Endometriosis

What is Endometriosis?

The lining of the womb or uterus is called endometrium. Endometriosis is an estrogen hormone-dependent condition that is characterized by the presence of ectopic endometrial tissue in places within the body but outside of the uterus. The disease state and symptoms can be modified by pregnancy, breast feeding and menopause.

The pathogenesis of endometriosis remains an enigma in gynaecology and a topic of heated debate.

There are 2 distinct entities:

  • Endometriosis (external – outside of the uterus)
  • Adenomyosis (in the muscle of the uterus).

How does Endometriosis grow or develop?

Endometriosis may develop in some women that are genetically prone to develop or grow the endometrial cells in ectopic sites outside of the uterus (runs in the families e.g., mother, sisters). In others it may develop due to retrograde flow of menstrual blood through the fallopian tubes or due to an altered immune environment in the pelvis.

What are the common sites affected by endometriosis?

Endometriosis predominantly affects the ovaries by forming cysts and the back of the uterus. It may also be found in the space between the womb and bowel and very occasionally in areas as remote as bladder, in caesarean section scars, lungs etc.

How does endometriosis present or manifest?

A woman may be completely asymptomatic and the condition may be diagnosed as an incidental finding during either sterilization surgery or during infertility assessment. Some women may suffer from painful periods and others may suffer from pain at the time of intercourse. Others may also experience painful opening of bowels around the time of the periods. It has been seen that occasionally women may have a cyclical bleeding (during menses) from the back passage (along with stools) or from the bladder (while passing urine). Women with endometriosis in the operation scar sites may find that the scar develops painful nodules that grow during periods.

It has been shown that less than 10% of women would be accurately diagnosed with the disease when they first present to the doctor with symptoms.

Does Endometriosis cause infertility?

Endometriosis can cause anatomical distortion of the pelvic organs due to scarring e.g chocolate cysts in the ovaries, adhesions etc. Distortion in the pelvis can impair the fertilization process. In addition it can affect the egg release process. Endometriosis is known to alter the immune environment within the body which in turn affects the fertilization process.

How does one diagnose Endometriosis?

A good clinical history and a thorough clinical examination help point in the direction of the correct diagnosis. To confirm the diagnosis, a woman will be advised to undergo a pelvic ultrasound assessment and laparoscopy (keyhole camera procedure) which is considered the “gold standard” tool. Other sophisticated tests such as MRI, intravenous urography (IVU), barium enema (X-ray procedure) may be required in some women with severe disease.

How does one treat Endometriosis?

Endometriosis can be managed either with the help of drugs or with surgery. The drugs used for the management are geared towards reducing the impact of the oestrogen hormone.

What are the drugs used for the management of endometriosis?

  • Painkillers
  • Combined oral contraceptive pill (COCP)
  • Progesterone only pill
  • Gonadotropin releasing hormone agonist (GnRHa e.g. Zoladex, Prostap, Luprolide acetate etc)
  • Mirena IUS (Progesterone loaded IUCD)

Initial management of pain symptoms is generally with painkillers or analgesics. If a woman is not desirous of fertility and pain is her main symptom, the use of the combined oral contraceptive pill continuously for 3 – 6 months followed by short breaks of 7 days could help relieve the symptoms.
In women that are overweight or obese, those that have a family history of blood clots, or those that smoke and those with an altered liver function, the use of oestrogen containing pills is contraindicated. In such cases, one may use the progesterone only pill continuously for 3 – 6 months

GnRH analogues are injections that will be given to cases with moderate to severe endometriosis. These injections are given either or a monthly or 3 monthly basis. The GnRH analogues temporarily switch off the ovaries thereby reducing the impact of oestrogen on the endometriotic deposits and causing a regression in their size and improvement in the pain symptoms. Women may need to use a small dose of hormone replacement therapy (HRT) during the GnRH analogue treatment to combat symptoms of low oestrogen such as hot flushes, night sweats, mood swings and irritability.
The Mirena IUS is a progesterone (levo-norgestrel) loaded intra-uterine device that has been found to have a beneficial impact on symptoms of pain.

Unfortunately, none of the above will allow a woman to conceive or fall pregnant during treatment.

What is the role of surgery in the management of endometriosis?

Surgery is indicated for the initial diagnosis and staging of the disease (laparoscopy). Subsequently, surgery is useful in correcting the anatomical distortion caused by the disease process in the pelvis, ovaries and other organs. This procedure generally helps relieve symptoms of pain and may help restore fertility potential. It may also be necessary to perform surgery prior to starting fertility treatment.

Surgery may be accomplished through minimal access or keyhole surgery (laparoscopy) or via the open abdominal cut (laparotomy) technique. The open techniques is generally used when the anatomical distortion and scarring from the disease process is extensive. It may also be necessary for those that have had multiple previous surgeries.

In those with extensive disease, it may be necessary to use GnRH analogue injections pre and post surgery to achieve a greater degree of relief in symptoms.

In women that have severe disease and have completed child bearing, it may be necessary to perform definitive surgery in the form of hysterectomy. The ovaries may be left behind if the woman is less than 45 years of age. This helps in reducing the risk of osteoporosis (thinning of the bones) and cardiac problems. The downside however is that the endometriosis process may recur as the ovaries will continue to supply the oestrogen hormone until the natural age of menopause.

Can endometriosis be completely cured with surgery or medications?

Unfortunately, one cannot completely cure endometriosis or eradicate the disease by surgery or medications.

Following surgery for mild, moderate or severe disease, the chances of recurrence may be as high as 50% in 2 – 3 years. Also, symptoms of pain may recur once the medications are stopped.

Can women conceive with a despite endometriosis?

In those with minimal to mild disease, conception can occur spontaneously. Failure to conceive following 6 – 12 months of trying may necessitate help in the form of assisted conception treatment e.g., Intra-uterine insemination of semen (IUI) or In-vitro fertilization (IVF). The IUI treatment may result in 10 – 15% chance of pregnancy and IVF results in 25 – 30% chance of success provided the reserve of eggs in a woman’s ovaries is good and the woman is less than 37 years of age.

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