Endometriosis

How common is Endometriosis

Endometriosis is the second most common gynaecological condition. We estimate that 2 million women have endometriosis in the UK. Endometriosis can occur at any time from the onset of menstrual periods until the menopause. It appears to be more common in women in their thirties who have delayed childbearing. It is extremely rare for it to be first diagnosed after the menopause, but not unknown. For the majority of women the condition ceases at the menopause.

What is Endometriosis

Endometrium is the tissue that lines the uterus (the womb). During the menstrual cycle the thickness of the endometrium increases in readiness for the fertilised egg. If pregnancy does not occur the lining is shed as a ‘period’.

Endometriosis is a condition where the cells that are normally found lining the uterus are also found in other areas of the body but usually within the pelvis. Each month this tissue outside of the uterus, under normal hormonal control, is built up and then breaks down and bleeds in the same way as the lining of the uterus. This internal bleeding into the pelvis, unlike a period, has no way of leaving the body. This leads to inflammation, pain and the formation of scar tissue.

Endometrial tissue can also be found in the ovary where it can form cysts, called 'chocolate' cysts. Endometrial deposits can also be found less often in more remote sites than the pelvis. Endometriosis can be found in or on the bowel, in or on the bladder, in operation scars and extremely rarely even in the lungs. It is also possible to have endometrial tissue that grows in the muscle layer of the wall of the uterus. This is called adenomyosis. Each month this tissue within the muscle wall bleeds in the same way as the endometrial tissue in the pelvis bleeds.

Adenomyosis can also be found in the muscle layer of the perineum - in the pouch of Douglas or cul de sac. It has to be clear that endometriosis is not an infection, is not contagious and is not cancer.

Why does it occur?

The most widely accepted theory is retrograde menstruation. According to this theory some of the menstrual blood flows backwards down the fallopian tubes and into the pelvis. Some of the endometrial cells, contained in the menstrual fluid, implant on the reproductive organs or other areas in the pelvis. These implanted cells cause endometriosis. What is not known is why these endometrial cells implant in some women and not in others.

Other theories are:

• Lymphatic or circulatory spread
• Genetic predisposition to the condition
• Immune dysfunction
• Environmental causes - such as dioxin exposure

Symptoms of endometriosis

The classic symptoms of endometriosis are painful periods, painful sex and infertility. But other symptoms which are common with other conditions can also be present. These symptoms may be related to: pain (painful periods, pain starting before periods, pain during or after sexual intercourse, ovulation pain, pain on internal examination), bleeding (heavy periods with/without clots, prolonged bleeding, premenstrual spotting, irregular periods, loss of dark or old blood before a period or at the end of a period), bowel and bladder symptoms (painful bowel movement, pain before or after opening bowels, bleeding from the bowel, pain when passing urine, pain before or after passing urine) and other symptoms (lethargy, extreme tiredness).

The majority of women with the condition will experience some of these symptoms. Some women with endometriosis will have no symptoms at all. The amount of endometriosis does not always correspond to the amount of pain and discomfort. Chocolate cysts on the ovary can be pain free and only discovered as part of fertility investigations. A small amount of endometriosis can be more painful than severe disease. It depends, largely, on the site of the endometrial deposits. All of the symptoms above may have other causes. It is important to seek medical advice to clarify the cause of any symptoms. If symptoms change, after diagnosis, it is important to discuss these changes with a doctor. It is easier to put all problems down to endometriosis and it may not always be the reason.

How is endometriosis diagnosed?

The only way to diagnose endometriosis is by a laparoscopy. This is a minor operation in which a telescope (a laparascope) is inserted into the pelvis via a small cut near the navel. This allows the surgeon to see the pelvic organs and any endometrial implants and cysts.

Occasionally diagnosis is made during a laparotomy. A laparotomy is a major operation, which involves a cut into the abdomen.

Ultrasound scans, blood tests and internal examinations are not a conclusive way to diagnose endometriosis.

Treatments

Treatment for endometriosis depends on symptoms that a woman experiences and whether she wants to have children. It may be treated with medication, surgery, or both. The treatment that a woman is offered should be decided in partnership between her and her doctor. The considerations about what type of treatment should be used, depend on several factors, such as:

• Age
• The severity of the symptoms
• The desire to have children
• The severity of the disease

Although symptoms of endometriosis may come back, therapy can relieve pain for a time.

Medical treatments

Pain Relief treatments

If the main problem of endometriosis is pelvic pain, the standard pain-killers could be the first line of treatment. These could be combined with hormonal treatments to enhance pain relief result.

Hormones may be used to relieve pain. The hormones may help slow the growth of the endometrial tissue. The most commonly prescribed hormones include oral contraceptives, gonadotropin-releasing hormone (GnRH) agonists, progestogens, and danazol.

Not all women, however, get pain relief from medications. Medication does not reduce adhesions or scar tissue, which may be the cause of pain. These medications are not for all women. As with most medications, there are some side effects linked to hormone treatment. Some women, however, may find the relief of pain is worth the discomfort of the side effects.

Oral contraceptives

Birth control pills are often prescribed for symptoms of endometriosis. The hormone in them helps keep the menstrual period regular, lighter, and shorter and can relieve pain. There is no evidence that birth control pills shrink endometriosis or increase fertility. The doctor may prescribe the pill in a way that prevents a woman from having periods.

GnRH

GnRH is a hormone that helps control the menstrual cycle. GnRH agonists are drugs that are similar to human GnRH but many times more potent than the natural substance. GnRH agonists lower estrogen levels by turning off the ovaries. This produces a temporary condition similar to menopause. GnRH agonists can be given as an injection, an implant, or nasal spray. Usually, patches of endometriosis shrink and pain is relieved. GnRH may help relieve pain during sex. Women taking GnRH may have hot flushes (hot flashes), headaches, and vaginal dryness. Treatment with GnRH usually lasts up to 6 months. After stopping GnRH, you will have periods again in about 6-10 weeks. Symptoms of endometriosis will recur in at least half of women who take GnRH, especially if symptoms are severe.

Progestogens

The hormone progesterone has shown to shrink patches of endometriosis. Progestogens (artificial derivatives of progesterone) work against the effects of estrogen on the tissue. You will no longer have a menstrual period when taking progestogens. Progestogens are taken as a pill or injection (Depo-Provera).

Danazol

Danazol is a synthetic hormone that shrinks endometrial tissue. It is taken as a pill and stops the menstrual cycle. You will no longer have a period while taking danazol. Danazol works very well to decrease pelvic pain and pain during sexual intercourse. Symptoms of endometriosis usually return in about 6 weeks after you stop taking the medication. The side effects of danazol may include weight gain, acne, deepening of the voice, and hair growth. Danazol treatment is not for everyone. Women who have liver, kidney, or heart problems cannot take danazol.

With the exception of the oral contraceptive pill, the drugs used to treat endometriosis are not contraceptives and barrier methods of contraception should be used during treatment.

Surgery

Surgery may be performed to remove endometriosis and the scarred tissue around it. Healthy ovaries and normal fallopian tubes are left alone as often as possible to increase the chances of pregnancy later. Surgery is most often done by laparoscopy. Laparoscopy has many benefits over open surgery. It requires a shorter hospital stay, very small incisions, and shorter recovery time. Surgery is often successful, both for treating pain and infertility, but symptoms may return. Many patients are treated with both surgery and medications to reduce recurrence. Not all conditions can be handled with laparoscopy. Sometimes laparotomy (open operation through a cut in the tummy) may still be needed. When pain is severe and does not go away after therapy and the woman has completed her family, a more extensive surgery may be required. Then the uterus, fallopian tubes, and ovaries may have to be removed. If the ovaries are left in place then the chance of persistent disease is increased with some women needing a further operation to remove the ovaries at a later date.

For radical surgery to offer hope of a cure for endometriosis then hysterectomy, the removal of the ovaries and removal of any endometrial growths should be done. Radical surgery should be the 'last resort' treatment and not contemplated until all other treatments have been tried or ruled out.

Complementary therapies

Options include acupuncture, aromatherapy, Chinese herbs, Western Herbs, homeopathy, nutrition, reflexology, naturopathy, Reiki and osteopathy. There are no clinical trials based on the efficacy of complementary therapies as treatments for endometriosis. However, many women do have improvement of their symptoms whilst using such therapies. It is probably wise to seek help from a qualified practitioner and not self medicate.