What is Endometriosis?

Endometriosis is a disorder of the female reproductive system, where endometrial tissue (the normal lining of the uterus) is found in areas other than the uterus.The most common place to find it is on the ovary, the back of the uterus and the ligamentous supports that hold the uterus in its normal position (uterosacral ligaments). It can also be found on the thin lining of the pelvic organs (the peritoneum), on the tubes, between the vagina and rectum (rectovaginal septum), in or on the bladder, in abdominal scars from previous surgery and even as far away from the pelvis as the lung!

Each time that you have a normal period, this endometriosis also does, and this leads to cyclical swelling, stretching of tissues, inflammation and scarring. Eventually all the scarring and inflammation can lead to symptoms even when you're not having a period.

• Endometriosis is not an infection.
• Endometriosis is not contagious.
• Endometriosis is not cancer.

What causes endometriosis?

The exact causes of endometriosis are still not fully understood. There are several theories behind this.

Retrograde menstruation: Normally during a period the menstrual blood comes out of the cervix and into the vagina. In some women a small amount of blood flows backwards down the fallopian tubes and into the pelvic cavity. This blood contains tiny seedlings of the lining of the womb - endometrium. It is not known why in some women this might implant and lead to endometriosis, but not in others.

Symptoms of Endometriosis

Pain is the major symptom, though its intensity may vary. It may be experienced as a sharp stabbing pain, a constant or intermittent dull ache, or as a severe cramping pain.

• Pelvic pain caused by endometriosis can be very variable. It may be like a dull ache, or may be more severe. It can be more localized into the rectum (back passage) or cause urinary symptoms.
• Painful periods are often the first sign of endometriosis. The pain usually begins a few days before the period is due and continues throughout the period.
• Pain during intercourse is often worse with a particular position and especially with deep penetration.
• Infertility

Other symptoms

Although the above problems are most common, some women experience other symptoms related to where endometriosis might have implanted:

• painful bowel movements during menstruation, or when passing wind
• bloating
• diarrhoea or constipation
• painful and frequent urination, or bleeding when passing water during the time of the period
• 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.

Who gets Endometriosis?
Endometriosis can occur at any time from the onset of menstrual periods until the menopause. It is extremely rare for it to be first diagnosed after the menopause. For the majority of women the condition ceases at the menopause.

It is more common in women whose relatives have endometriosis, in women who have cycles shorter than 28 days and those who typically have a period lasting longer than a week.

Diagnosis

The only way to diagnose endometriosis is by a laparoscopy. This is where a small telescope (a laprascope) is passed through the umbilicus to gain access to the pelvis. A picture of the pelvis is viewed on a TV screen and the presence of endometriosis and its stage assessed.

Treatment

Options for treatment may include no treatment at all (if the symptoms are tolerable), drug therapy or surgery.

Contraceptive pill/Hormonal Treatments

Hormonal treatment aims to stop ovulation and allow the endometrial deposits to regress and die. They either put the woman into a pseudo-pregnancy or pseudo-menopause.

Drugs used include:

Contraceptive pill

• Combined Oral Contraceptive Pill
• Mirena Coil

The Pill is one of the most commonly used treatments for endometriosis, and is a good choice for young women with mild disease who also require effective contraception.

Progestogens
 

• Medroxyprogesterone (Provera)
• Norethisterone (Primolut)
• Dydrogesterone (Duphaston)

Progestogens works by thinning out and shrinking down the endometriosis and also by suppressing the normal cycle of the ovary.

GnRH analogues
 

• Leuprorelin (Prostap)
• Goserelin (Zoladex)
• Nafarelin (Synarel)
• Buserelin (Suprecur)

GnRH stands for Gonadotrophin Releasing Hormone is a drug that acts the same way as the body's own hormone. The body normally makes GnRH in a small gland in the brain (the pituitary) and it is this hormone that stimulates the ovary to develop eggs and produce oestrogen, leading to the normal menstrual cycle.

Danazol is a drug that was once used as first-line medical treatment for endometriosis and it is effective in 80-90% of cases. Fortunately, there is now good evidence demonstrating other drugs as equally effective, as Danazol can have some quite unpleasant side effects. It works by preventing ovulation and reducing oestrogen levels as well as having a directly suppressive effect on the endometriosis itself. Gestrinone works much the same way as Danazol but with milder side effects.

All the hormonal treatments have side effects. These vary in different women

Surgery

Surgical treatment for endometriosis is usually carried out in one of the following situations:

• At the time of diagnosis for mild to moderate endometriosis
• If medical treatment hasn't worked
• If subfertility is a problem
• If there is moderate to severe endometriosis, particularly with endometriomas
• When endometriosis recurs

Surgery can either be conservative or radical. The aim of conservative surgery is to return the appearance of the pelvis to as normal as possible. This means destroying any endometriotic deposits, removing ovarian cysts, dividing adhesions and removing as little healthy tissue as possible.

Radical surgery means doing a hysterectomy with removal of both ovaries and is reserved for women with very severe symptoms, who have not responded to medical treatment or conservative operations. Sometimes, if there are other reasons to carry out a hysterectomy it is done earlier than this.