Endometriosis: what to know
Endometriosis is a gynaecological condition wherein the uterine tissue begins growing in other parts of the body, which can have adverse effects on the patient. In this article, a consultant gynaecologist explains how endometriosis occurs, what the symptoms are, and what treatments are available for patients to explore.
An estimated 15 per cent of people who experience menstruation worldwide are thought to have endometriosis, but this number may be inaccurate, as many people can go on their whole lives without a diagnosis due to a lack of awareness of the condition.
What is endometriosis?
During the menstrual cycle, the period of ovulation involves an increase in oestrogen production, which signals to the endometrium (the uterine lining) to thicken in preparation for the implantation of a fertilised egg. In most cycles, the egg does not become fertilised, which leads to the endometrial tissue breaking down, thus preparing the uterus for the next cycle by exiting through the vagina; this is menstruation.
With endometriosis, the endometrial tissue grows in other parts of the body – most commonly in the pelvic area on the lining of the abdomen, the ovaries, and the fallopian tubes, but it can also reach as far as the lungs and even the heart – and though not in the uterus, it still responds to the oestrogen increase, thickening and then subsequently shedding. However, for this tissue, it cannot easily pass through the vagina and is therefore trapped within the body. Over time, this can lead to the development of internal scarring, tissue adhesion, and cysts, which can be quite painful for patients – but not always. Some patients are asymptomatic and will not know they have the condition until they try to become pregnant.
What are the symptoms of endometriosis?
Symptoms are not universal, but common ones of endometriosis include:
- Long-term pelvic pain
- Abnormally painful menstruation and cramps
- Abnormal menstrual bleeding outside of periods
- Pain with sexual intercourse and vaginal penetration
- Pain with urination and passing stool; constipation or diarrhoea
- Fatigue
- Bloating
Because there is some degree of pain and discomfort associated with even normal menstruation, patients with endometriosis can go a very long time without a diagnosis of endometriosis, instead thinking that their period is just on the ‘extreme’ end of the spectrum.
Does endometriosis cause infertility?
Endometriosis can have a range of effects on fertility, and it will vary from case to case; some women will have no difficulties with conception, whereas others can struggle with:
- Pain during sexual intercourse
- Blockage of the fallopian tubes
- Scarring and inflammation
- Pelvic tissue adhesion
What causes endometriosis?
Endometriosis only develops after a patient has begun to menstruate, so it does not affect prepubescent girls or post-menopausal women. There is no consensus at the moment of what causes endometriosis; leading theories include that of immune system function, stem cell behaviour, genetics, and retrograde menstruation, which suggests that sometimes, the menstrual blood and tissue that is supposed to exit the body instead flows upwards, through the fallopian tubes into the pelvis, where the endometrial cells can spread, attaching themselves to organs and structures and regrowing.
How is endometriosis diagnosed?
The diagnostic investigation for endometriosis typically begins with a pelvic exam and a review of the patient’s symptoms and menstrual experience. Next, there will be further examinations of the pelvis and gynaecological organs, which could consist of a transvaginal ultrasound or an MRI to visualise the interior of the pelvis, which can reveal the unusual tissue structures of endometrial tissue.
A conclusive diagnosis, however, can only be achieved with a laparoscopic procedure, where a surgeon makes a small incision in the abdomen and inserts the small and thin tubular camera, called the laparoscope, to view the inside of the pelvis in real-time and full colour. During this procedure, the surgeon can also take samples of the tissue for analysis (called a biopsy), or initiate treatment by removing some of the damage such as growths and cysts.
How is endometriosis treated?
Currently, there is no cure for endometriosis, and it can only be managed to reduce pain and symptoms. Treatment can be medicinal, surgical, or both. The best treatment plan will be designed with consideration of a patient’s symptoms, age, plans for future pregnancies, and the extent of the tissue growth.
Medication tends to be the first method used for treating endometriosis, such as:
- Painkillers for pain management, like ibuprofen or paracetamol. These can be prescribed or purchased over the counter.
- The combined contraceptive pill, which contains oestrogen and progestin (a synthetic form of progesterone), is used to suppress the ovaries and pause or lighten the period and will thus ease the pain. The hormonal coil can also be used with the same effects.
- Gonadotrophin-releasing hormone (GnRH) antagonists are administered via injection and halt the period entirely by lowering the oestrogen levels in the body. They also help shrink endometriosis-related growths and pain, but can cause menopausal-like symptoms.
If medicinal treatment is unfruitful, the option of surgery is available. Surgery for endometriosis, which can be performed laparoscopically in most cases, can be categorised as either conservative, complex, or radical.
Conservative surgery excises or ablates the endometrial tissue using blades, heat, electricity, or lasers. This has the best chance of preserving the patient’s ability for conception. Complex surgery is needed if there is tissue affecting bladder and bowel function, and requires a multidisciplinary team, such as gastrointestinal surgeons. Radical surgery is for patients who do not want more children (or at all), and is considered only when other treatments have failed, as it is likely to leave the patient infertile, as it involves a hysterectomy and/or an oophorectomy.