many years before treatment is started.

Endometriosis is a common condition. The tissue that normally lines the uterus (also called the endometrium) is found in places outside of the uterus. This misplaced tissue is commonly found on the ovaries or the tissue lining the pelvis (peritoneum), however it 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 (also known as 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 swell with blood in order to prepare for a possible pregnancy. If a pregnancy does not occur then both the endometrium and the implants break down and bleed (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 endometriomas.

The causes of endometriosis are not fully understood and there may be many reasons why it occurs in about 10 per cent of women. Potential causes include genetics, especially if there are other family members with the condition, problems with the immune system and possibly environmental toxins (yet to be proven). Retrograde menstruation is considered the main source of endometrial cells reaching the pelvis and pelvic organs.

Retrograde menstruation is when lining cells from the uterus, which are normally shed during the period, flow back along the uterine (Fallopian) tubes into the pelvis where they become implanted and begin to grow.

This theory could explain why implants are most commonly found on the ovaries, or near the end on the uterine (Fallopian) tubes. However, it does not explain cases where endometrial cells are found outside the pelvic cavity.

There is no simple test to diagnose endometriosis. The only sure way to diagnose endometriosis is by laparoscopy.  A laparoscopy is an operation performed under a general anaesthetic, where a small telescope (laparoscope) is inserted into the abdomen through a small hole cut in the belly button.  The laparoscope has a lens at one end which magnifies and lights up the pelvic organs, so that the gynaecologist can look for endometrial implants and cysts within the pelvis.

There are degrees of the condition depending on the amount of endometriosis seen and the degree of scarring. Endometriosis may be classified either as mild, moderate or severe or by Stages 1 through to 5.
 
It is not possible to accurately diagnose endometriosis from your symptoms and an external examination alone. The symptoms of endometriosis vary widely and many of them are easily confused with other conditions.  For example, many women experiencing bowel symptoms are first misdiagnosed with conditions such as irritable bowel syndrome or spastic colon.

There are other (non surgical) tests that a gynaecologist may perform, including a pelvic/vaginal examination, ultrasound, CA125 ovarian tumour marker or MRI scan, however none of these are able to definitely confirm endometriosis.

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 varies 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. For example, mild endometriosis consisting of a few implants in the Pouch of Douglas can cause debilitating pain while severe endometriosis located on the ovaries may cause little pain.

As the condition progresses the number and severity of symptoms experienced often increases, as does the number of days in the month during which the symptoms are felt. Thus, in the early stages of the disease one or two mild symptoms may be felt for the first day or two of a period. Later, as the condition worsens a larger number of symptoms may be felt with increasing severity for a greater proportion of the month.

Symptoms 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:

  • Bowel or bladder symptoms, including 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

It is important to seek help when your symptoms are interfering with your daily living and quality of life, for example:

  • Missing work, school or recreational activities
  • When medicines used for period pain don't help
  • When you need to stay in bed
  • When symptoms are getting worse
  • When symptoms occur cyclically

Infertility is present in about 30 per cent of women with endometriosis.

In mild endometriosis there is no obvious reason why infertility occurs, but it is believed that there may be some body chemicals released from the endometriosis cells that interfere with the ability to conceive or affect early normal development of the embryo.

In moderate to severe forms, scarring may cause interference with ovulation and the passage of the egg along the tube because of damage or blockage. It can also prevent the sperm from reaching the egg.

It is important to remember that not all women with endometriosis are infertile. Many women have children without difficulty; have already had children before they are diagnosed; or over time, eventually have a successful pregnancy.

Many women are told that pregnancy is a cure for endometriosis, but unfortunately, this is a myth. In the majority of women pregnancy leads to an improvement or a disappearance of the condition, particularly during the latter months of the pregnancy; however the beneficial effects are usually only temporary and many women will experience a recurrence within a few years.

Surgical treatment of endometriosis is believed to increase the chances of pregnancy. In a recent trial, laparoscopy was found to be approximately 31 per cent effective for pregnancy in women with endometriosis, in comparison to 17 per cent for women who did not have the surgery, though approximately 50 per cent of women will receive a recurrence of endometriosis after pregnancy.

If surgical treatment is unsuccessful, in vitro fertilization (IVF) treatments may also be considered; however, before trying this form of treatment, it is important that your endometriosis is properly treated, as the oestrogen levels involved may flare up any existing endometriosis.