What is endometriosis?

Endometriosis is a relatively common condition where tissue behaving similarly to the tissue covering the inner surface of the womb (endometrium) is found in locations outside the womb.

This ectopic, as it is called, tissue can be found in various body parts, such as:

• the ovaries and the fallopian tubes
• outside the womb
• the peritoneum (the inner lining of the tummy that is)
• the bowel, bladder and rarely even in the lung

Endometriosis is more common between the ages of 25 and 40 and is uncommon in women having entered menopause.

What are the symptoms of endometriosis?

Endometriosis is a chronic disease with a wide range of symptoms. Some women can have very intense symptoms interfering with every day life activities and others may have no symptoms at all.

The most common symptoms are:

• heavy or painful periods
• pain in the pelvis, lower abdomen or lower back
• pain during or after sexual intercourse
• irregular bleeding between periods
• difficulty in achieving a pregnancy

In most women the pain is located between their hips, high in the legs. Some women experience constant pain. The intensity of the symptoms has more to do with the location than the actual size of the lesion. In fact, a small lesion can be more painful than a large one.

What are the causes of endometriosis?

There is no clear evidence on the exact causes of endometriosis. Several theories have been proposed that are concisely presented below:

Retrograde menstrual period flow

That happens when the period blood flows “backwards” and through the fallopian tubes is spilled into the abdomen instead of leaving through the vagina. Consequently, the endometrial tissue is implanted on abdominal organs. However, in clear contrast, very few women will get endometriosis from the retrograde period flow.

Inheritance

It is believed that there is some kind of inheritance involved in endometriosis since it has been observed that the disease is more common in the sisters and mothers of those women that have endometriosis. That probably signifies that there are some genes that contribute in the disease.

Dissemination with the circulation and the lymph nodes system

Despite been unexplained, it is believed that endometrial cells can enter the blood circulation or the lymphatic vessels (that connect the body’s lypmh nodes) and travel to remote organs such as the lung, the eye and the brain.

Immune system disorders

There is a theory that, in some women, the body cannot ‘clear’ the endometrial cells effectively. In many women with endometriosis it has been shown that their resistance (immunity) is impaired to other conditions as well.

Metaplasia

Metaplasia is the process where cells of one type transform into cells of another type in order to adapt better to the environment. It is believed that some cells located in the pelvis have maintained this ability and, for example, after the period influence they transform into endometrial cells.

What are the endometriosis consequences?

Main endometriosis complications include the difficulty or inability ot get pregnant (subfertility). In some cases, adhesions and cysts (fluid- filled sacs) can develop in the ovaries.

Fertility issues

Endometriosis can damage the ovaries and the fallopian tubes, causing subfertility. Despite that, up to 70% of women with mild to moderate endometriosis will eventually get pregnant without any treatment.

Medical treatment cannot improve fertility. Surgical removal of the lesions might be beneficial but it is not guaranteed that a woman can then achieve pregnancy. If a natural conception is not possible, then IVF techniques increase the pregnancy rates even though they are, generally, lower when compared to other women.

Adhesions and ovarian cysts

Endometriosis can cause:

• adhesions, areas of tissue caused by endometriosis that can make adjacent organs to “stick” together
• ovarian cysts, also called chocolate cysts. These cysts contain fluid and blood and can substantially grow in size and also be very painful
• a combination of both if endometriosis is on or near the ovaries. Both adhesions and cysts can be removed surgically although they might reappear in the future.

How is endometriosis diagnosed?

After discussing with you about your symptoms, a complete medical history that includes questions about any menstrual disorders, your period and any complaints during intercourse is taken. To complete the picture, a pelvic examination will be performed in order to evaluate the presence of any adhesions or cysts.

Ultrasound

Ultrasound is not very good in identifying endometrial implantations and is not helpful in the diagnosis of adhesions. However, it can evaluate the mobility or fixation of internal organs.

Ultrasound is extremely useful in identifying endometrial cysts (endometriomas). Endometrial cysts features include:

• homogeneous, localised lesions that contain low echogenicity elements and have characteristic ultrasound appearance
• endometrial (or chocolate) cysts are usually found on one side only. Rarely, they can be on both sides and have internal septations
• multiple cysts
• wall nodules. If these nodules are hyperechogenic (bright white) then it is more possible that the cyst might be an endometrioma
• no internal vascularisation
• absorption (unlike functional cysts) is not possible

In the image following you can see the characteristic ultrasound appearance of an endometrial cyst of a case we dealt with. The pattern of the cyst content and the lack of any vasculature inside thw cyst are evident. The case was successfully treated by laparoscopy.

MRI

MRI has increased specificity to diagnose endometrial cysts. Therefore, it may have a role in evaluating cysts and their response to treatment. Increased cost and difficulty to repeat the test limit its use.

Laparoscopy

Laparoscopy is the gold standard to diagnose endometriosis. It can also be the best treatment modality since it allows meticulous excision of endometrial cysts, protecting the rest of the ovary. Protected. Moreover, with extensive laparoscopic surgery, the pelvis can be cleared from endometrial nodules found scattered in the pelvis.

How is endometriosis treated?

The indicated treatment is chosen based on each woman’s individual needs. General treatment directions include an effort to achieve:

• pain relief
• minimisation of endometrial growth tissue
• improvement of fertility
• elimination of endometriosis relapse risk

The exact treatment choice will be decided after discussing with you about your needs and factors that will influence the decision include:

• your age
• if your main symptom is pain or difficulty getting pregnant
• if you wish staying pregnant, because some treatment options will not permit pregnancy
• if you would consider a surgical operation
• if you have already used some treatment in the past

If your symptoms are mild, or if you do not have any sub fertility issues, or if you are close to menopause and symptoms will soon get better, you may not need any treatment at all.

In 30% of the cases, endometriosis can improve without any intervention but it is is more common (40%) that the condition will worsen with time. One of your options is, if you wish so, to manage endometriosis conservatively and to intervene if symptoms aggravate.

Pain management

Non- Steroid- Anti Inflammatory- Drugs (NSAID) like ibuprofen and naproxen are relatively successfulParacetamol, alone or in combination with codeine can be helpful in less severe cases.

Hormonal treatment

The purpose of hormonal treatment is to reduce or completely eliminate the estrogen production in your body, which are the hormones stimulating the endometrial lesions. Without estrogen, endometrial lesions are expected to shrink somewhat, thus improving symptoms. Nevertheless, hormonal treatment does not have an impact on adhesions and cannot improve sub fertility.

Commonly used hormonal medications include:

• the combined contraceptive pill (known as “the pill”)
• intrauterine device (spiral) that releases progestagen (LNG-IUS, Mirena)
• substances similar to the gonadotrophins releasing hormones (GnRH analogues)
• progestagen

Each one of these methods has its own side effects, but similar effectiveness. These treatment options forbid pregnancy (in fact, the first two ones are officially licensed as contraceptive methods). Progestagens are not currently used often any more.

The contraceptive pill and endometriosis

The contraceptive pill contains the combination of the hormones estrogen and progestogen. It helps to ease the symptoms and can be used for many years. Blood loss during periods becomes less and the pain diminishes as well.

Progesterone releasing Intrauterine System (LNG- IUS, Mirena)

The Mirena IUD (spiral) can be easily inserted into the uterus and it releases progestagen for many years. This way, the inner lining of the womb (endometrium)gets thinner and both the period pain and blood loss decrease. In some cases, the periods can stop altogether. After placing the IUD, it can stay in place up to five years. Possible side effects include irregular bleeding for up to 6 months, breast tenderness and acne.

Progestins

Progestins are synthetic hormones that act as the naturally produced by the body hormone progesterone. Progestins make the inner lining of the womb (called endometrium) become thinner. Consequently, the period blood becomes less. In the same way, progestins prevent the endometrial tissue from growing fast. Their efficiency is comparable to the contraceptive pill. Lately, dienogest is increasingly used in treating endometyriosis.

The commonest side effects are: bloating, mood changes, irregular bleeding between periods and body weight gain.

Importantly, progestins cannot offer contraception.

Substances similar to the gonadotrophins releasing hormones (GnRH analogues)

GnRH analogues are synthetic hormones that cause, temporary, artificial menopause since they reduce the body estrogen production. Symptoms caused are similar to the menopausal ones (hot flashes, vaginal dryness, decrease in libido). This substances are administered for a short period of time (maximum duration of 6 months) and sometimes, supplementary hormones are supplied in order to assist with the caused symptoms. After discontinuation of the therapy, endometrial symptoms may relapse.

Surgical treatment

Surgical methods can be used to remove or destroy endometrial lesions which can prove beneficial for fertility and for symptoms reduction. Surgical options include:

• laparoscopy, the commonest and less interventional method
• laparotomy (open surgery)
• hysterectomy (removal of the womb)

Laparoscopy

Laparoscopy is performed through small skin cuts (incisions) and the whole operation is performed by using a camera and instruments. Endometrial tissue is either removed or destroyed. The operation is performed under general anesthesia. Endometrial cysts can also be removed with laparoscopy. Results using laparoscopy have been shown to be beneficial for fertility, even though problems may appear in the future again, particularly if the endometrial tissue has not been completely removed.

Laparotomy

Laparotomy is an open surgery method in order to remove the lesions. It is the preferable mode of treatment in severe and extensive disease or if the pelvic organs are “stuck” to each other. The incision line is on the bikini line and the operation is performed under general anesthesia. Recovery is slower compared to laparoscopy.

Hysterectomy

Hysterectomy (removal of the womb) is a major operation and discussion about it should only be reserved for those women that have decided they do not wish to have any more children and other treatment methods have failed. Hysterectomy is only rarely needed since the other methods usually suffice. Besides, hysterectomy cannot guarantee that the endometrial symptoms will not continue.

In conclusion, endometriosis is a disease with a great impact on a woman’s quality of life. However, there are ways to ease the presenting symptoms and to diminish any discomfort caused by this chronic disease. Discussing together about your individual needs and complaints will ensure that you will make the right management choice.