Endometriosis

Overview

Endometriosis is a common gynecological problem and it is one of the major causes of infertility in women. In fact, it is reported in as many as 40% of women with fertility problems. Typically, it involves the abnormal growth of inner uterine lining or endometrium in locations outside of the uterus. Patients describe this as a very painful condition.

It can affect women of any age, although it is seen to occur more frequently in those of reproductive age. Symptoms can appear at any time following the onset of menses and last until menopause. Symptoms have been known to persist even after menopause particularly if there is significant scarring of pelvic tissues and organs.

What Is Endometriosis?

Endometriosis is a gynecological disorder in which the endometrium or tissue forming the inner lining of the uterus begins to encroach into other locations outside of or around the uterus. Typically, this involves the ovaries, fallopian tubes, the cavity behind the uterus and the inner lining of the pelvic cavity. In severe cases, this condition may extend to the bowels or bladder as well. It is also possible, although extremely rare, for other parts of the body such as the diaphragm or skin to be affected. These growths (known as endometrial implants) are not malignant. Instead, they behave exactly as the inner lining of the uterus normally does.

In other words, they undergo changes associated with the menstrual cycle. As the cycle progresses, the implants thicken with blood and then break down. The discarded inner lining of the uterus is normally expelled through the vagina. This is what causes menstruation. However, ectopic endometrial tissue has no outlet and hence cannot be expelled. It accumulates and irritates the surrounding tissues and organs, causing inflammation and swelling accompanied by severe pain. Eventually, cysts appear on the ovaries and lesions can develop in the pelvic lining. The formation of scar tissue can even cause organs to become stuck to each other.

How Does It Develop?

It is not as yet known why endometriosis occurs. A number of theories have been put forward as to what causes endometrial tissue to grow outside of the uterus.

• One possible explanation is that endometrial cells might get introduced into the fallopian tubes or pelvic cavity by means of a backward flow of menstrual blood. The reverse flow of menstrual blood is not uncommon but the presence of other factors such as impaired immunity can increase the risk of displaced endometrial cells becoming firmly implanted.
• It is also believed that under certain conditions, particularly under the influence of hormones such as estrogen, other types of cells such as those of the pelvic lining may become transformed into endometrial cells.
• Having an impaired immune response which is unable to recognize and destroy ectopic endometrial growths, allowing them to persist and develop into implants.
• Following a surgical procedure such as a Caesarean section or a hysterectomy, it may be possible for endometrial cells to become implanted in the incision.

Certain risk factors are recognized in connection with endometriosis:

• Having a close female relative with this disease can increase one’s own chances fivefold.
• Irregular menstruation raises the probability of developing endometriosis.
• Having a late first pregnancy or having no history of pregnancy at all.
• Early onset of menses and delayed onset of menopause.
• Having a low body mass index.
• Consuming alcohol.
• Pre-existing gynecological disorders affecting the uterus or causing obstruction in the normal elimination of menstrual blood.
• Having an excess of the hormone estrogen.
• A history of having undergone surgical procedures such as hysterectomy or Caesarean section.
• A previous ectopic pregnancy.

How Do I Recognise The Signs?

The first signs of endometriosis may be felt some years after menarche (onset of menses). Some women experience no symptoms. Otherwise, the main complaint associated with endometriosis is extreme pain. Patients often report a pain far exceeding that of menstrual cramps in severity. Symptoms are particularly intense around the time of menstruation and intensity can vary from one month to the next. Symptoms can also subside temporarily during pregnancy. The following is a list of possible clinical indications:

• Severe pain in the pelvic region around the time of menstruation.
• Pain may also be experienced during or post vaginal intercourse.
• Excessive menstrual bleeding.
• Menstrual period lasting longer than 7 days.
• Spotting or minor bleeding between periods.
• Pain during urination or during bowel movements. This is more likely to occur around the time of menstruation.
• Blood may appear in the urine during menstruation.
• Lowered fertility.
• Fatigue.
• Constipation or diarrhea.
• Bloating.
• Nausea.

Are There Different Stages of Endometriosis?

The American Society for Reproductive Medicine has developed a scheme for identifying four stages of endometriosis. This scheme is based on diagnostic findings. Severity is graded based on the location, extent, and depth of endometrial implants, the extent of adhesions and cysts on the ovaries. Grading does not correlate with the intensity of symptoms that the patient may experience. Nor does it correlate with the extent to which the patient’s fertility may be affected. For instance, women with only mild endometriosis may actually experience severe pain. The four grades are:

• Minimal: Endometrial implants are fairly shallow, generally located on the ovary, and the resultant lesions are small.
• Mild: Slight lesions associated with shallow implants on the ovary and pelvic lining.
• Moderate: Deep implants on the ovary and pelvic lining. The resultant lesions are larger and more in number.
• Severe: Deep implants on the ovary and pelvic lining, accompanied by severe lesions on the fallopian tubes and bowels.

What Are The Complications That Could Arise?

This disorder is known to be one of the top causes of infertility in women. It can physically hamper the movement of sperm or ova through the reproductive tract or even damage them. In less severe cases, however, the patient may be able to conceive and successfully carry a baby to term.
The formation of scar tissue can cause adhesions when one section of injured tissue comes into contact with another and binds together. For instance, an ovary might become stuck to the pelvic wall. Women with endometriosis are at a higher risk of developing certain forms of cancer, particularly endometriosis-associated adenocarcinoma.

What Tests Help To Diagnose Endometriosis?

Endometriosis is often diagnosed when a patient seeks medical help for infertility. Alternatively, the symptoms may be mistaken for those of primary dysmenorrhoea, pelvic inflammatory disease or irritable bowel syndrome. The patient’s family history may provide an indication of a possible case of endometriosis.

The first stage of diagnosis involves a pelvic examination. The physician may be able to feel lesions during a vaginal examination. This may be followed by a transvaginal ultrasound which helps detect abnormalities like cysts on the ovaries. This technique cannot, however, detect peritoneal lesions or scar tissue. Hence, a minimally invasive procedure known as laparoscopy in order to obtain visuals of the inside of the pelvic cavity. This procedure allows the collection of tissue samples for a biopsy which will help confirm a diagnosis of endometriosis.

Treatment and prevention

Treatment – depending on the severity of the symptoms that the doctor will decide if medication will be provided or a surgery would be done.

• Pain medications – the doctor may suggest taking over-the-counter pain medications to help ease period cramp pains.
• Hormone therapy – supplemental hormones are effective in reducing or eliminating the pain of endometriosis at times. The rise and fall of hormones during the menstrual cycle cause endometrial implants to thicken, break down and bleed.
• Constructive surgery – in case you are trying to get pregnant, surgery to remove as much endometriosis as possible while preserving the ovaries and uterus can increase chances.
• Hysterectomy – in severe cases of endometriosis, surgery to remove the uterus, cervix and both the ovaries is the best treatment.

Prevention – since there is no sure shot cure for this condition. There are certain risk factors that can help you understand if you have or will develop endometriosis –

• Starting your period at a young age.
• Short menstrual cycle.
• Low body mass index (BMI)
• Uterine abnormalities.
• Any medical condition that prevents the normal passage of menstrual flow out of the body.

References