Endometriosis

 

What is endometriosis?

 

Endometriosis is when the lining of the womb (endometrium) is present on other organs inside your body. Endometriosis usually involves the ovaries, the fallopian tubes and the lining of your pelvis. It may also involve the bowel in a condition known as rectovaginal endometriosis. Rarely it is found in organs outside the pelvis such as the diaphragm or the lungs.

 

This displaced endometrial tissue continues to behave like it usually does; it thickens and bleeds with every menstrual cycle. As it cannot leave your body it becomes trapped, continuing to grow. If it is in the ovaries, it may cause the formation of cysts known as endometriomas. The surrounding tissues may become inflamed, irritated and form scar tissue causing the pelvic organs to stick to each other. Women with endometriosis usually have pain and difficulty getting pregnant; or they may have no symptoms at all. 

 

It is estimated that 10% of women suffer with endometriosis. 50% of women with difficulty conceiving and around one third of the women with pain have endometriosis. Endometriosis is rare in girls before they start their periods.

 

 

What are the symptoms of endometriosis?

 

Endometriosis symptoms tend to be related to your period, and are therefore "cyclical". The most common symptom is pain. When a woman with endometriosis has her period the endometrium (lining of the womb) outside the womb bleeds. This blood irritates the organs in the pelvis and creates inflammation.

 

Other common symptoms are:

 

  • Painful periods: Pain and cramping that start during the week leading up to your period. It may continue for several days during your period. The pain sometimes radiates to your lower back and down your legs.

  • Pain during intercourse: This is a very common symptom.

  • Pain during bowel movement: If the bowel is affected by endometriosis then going to the toilet may be painful, especially during the period.

  • Subfertility: Endometriosis makes it difficult to conceive in 2 ways:

    • The fallopian tubes are blocked or trapped in scar tissue, making it very difficult to pick up and transfer the egg after ovulation.

    • Inflammation creates a hostile environment for the ovulation, fertilisation and implantation processes.

  • Non-specific symptoms: Tiredness, bloating and nausea are all common. 

 

It is important to remember that the severity of the symptoms is not necessarily related to the stage of the disease. Sometimes minimal endometriosis is more painful than severe.

 

Endometriosis sometimes co-exists with other conditions. These conditions may be originating from the bowel such as irritable bowel syndrome (IBS) or from the bladder such as interstitial cystitis. They all share similar symptoms, making the diagnosis of endometriosis very challenging.

 

How is endometriosis diagnosed?

 

The gold standard for the diagnosis of endometriosis is a laparoscopy and biopsy of any suspicious areas. Before jumping into surgery however, it all begins with a detailed medical history. We are interested in your symptoms, their length, any factors that may make them worse, their relation to your period. If the suspicion of endometriosis is raised then tests that help making the diagnosis of endometriosis are:

 

  • Pelvic examination: Tenderness on the womb or the ovaries is usually present. Cysts in the ovaries may be present and identified as well as  scar tissue behind the womb. 

  • Ultrasound: The most accurate method for the assessment of the womb and ovaries is the transvaginal ultrasound scan. A thin probe is inserted in the vagina and with the use of ultrasound waves, it creates images of the womb and ovaries. Mild, superficial  endometriosis can not be seen but endometriomas (endometriotic cysts in the ovaries) can be identified.

  • Magnetic Resonance Imaging: MRI scans use a magnetic field to create detailed images of the inside of the body. It is useful prior to an operation to excise severe endometriosis, to identify where the endometriotic nodules are (but it can't see mild disease).

  • Laparoscopy (Keyhole Surgery): Laparoscopy involves up to four small cuts in the abdomen. A telescopic microscope (called a laparoscope) is inserted into the body through the belly button, to help diagnosis or treatment. A laparoscopy and excision of the suspected endometriotic lesion is the gold-standard  to make the diagnosis of endometriosis.

 

 

How is endometriosis treated?

 

With either medications or surgery. The decision relies on a variety of reasons mainly previous treatments and your wishes for  fertility.

 

The medical treatment options include:

 

  • Painkillers: A combination of paracetamol and NSAIDS (nonsteroidal anti-inflammatory drugs) such as ibuprofen, diclofenac or naproxen usually helps to ease the period pain. 

  • Hormonal contraceptives: The oral contraceptive pill or the vaginal ring may control the hormones responsible for endometriosis. Taking the pill back to back for three months rather than every month,  helps sometimes to reduce the frequency and the severity of painful periods. Progesterone only contraceptives  such as the Mirena coil, the implant, the injection or the mini-pill, can stop the periods and the growth of endometriosis, temporarily improving  symptoms.

  • Gonadotrophin-releasing agonists (GnRH): These injections cause temporary menopause and  dramatically improve the endometriosis-related pain. They have many side effects however including hot flushes, night sweats and if they are prescribed for more than six months, they may cause ostoporosis (thinning of the bones). To minimise the side effects, an add-back hormone replacement therapy is usually prescribed.

 

If the medical management has not been effective, then surgery is the next option. Not only it can be used to diagnose endometriosis, it can also be used to treat it. The most common procedures are:

 

  • Laparoscopic excision of endometriosis: If you have endometriosis, then keyhole surgery to remove the lesions and/or the endometriomas improves pain and also the chances of success in getting pregnant. Even in severe cases the excision can be completed through keyhole surgery.

  • Hysterectomy with removal of the ovaries: If everything else has failed and you have completed your family then this is the final option. This way the oestrogen stimulation of the endometriosis stops.  Removing the ovaries will make you menopausal, and HRT is strongly recommended to improve your quality of life.

 

 

Things to remember

 

  • Endometriosis is a condition that can severely impact on quality of life.

  • The stage of the disease is not necessarily related to the severity of the symptoms.

  • Many years many pass until the diagnosis is made.

  • The gold standard for diagnosis is a laparoscopy and biopsy.

  • Treatment aims at  improving quality of life and fertility

Hampshire Women's Health

The Candover Clinic

Aldermaston Rd

Basingstoke

RG24 9NA

07864 628038

The Hampshire Clinic

Basing Rd, Old Basing

Basingstoke

RG24 7AL