Endometriosis
What is Endometriosis?
Endometriosis is a common and often painful condition affecting between 10% and 20% of women at some point in their reproductive life. The tissue that normally lines the uterus (the endometrium) is found in sites outside the uterus. This is commonly found on the ovaries, and the lining covering the pelvic organs (peritoneum). It can also involve the uterus, bowel, bladder, utero-sacral ligaments (fibrous tissue that helps to hold the uterus in place) and in the Pouch of Douglas (an area between the uterus and the bowel). Rarely, endometriosis can be found in other parts of the body.
Endometriosis develops on the surface of tissue or organ(s) where it has been deposited, can grow and causes inflammation. These implants (deposits) respond to female hormones such as oestrogen in the same way as does the lining of the uterus (endometrium), however, when these implants bleed the blood cannot escape from the body during a period, so it bleeds directly onto the surface of the surrounding organs and tissues. This causes irritation which leads to inflammation, scarring and, sometimes, the development of adhesions between organs so that they stick together. On the ovary, the patches can increase in size and burrow in to form cysts, known as a chocolate cyst or an endometrioma.
Endometriosis can have a major impact on a woman's quality of life with the symptoms interfering with relationships, work, and family life. There is often a delay in diagnosing endometriosis and consequently some women have symptoms for up to 12 years before treatment is started.
What causes endometriosis?
Menstruating (bleeding) backwards through the fallopian tubes could be a source of endometrial cells reaching the pelvis and pelvic organs, and implanting. However there are numerous other theories as to how endometriosis can develop, and the cause(s) of endometriosis are not fully understood.
What are the Symptoms of Endometriosis?
Many women do not have any symptoms or signs of endometriosis, and the first clue that they have this condition is when their specialist performs a telescopic examination (laparoscopy). The commonest symptoms are infertility and pain. There can be severe pain during menstruation (dysmenorrhoea), pain when the penis penetrates deeply into the vagina when making love (deep dyspareunia), longstanding (chronic) pelvic pain, and pain on ovulation or when you have a bowel movement (dyschezia). Rarely, there can be symptoms involving your bladder or bowel including bleeding, which vary in intensity during the menstrual cycle.
How is Endometriosis Diagnosed?
Occasionally your family doctor or specialist may be able to see endometriosis by examining you. This would include finding endometriosis in your vagina, in a scar from past surgery or by feeling "nodules" of endometriosis when doing a vaginal or rectal examination. Such "nodules" can be more easily felt if your doctor examines you whilst you are menstruating. Other findings that can suggest (but not confirm endometriosis) are if your doctor finds your uterus to be retroverted (tilted backwards) and fixed (immovable) or there are tender swellings in your pelvis on examination. However, these findings can also be confused with other conditions. An endometriotic cyst on your ovary (endometrioma) can be detected by doing an ultrasound examination; however, other types of cyst can have a similar appearance.
In the majority of circumstances, the "gold standard" for diagnosing endometriosis is by performing a laparoscopy (a telescopic examination of the pelvic organs under anaesthetic). You can find out more about laparoscopy by going to the Bubtree web page entitled Fertility Surgery.
What are the Treatments for Endometriosis?
The following summary is a general guide to treatment, and individual management is best decided after consulting with a specialist who has a great deal of experience in managing endometriosis. The best treatment depends upon whether your primary goal is to become pregnant or to treat pain. For both situations, an accurate diagnosis by laparoscopy and surgical treatment of endometriosis is the gold standard of initial care. Whilst in general in-vitro fertilization success rates are somewhat lower in women with endometriosis, pregnancy rates man be improved by pre-treatment for 3-6 months with certain medication. Otherwise, where the primary goal is to become pregnant, the available evidence suggests that treatment with medication is not helpful. After appropriate initial management, in-vitro fertilization remains the single most effective treatment for endometriosis associated with infertility.
Where the primary goal is to manage pain, initial diagnosis and treatment should usually involve laparoscopy (surgery), and various medicines can be helpful. Where treatment is primarily by medication, symptoms often recur after these medicines are stopped. After surgical treatment, some women benefit from an approach to treatment that can help to prevent the recurrence of symptoms for a period of at least three years. If there is an endometriosis containing cyst on an ovary (endometrioma), the best surgical treatment is usually to remove the lining ("capsule") as part of surgical treatment.