Endometriosis

Symptoms & causes Diagnosis & treatment Doctors & departments Care at Vejthani

Overview

Endometriosis is a disease that affects women globally and is characterized by a formation of tissue that lines the uterus (endometrium) outside of the uterus appearing in the wrong places such as the fallopian tube, pelvic cavity, or ovaries. This can cause extreme pain and affect fertility of women.

Endometriosis is classified from stage 1 to stage 4 according to the amount of endometrial tissue present and how widespread it is in the body. The severity of symptoms does not define the stage of the disease.

Endometrial-like tissue thickens, degrades and bleeds with each menstrual cycle just like the normal tissue but cannot flow out of the body. The pelvis and other body parts may develop scar tissue (adhesions, fibrosis) because of the persistent inflammatory reaction it generates.

If the endometrial-like tissue grows in the ovaries, cystic ovarian endometriosis or endometrioma occurs. If it grows in pelvic peritoneum, it is called superficial endometriosis. If found in the recto-vaginal septum, bladder, and bowel, it is called deep endometriosis. Endometriosis can also be found outside of the pelvis, but this is uncommon.

During the menstrual period, endometriosis can cause severe pain due to inflammation that is increased as well as adhesions and fibrosis. It can also cause fertility problems to arise. However, there are effective treatments to overcome all the problems.

Symptoms

All women of reproductive age are susceptible to endometriosis. Some symptoms may be noticeable, others may not be. Although symptoms are broad and can varies individually, it usually starts with increasing pelvic pain during menstrual period worse than the common menstrual cramps.

Symptoms of endometriosis include:

Painful periods. Also known as dysmenorrhea, is a severe menstrual cramp that start prior and continue for several days during the menstrual period. It is usually felt in the lower abdomen and lower back. In some, the discomfort prevents women to do normal activities.
Painful sexual intercourse. It is common for women with endometriosis to experience pain during or after the intercourse.
Painful bowel movements or urination. Endometriosis can affect the bladder which can cause pain or discomfort in bowel movements and urination particularly during menstruation due to inflamed tissues.
Abnormal bleeding. Women with endometriosis may experience spotting or intermenstrual bleeding in between periods. In some, it can cause a heavy period or excess bleeding.
Infertility. Endometriosis is often discovered unintentionally. It happens when a person who has difficulty getting pregnant, starts to explore possible treatments.
Other signs and symptoms. During periods, women may also experience feeling sick, diarrhea, constipation, nausea, abdominal bloating, depression, or anxiety.

The level of pain and the duration to which the symptoms are experienced cannot accurately predict the severity of endometriosis. Experts cannot determine the exact cause why some cases are severe, and some are not. Or why it is more painful for one but not for the other.

Endometriosis has a broad range of symptoms, often similar to other diseases. In some cases, it can coexist with other conditions which makes the diagnosis more difficult such as with irritable bowel syndrome (IBS). Similarity in symptoms include diarrhea, constipation, and abdominal cramping. With pelvic pain as a common symptom, endometriosis can disguise as pelvic inflammatory disease (PID) or ovarian cysts.

Women who experience symptoms of endometriosis should consult a healthcare provider for better diagnosis.

Causes

Endometriosis has no definite cause. Several hypothesis are:

Retrograde menstruation. Menstrual blood with endometrial cells exits the body through the cervix and vagina during normal periods. In retrograde menstruation, it can return through the fallopian tubes and into the peritoneal cavity instead of flowing out. The cells develop throughout each menstrual cycle. As it sticks through the surfaces of the pelvic walls and organs, it will continue to thicken and bleed. This will increase the chances that endometriosis will develop.
Transformation of peritoneal cells. Hormones or immunological factors activates peritoneal cells to change into endometrial-like cells. If the cells make it to the abdominal cavity, it can lead to endometriosis. This is known as the “induction theory”.
Embryonic cell transformation. Embryonic cells which are still in the early stages of formation can potentially turn into endometrial-like cells especially during puberty. Hormones like estrogen are the major contributor for its transformation.
Surgical scar implantation. Endometrial-like tissue can connect itself to an incision following surgery, such as hysterectomy or C-section.
Endometrial cell transport. Endometrial cells may travel in other areas of the body through the lymphatic system or bloodstream. Lymphatic system is a network of tubes and glands that compose the immune system.
Immune system disorder. Altered or impaired immunity can lead to inability of the body to find and to remove the endometrial-like tissue which has formed outside the uterus.

Risk factors

Development of endometriosis may come from different risk factors, such as:

Early menarche (period before age of 11)
Late menopause
Short menstrual cycles interval (less than 27 days)
Prolonged menstrual flow, longer than 7 days
Never been pregnant
Family history of endometriosis
High level of estrogen in the body
Low body weight
Condition that blocks the menstrual flow
Disorders of the reproductive tract

All menstruating women are susceptible to endometriosis. Typically, endometriosis appears few years after the start of menstruation. Signs and symptoms may vary for every individual. It can potentially become better during pregnancy and may resolve on its own during menopause.

Diagnosis

The doctor will ask for the symptoms experienced by patients and their personal medical history as well as the area of pelvic discomfort. Aside from endometriosis, the will also check for possible illness that causes similar symptoms.

Physical signs of endometriosis can be seen through these tests:

Pelvic exam. This is a physical exam that involves organs in the pelvis area. Usually, the doctor will feel for signs of scar tissue behind the uterus or cysts. Unless a cyst has formed, it is usually not possible to determine smaller areas of endometriosis.
Ultrasound. This test can detect endometriosis-related cysts (endometriomas). Although it cannot confirm if the patient has endometriosis, it can provide a clear image of the reproductive organs beneficial for diagnosis. Ultrasound uses sound waves to produce the images. A tool known as a transducer is used to take the pictures and is either inserted into the vagina (transvaginal ultrasound) to see the uterus, pelvic area and reproductive organs, or placed in the abdomen.
Magnetic resonance imaging (MRI). A precise description of the position and size of the endometrial implants is provided to the doctor through an MRI. This is especially helpful for patients with surgical planning. MRI is a noninvasive procedure that uses magnetic and radio waves which provide precise images of the organs and tissues inside the body.
Laparoscopy. This is a surgical procedure that involves making a small cut in the abdomen area. The surgeon will insert a laparoscope (a tube with a light and a camera) through a small incision near the navel to check the tissues in and around the uterus, and to confirm if there is a growth of endometrial-like tissue. A laparoscopy can reveal details on the placement, size, and extent of endometrial implants. It is minimally invasive and is done under general anesthesia.

During this procedure, the surgeon may take a tissue sample, called a biopsy, for a laboratory examination. The biopsy can confirm endometriosis. Most often, if the surgeon was able to accurately map the endometriosis, and one surgery is enough to completely treat it.

Treatment

There is no one approach treatment for endometriosis. The severity of symptoms and pregnancy goals are some of the factors that will determine the appropriate course of action. Doctors often advise trying the conservative approach first such as medication. If unsuccessful, surgical treatment may be recommended. The goal of the treatment is to manage existing symptoms and resolve fertility issues.

Medication for pain control

Pelvic pain or dysmenorrhea is one of the prevalent symptoms of endometriosis and can be managed by hormone therapy, pain relievers or both. The doctor will prescribe painkillers such as the nonsteroidal anti-inflammatory medications (NSAIDs) ibuprofen, naproxen sodium or aspirin.

Most of these drugs are available over the counter with no prescription. However, it is recommended to consult a doctor first to avoid problematic side effects with long-term use.

Hormone therapy

Hormone therapies are available in managing endometriosis. To change the hormonal conditions that encourage endometriosis. It reduces endometrial tissue growth and stops new endometrial tissue implants. Menstrual cramps can occasionally be lessened or eliminated with the help of additional hormones. However, the symptoms can comeback after discontinued use.

This option is not recommended to those who are trying to get pregnant since it affects the ovulation.

Hormonal treatments include:

Hormonal contraceptives. The hormones that cause the monthly accumulation of endometrial tissue can be regulated with the aid of birth control tablets, patches, and vaginal rings. Using hormonal contraceptives cause lighter and shorter periods. It may help lessen or get rid of painful periods.
Gonadotropin-releasing hormone (Gn-RH) agonists and antagonists. This treatment will lower the estrogen levels, blocking the production of ovarian-stimulating hormones and prevent menstruation which causes the endometrial tissue to degenerate. These drugs temporarily stops the menstrual cycle. Ovulation and menstruation will return after ending the treatment.

The common side effects associated with this treatment are menopausal-type symptoms such as bone loss, vaginal dryness, and hot flashes. Small quantity of estrogen or progestin together with Gn-RH agonists and antagonists are usually recommended to manage the menopausal-type symptoms.

Progestin therapy. Progestin-based treatment stops menstruation and the growth of endometrial-like tissue and provides comfort from symptoms such as pelvic pain. Widely available progestin-based therapies are intrauterine device with levonorgestrel, contraceptive implant, contraceptive injection or progestin pill.
Aromatase inhibitors. These are prescribed in combination with other hormonal treatments such as progestin and other hormonal contraceptive. Aromatase inhibitors suppresses the ovaries which lowers the estrogen level in the body.

Conservative surgery

Conservative surgery is one of the recommended approach in managing endometriosis. This is beneficial for patients with severe symptoms and those planning to get pregnant. The surgery can remove the endometrial-like tissues while keeping the uterus and ovaries intact. However, there is still a chance that the condition and its symptoms may recur.

Conservative surgery is usually done through as laparoscopy or abdominal surgery. Laparoscopic surgery involves making a small cut in the navel to insert a laparoscope and a second small incision for the removing of endometrial tissue. Hormone therapy is suggested to help manage the pain after the surgery.

Fertility treatment

Endometriosis is a known cause of infertility in women. The doctor, with the help of a fertility specialist, can provide a fertility treatment plan suitable to the needs of the patient. The treatment usually aims to find the best option to support a pregnancy. There are a number of treatment options for infertility caused by endometriosis, although success rates can vary. These include laparoscopic surgical excision of endometriosis, ovarian stimulation using intrauterine insemination (IUI), and in vitro fertilization (IVF).

Hysterectomy with removal of the ovaries

Hysterectomy is a surgical procedure for the removal of uterus. It is usually recommended when there are many endometrial and scar tissue present. The procedure aims to provide relief from severe pelvic pain and heavy flow during menstrual period. However, symptoms may still come back even after the surgery. Pregnancy is no longer possible after hysterectomy.

Hysterectomy may still negatively impact one’s health in the long run, even without oophorectomy, especially if the procedure is done before the age of 35. Hysterectomy is normally recommended when less invasive treatments fail.

In some cases, the doctor may advise removal of the ovaries, called oophorectomy, either with or without a hysterectomy. Without the ovaries, menopause sets in. Women with hormone-related pain may find relief after this surgery. However, there will be an increased risk to complications associated with menopause such as risk of heart diseases, certain metabolic conditions, bone loss, hot flashes and early death. If the uterus remains intact, pregnancy after this procedure is still possible through in vitro fertilization.

Endometriosis often requires multidisciplinary treatment in order to manage different symptoms. It is important to find a specialist doctor that has the expertise to provide an effective treatment plan.

Diseases & Conditions Endometriosis