Endometriosis is a painful disorder of the uterine lining that affects approximately 10 to 15 percent of women worldwide during their reproductive age. While it is associated with chronic inflammation, the cause of such inflammation remains unknown. Endometriosis is a heavily researched and studied condition with potential cures being studied in clinical trials yearly.
1. What is Endometriosis?
Endometriosis is a gynaecological disorder that is associated with the growth of endometrial cells also known as endometrial implants-which usually line the uterus-outside of the uterus in places such as ovaries and fallopian tubes. Endometriosis can affect an individual’s ability to perform daily tasks leading to a reduced quality of life. This effect is especially exaggerated if endometriosis affects the organs outside of the pelvic cavity.
2. What causes Endometriosis?
The exact causes of endometriosis are not known. However, there are certain factors known to contribute to the development of endometriosis. While the following factors have helped scientists and researchers formulate different theories, none of them have been able to explain fully how endometriosis develops:
- Genetics: Endometriosis is often hereditary and it affects Asian females more than other races and ethnic groups
- Retrograde menstruation: When women menstruate, it is believed that some menstrual debris flows back up to the fallopian tubes. Anatomically, there is no solid connection between the fallopian tubes and ovaries, instead, there is a small free space that allows the menstrual debris to be released into the pelvic and abdominal cavities. As most menstrual debris is just endometrial cells, this allows these cells to implant outside of the uterus. However, researchers have found that this may not be the only cause of endometriosis as there are women with retrograde menstruation who do not experience endometriosis
- Immune System: A defective immune system may alter the body’s response to ectopic endometrial cells. Alternatively, endometrial cells can travel through the lymphatic system-which is part of the immune system-to settle onto other organs.
3. How do you detect Endometriosis?
While endometriosis does not typically present with symptoms, when it does, some of the symptoms may include:
- Pelvic pain, which worsens just before menstruation and reduces after. This pain is concentrated in areas where the endometrial implants are located and any pressure on those areas can worsen the pain significantly
- Painful sexual intercourse
- Cramping during sexual intercourse
- Pelvic pain during urination or defecation
- Cramping while defecating
- Painful pelvic examinations
The intensity, frequency, and nature of pain differs for all women, with some suffering from pain that progressively worsens while others may suffer from intermittent bouts of pain.
Apart from the debilitating pain, endometriosis can cause infertility, the exact cause of which is unknown. Chronic inflammation as a result of ectopic endometrial implantation may play a role in the narrowing of the fallopian tubes which may alter the processes of ovulation and fertilisation.
Some common symptoms of endometriosis include:
- Irregular or heavy menstruation
- Constipation or diarrhoea
- Lower abdominal pain
- Chronic fatigue
- Blood-tinged urine, especially during menstruation
- If the endometrial implants have made their way to other organs, symptoms related to those organs may be present as well. For example, endometrial implants in the brain can cause seizures and headaches
4. How do doctors diagnose Endometriosis?
The diagnosis of endometriosis begins with a physical pelvic examination performed by a gynaecologist. Pain during the examination and the presence of nodules, which may be felt by the physician, may indicate the possibility of endometriosis, however, this is not enough for a diagnosis to be made.
If endometriosis is suspected, ultrasound imaging is performed to rule out other potential causes of pelvic pain and other associated symptoms. However, this is also not enough for an accurate diagnosis to be made.
Surgical inspection of the pelvic area to directly visualise endometrial implants is the only way to make a definite diagnosis. This surgery is often performed laparoscopically and allows the surgeon to visualise, and take tissue samples of the visible endometrial implants. In cases where no endometrial implants are visible, random tissue samples may be taken to diagnose microscopic endometriosis.
5. How to treat Endometriosis?
There is no definite cure for endometriosis but medical and surgical therapies can be used to alleviate symptoms and enhance fertility and these include:
Most medications aim to manage the pain and slow the progression of the disease by altering cyclic hormone production.
- Non-steroidal anti-inflammatory drugs (NSAIDs): These are over-the-counter painkillers that are effective in relieving the pain associated with menstruation and endometriosis. However, they do not help to reduce the size of the endometrial implants or slow the progression of the disease.
- Gonadotropin-releasing hormone (GnRH) analogs: These work by inhibiting the release of oestrogen from the ovaries mimicking menopause. This hormonal change not only alleviates pain but also reduces the size of the endometrial implants.
- Birth control pills: This is often used by women with endometriosis and severe menstrual pain. It reduces pain but also completely stops menstruation.
- Progestins: Women who do not benefit from birth control or do not wish to take oral contraceptive pills can take progestins instead which are more potent, and slow the progression of the disease significantly.
Surgical therapy is recommended when symptoms become debilitating and/or there are anatomical changes that worsen the symptoms. The two main approaches are:
- Conservative Therapy: This approach includes laparoscopic surgery during which endometrial implants are destroyed or excised but the ovaries and uterus are preserved. This is generally preferred as women suffering from endometriosis are quite young and may not wish to undergo more radical treatment options.
- Radical Therapy: This includes a full hysterectomy in which the uterus, fallopian tubes, and ovaries are removed from the body, in addition to the endometrial implants.
Since the recurrence rate of endometriosis is quite common after surgical intervention, medical therapy is often continued to prevent its recurrence and to manage the associated symptoms.