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Endometriosis

Endometriosis is a medical condition in which the endometrial tissue (i.e the lining of the womb which sheds off with every cycle at menstruation) is found in other places outside the uterus, like on the pelvic wall, the ovaries, and the bowel (the intestines). Endometriosis most commonly causes severe menstrual pain (dysmenorrhoea), and is often underdiagnosed, because of a wrong assumption that it is normal for periods to be painful.

It is not yet very clear why the endometrium is found outside the uterus in endometriosis, but there are a few likely reasons. When the endometrium is being shed during a period, it is possible that while the blood flows out through the vagina, some of it flows backwards through the tubes and ends up in the pelvic area, from where it can attach to the pelvic walls, organs, and even the bowel. (retrograde menstruation). Another possible reason is that the cells from the endometrium can be carried from the uterus to other parts of the body through the lymphatic or blood vessels. It has been shown that after one has any surgery involving the uterus (like a myomectomy or a Caesarean section), endometrial cells can be carried to the site of the skin incision and thus endometriosis develops on the surgical scar.

Endometrial tissue that is found outside the uterus is influenced by the female hormones, the same as inside the uterus. So, the tissue thickens during the cycle and is shed when menstruation begins. It is unable to flow out, and thus remains there and irritates the surrounding areas. This can cause scar tissue (called adhesions) to form, and make the organs stick to each other or stick to the walls of the abdomen and the pelvis. In the ovaries, endometriosis can cause a type of ovarian cyst called an endometrioma, which contains a thick, dark coloured fluid.

The symptoms of endometriosis include the following:

  • Painful menstrual periods – this pain is usually severe, starts some days before the period starts, and continues for some days after the period has ended. The pain sometimes extends from the lower abdomen to the back and thighs
  • Constipation, diarrhoea, pain on passing stool or urinating, which is related to the period, i.e it starts when the period starts or is about to start, and ends when the period ends or extends for a few days
  • Painful intercourse
  • Chronic pelvic pain
  • Cyclical pain in some parts of the body – the skin, chest (if it is located in the lungs; can also cause a cyclical cough)
  • Infertility
  • Some women with endometriosis will have no symptoms of pain even if the endometriosis is severe, while others with severe pain might not have much pain.

The first suggestion of a diagnosis of endometriosis from the complaints alone, if one has the classic symptoms of severe cyclical pain. An ultrasound scan can suggest that the organs are stuck to each other, and can pick up an endometrioma. An MRI scan gives a more specific diagnosis of endometriosis. However, the best way to make a diagnosis is to have a laparoscopy – a theatre procedure in which thin, rod like instruments are introduced into the abdomen through small cuts. A camera is attached to them and the images are projected on a screen. This way, the pelvis and abdomen can be seen directly and areas of endometriosis identified. They usually appear as dark spots or patches on the organs or walls. The advantage of having this procedure is that it enables a diagnosis to be made, the severity determined, and treatment to be done at the same time. The main factors that are considered in offering treatment for endometriosis are the severity of the symptoms, the age of the affected person, and whether or not you are trying to get pregnant. Treatment can be either with the use of medications or surgical, and sometimes both will need to be done.

  • Pain medications: These are given to remove the pain so that you can go about your regular activities. Sometimes, you may need to be on more than one pain medication at the same time, in order to achieve adequate relief.
  • Hormonal contraceptives: The use of hormonal contraceptives is to disrupt the hormonal levels of a normal menstrual cycle, thus preventing the displaced endometrial tissue also from growing, shedding, and causing harm. This is not a permanent treatment, as normal menstruation resumes and the symptoms start again in most cases when the medication is stopped.
  • GnRH agonists: This is a type of hormonal medication. The drug acts by preventing the body from producing estrogen, thus causing menstruation to cease. The displaced endometrial tissue is unable to grow at all, and so begins to shrink. It is usually more effective than the hormonal contraceptives, but is also not permanent. However, it provides relief for longer periods after it has been stopped and menstruation resumes.
  • Laparoscopic treatment of endometriosis: A laparoscopy is done and the endometrial patches or spots are identified and removed. Adhesions (scar tissue) which have formed from the endometriosis can also be separated and removed, together with any endometriomas that may have formed on the ovaries. In severe cases, a laparoscopy is followed up with the use of GnRH agonists for a few months.
  • Surgical removal of endometriotic deposits outside the abdomen: a surgery might be necessary to remove endometriosis from the skin, or the lungs.

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