Definition & Pathology

Endometriosis is a disorder of unknown cause affecting 10-20% of women of menstruating age. Patches of endometrial tissue (tissue lining the uterus) appear beyond the uterine cavity in sites such as the ovaries, fallopian tubes, bladder and the tissues lining the pelvis.

These endometrial foci, although ectopic or displaced continue to act as normal endometrial tissue would during menses. That is, that they respond to hormones, and during menstruation they thicken, breakdown and then bleed on a cyclical basis. Bleeding from the ectopic endometrial foci becomes trapped and the surrounding tissues may becomes irritated or inflamed causing scar tissue to form, sometimes as bands of fibrous tissues (adhesions) between organs/structures in the abdomen. This problem can cause pelvic pain, especially during a menstrual cycle.

As the disorder progresses, the ectopic tissue tends to gradually increase in size and may spread to other locations. This varies in each individual. Also, the tissue may remain on the surface of the structures or may penetrate deeply forming nodules. Endometriosis may be classified as mild, moderate or severe depending on the amount of Endometriosis seen and the level of the scarring present.

Causes

Although the cause of Endometriosis is not fully understood, it is more common in women who have a family history of the disorder, have shorter than normal cycles but with bleeding lasting longer than average and in white or Asian women. Because Endometriosis is hormonal dependent, it is not seen before puberty and regresses during pregnancy (temporarily) and after the menopause.

Symptoms

Not all cases of Endometriosis cause symptoms. However, the majority of women suffering from Endometriosis usually experience pain in the lower abdomen and pelvic area, especially just before and during menstruation. Painful sexual intercourse is also a common symptom. Painful bowel movements and diarrhoea/constipation or bladder symptoms may also occur if the disease involves segments of the intestine or bladder. Bloating and fatigue are also common. In addition to these symptoms, approximately 30-40% of women with Endometriosis also have trouble getting pregnant. Furthermore however, almost 40% of women with infertility are later discovered to have Endometriosis even in the absence of any other symptoms.

Diagnosis

Because the symptoms of Endometriosis may vary widely, other conditions causing similar symptoms, may sometimes be mistaken for Endometriosis. This is partly why Endometriosis is not always easy to detect. Although a history of symptoms and positive physical examination may highly suggest Endometriosis, they are not diagnostic. The only certain way to diagnose Endometriosis is by visualisation +/- biopsy of the pelvic cavity. This is done by Laparoscopy.

Although a Laparoscopy is the definitive diagnostic test when Endometriosis is suspected, other tests, apart from a physical examination, may be performed to confirm the suspicion before doing a Laparoscopy. These tests may include a pelvic ultrasound and other imaging tests. However, usually only moderate to severe disease is positively suggested via imaging.

Treatment

There are many different options by which to treat Endometriosis. The treatment approach that you and your choose must take into account the extent and location of the disease, the severity of symptoms, your age, any reproductive plans, duration of the fertility problems and your lifestyle needs. Treatments are aimed at eradicating endometriotic foci, improving and lessening symptoms and optimising fertility. It is important to note, however, that because Endometriosis is a chronic condition, recurrence can occur, even years later.

Treatment for Endometriosis usually includes a combination of pain medications, hormonal therapy, surgery and natural therapies.

Pain Medications

Pain medications may be recommended to help control pain. These usually involve various over-the-counter analgesics or anti-inflammatory drugs. However, prolonged use of analgesia may have negative side effects and may also become less effective with time as your body becomes accustomed to it. Also, if the maximum dose of the analgesia has already been reached without providing adequate symptom control, other treatment options should be sought.

Hormonal Therapy

Hormonal therapies are based on the fact that endometrial foci, like normal endometrium, respond to hormones (oestrogen and progesterone), and as such are never seen before puberty and regress during pregnancy and after the menopause. In other words the disease state is improved through the suppression of menstruation, and treatments involve suppression of a woman’s menses.

Hormonal therapy may be used as adjuvant therapy pre-or-post surgery, to optimise lasting results.

It is important to note that hormonal therapies may produce side effects. Individual responses do vary. The type and degree to which a woman may respond is also highly dependent on which hormone therapy is being taken. In addition, there may be a recurrence of symptoms after stopping treatment.

Surgery

Anatomical factors such as adhesions, cysts endometriomas and involvement of pelvic organs require surgery as these cannot be eliminated or dissolved by hormonal therapies. In addition, surgical treatment of Endometriosis is believed to increase the chance of pregnancy in women with reduced fertility due to Endometriosis.

The goal then of surgical management for Endometriosis is to remove and repair as many anatomic factors as possible caused by the disease.

Conservative Surgery

Conservative surgery removes endometrial foci, scar tissue and adhesions without removing your reproductive organs, thereby improving symptoms whilst maximising fertility. This is usually done Laparoscopically.

Rarely, a Laparotomy (open surgery) may be required. Laparotomies, although once popular, have been superseded by the more advanced Laparoscopic technique, which is preferred as it has many advantages over Laparotomies including:

• Avoidance of large painful skin incision
• Less blood loss
• Less tissue trauma
• Less post-operative pain
• Less post-operative adhesion formation
• Shorter hospital stay and convalescent period
• Less cost

These advantages culminate to give an overall reduced morbidity compared to Laparotomy.

Radical Surgery

In rare cases, and only in women with very severe disease who have completed their family or have no fertility issues, a Hysterectomy and Oophorectimes may be indicated.

Fertility Treatment in Endometriosis

Approximately 30 % of women with Endometriosis report difficulty getting pregnant. It is believed that fertility problems in Endometriosis arise because of a release of complex chemicals that interfere with the ability to conceive or with early embryonic development. Adhesions also may contribute to this problem.

Despite these complications, not all women with Endometriosis have difficulty getting pregnant. It may take them longer to get pregnant, but most women with mild Endometriosis can have children unassisted. As Endometriosis tends to worsen with time, thereby reducing chances of becoming pregnant, women are sometimes advised not to delay having a family.

In moderate-severe Endometriosis, Laparoscopic surgery to remove endometrial foci is believed to increase the chance of pregnancy. Assisted reproductive technologies including IVF may also be considered, not only if surgical treatment is ineffective, but also if the woman’s age is at the higher end of the reproductive spectrum, or if the duration of failed conception is protracted (even in mild cases of Endometriosis).