What is Endometriosis?
Endometriosis is a fairly common disorder diagnosed in women of the reproductive age group. It is a chronic, painful disorder where the endometrial tissue lining the uterus grows in ectopic sites such as ovaries, tubes, and ligaments that support the uterus. Other locations include bladder, bowel, vagina, rectum, vulva and abdominal surgical scars.
The misplaced endometrial tissue responds to hormonal changes in the menstrual cycle in the same manner as the normal endometrial tissue. Like normal endometrial tissue, this tissue also builds up (proliferates) and breaks down and sheds during menstrual phase. However, it cannot escape from the body and bleeds into the abdominal and pelvic cavities causing severe pain during and before periods.
As a result of the internal bleeding, locally there is inflammation which heals with scar tissue formation. Ultimately, this leads to problems such as infertility when ovaries and tubes become involved.
Various theories have been proposed to explain the presence of endometrial tissue in abnormal ectopic sites. These include:
- Regurgitation Theory – This theory proposes that menstrual blood flows backward through the tubes and gets implanted in sites such as tubes, ovaries and peritoneal cavity. After getting implanted, it grows in the new site causing endometriosis..
- Metaplastic (Embryonic) Theory – According to this theory, remnants of embryonic tissue which develop into endometrium persist within the abdomen and pelvis. This persisting embryonic tissue can differentiate into endometrial tissue giving rise to endometriosis at ectopic sites.
- Benign Metastases Theory – This theory proposes that uterine endometrial tissue spreads to distant sites via blood and lymphatic channels.
- Stem Cell Theory – This theory proposes that stem cells from the bone marrow differentiate into endometrial tissue.
- Surgical Transplantation Theory – This theory suggests that accidental transplantation may occur during surgery e.g. endometriosis on abdominal surgical scars.
- Nulliparity (never having given birth)
- Family history (mother, aunt or sister having the disease)
- Any condition that prevents normal outflow of menstrual blood e.g. imperforate hymen
- History of pelvic infection
- Abnormalities of uterus
- Accidental transplantation of endometrial tissue during abdominal/pelvic surgery such as Cesarean section or Hysterectomy.
- Dysmenorrhea or painful periods
- Heavy bleeding during periods
- Dyspareunia or painful sex
- Painful urination during menses
- Painful bowel movements during periods
- Tiredness and low back pain
- Gastrointestinal symptoms such as diarrhea, constipation and nausea
- Frequent allergies and sensitivities
- Frequent yeast infections
- Infertility – In addition to the pain and discomfort associated with endometriosis, most women face the unfortunate possibility of being unable to conceive.
This is because the inflammation and scarring seen in endometriosis can cause blockage of the tubes and prevent fertilization. Other mechanisms include direct damage to the egg and/or sperm.
Women with endometriosis are often advised by the doctor not to delay pregnancy as the disease may worsen over time.
- Ovarian Cancer – Though still low, women with endometriosis have a higher rate of ovarian cancer than expected. Another cancer called endometriosis-associated adenocarcinoma may rarely develop later in life in women who suffered from endometriosis.
When a diagnosis of endometriosis is suspected, the following tests may be done:
- Pelvic Exam (Internal Examination) – The gynecologist manually feels behind the uterus for cysts or scars that may have formed due to endometriosis. Very often it is not possible to palpate small areas of endometriosis, unless they have given rise to cysts or scars.
- Ultrasound/MRI Scan – Ultrasound is a diagnostic test that uses sound waves to create images of various body parts. A pelvic or transvaginal ultrasound may be done to detect endometriosis. Cysts associated with endometriosis may be detected in this manner. Occasionally an MRI scan may be necessary if ultrasound fails to provide evidence.
- Laparoscopy is the only test that can make a definitive diagnosis of endometriosis. This is an invasive procedure.
Under general anesthesia, a slender viewing instrument (laparoscope) is inserted into the abdominal cavity through a tiny incision. The doctor inspects the abdominal and pelvic cavities for presence of endometrial tissue, and associated cysts or scars.
A sample of the tissue may also be obtained (biopsy) and sent for microscopic examination for confirmation.
Laparoscopy can give information about the location, extent and size of the endometriosis to help decide the best treatment options.
Management of endometriosis depends on the extent of the disease, symptoms, and whether the woman wants to have children. Endometriosis may be treated with medicines, surgery, or both.
Usually, doctors advise conservative treatment approaches first, opting for surgery only as a last resort.
- Pain Medications – Non-steroidal anti-inflammatory drugs such as ibuprofen and naproxen are prescribed for relief of pain and cramps associated with endometriosis.
- Progesterone or Progestin, may be given as a pill, injection, or an intrauterine device (IUD). It improves symptoms by reducing a woman's period or stopping it completely. Pregnancy is also avoided.
- Gonadotropin Releasing Hormone Agonist – For women who wish to get pregnant, the doctor may prescribe a gonadotropin-releasing hormone (GnRH) agonist.
This medicine prevents the body from making the hormones causing ovulation, menstrual cycle, and the growth of endometriosis. This treatment causes a temporary menopause like phenomenon.
After stopping the medications, the periods return and the woman has a better chance of getting pregnant.
- Hormone Therapy (Birth Control Pills) - Birth control pills are effective in reducing the pain associated with endometriosis. Hormonal medication may also slow down the growth and proliferation of the ectopic endometrial tissue and prevent new implants of endometrial tissue.
However, hormonal therapy does not provide a cure for endometriosis. There may be a recurrence of symptoms following discontinuation of treatment.
In addition, this therapy cannot be used in women who wish to conceive.
Forms of hormonal therapy include oral pills, hormonal patches, injections, vaginal rings and intra-uterine devices.
- Danazol causes suppression of the growth of the endometrium by blocking the formation of ovarian-stimulating hormones, thus preventing menstruation and the symptoms of endometriosis. This drug is not generally the first choice as it causes more severe side-effects compared to hormonal therapy. It can also cause damage to the fetus and women are advised against becoming pregnant while on danazol.
- Conservative Surgery – Surgery is usually undertaken when symptoms are severe, hormones are not providing relief or if the woman has fertility issues. Through laparoscopic surgery, the doctor removes the endometrial tissue present in the abnormal locations. Following surgery, hormone therapy may be resumed unless the patient is trying to conceive.
- Assisted reproductive techniques like in-vitro fertilisation (IVF) may be used to help the patient have a baby.
- Hysterectomy involves surgical removal of the uterus and cervix. Both the ovaries may have to be removed (oophorectomy) to reduce chances of recurrence. This is because the estrogen produced by them may continue to stimulate any residual endometrial tissue and cause persistence of symptoms. If the ovaries are retained, endometriosis is less likely to return if the ectopic endometrial implants are also removed along with the hysterectomy.
Hysterectomy is not suitable for women who wish to get pregnant.
- Exercise regularly and reduce intake of caffeine and alcohol to alleviate endometriosis symptoms.
- Consult a gynecologist and have regular check-ups to monitor progress/control of disease.
- Warm baths and heating pads may help reduce pain and cramping by relaxing the pelvic muscles.
In addition to medical therapy, trying out alternative treatments and taking the recommended dietary supplements may help in alleviating pain and discomfort associated with this condition.
Endometriosis - References:
- Endometriosis - (https://en.wikipedia.org/wiki/Endometriosis)
- Endometriosis - Definition - (http://www.mayoclinic.org/diseases-conditions/endometriosis/basics/definition/con-20013968)
- What is endometriosis? - (http://www.womenshealth.gov/publications/our-publications/fact-sheet/endometriosis.html)
- Know More About Endometriosis - (http://www.acog.org/Patients/FAQs/Endometriosis)
- More Information on Endometriosis - (http://www.endometriosisassn.org/endo.html)
- Robbins and Cotran Pathologic Basis of Disease, 9th edition
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Dr. Lakshmi Venkataraman. 2021. Endometriosis - Causes, Symptoms, Diagnosis, Treatment. Medindia, viewed Jan 29, 2023, https://www.medindia.net/patients/patientinfo/endometriosis.htm.
Latest Publications and Research on Endometriosis
- Patient perceptions of misdiagnosis of endometriosis: results from an online national survey. - Published by PubMed
- Ulipristal Acetate Prior to Surgery for Endometriosis. - Published by PubMed
- Preoperative Ultrasound Indications Determine Excision Technique for Bowel Surgery for Deep Infiltrating Endometriosis: A Single, High Volume Center. - Published by PubMed
- [Ovarian stimulation: complications caused by thoracic endometriosis]. - Published by PubMed
- Ignored Because It Is Benign - It Is Time to Treat Endometriosis as if It Were Cancer. - Published by PubMed
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