Endometriosis
Endometriosis is a gynaecological condition caused by the presence of endometrial cells outside the uterus. It is known to be a leading cause of infertility in women. There is no known cure, but there are plenty of treatment options for combating symptoms.
Endometriosis is an often painful condition that affects millions of women worldwide. Even so, there is a lack of information in the general public and it can take years and many consultations to be accurately diagnosed. This is also partly due to the normalisation and minimisation of women’s pain.
Every month, the lining of a woman’s uterus—the endometrium—thickens in preparation for a potential pregnancy. In the absence of a fertilized egg, this lining is shed as period blood. A woman suffering from endometriosis will have endometrial–like tissue growing outside the uterus. The tissue acts just like the endometrium in the uterus: it thickens, disintegrates, and is shed with each menstrual cycle, but because the tissue has no way to exit the body, it becomes trapped. This can cause lesions, nodules, or cysts, as well as inflammation, which can lead to the formation of fibrous scars and adhesions connecting neighbouring organs.
Endometriosis mostly affects women, however, in rare cases it is also found in men. There have been at least twenty reported cases of male endometriosis in which similar abnormal tissue was found—mostly attached to the bladder, lower abdominal wall, and inguinal region.
Symptoms
A number of symptoms can be caused by endometriosis, however, the severity of the symptoms doesn't always indicate the seriousness of the condition.
The most common symptom is pain, including:
- Very painful menstrual cramps, abdominal pain, and lower back pain, often flaring up around the time of your period—this pain can become more severe over time.
- Chronic pain in the lower back and pelvis
- Pain during or after sex — this is usually described as a ‘deep’ pain and is different from pain that can be felt at the entrance to the vagina during penetration
- Intestinal pain
- Painful bowel movements or pain when urinating during menstrual periods—in rare cases there may also blood blood in the stool or urine
Other symptoms include:
- Digestive problems—diarrhea, constipation, bloating, or nausea, especially during menstruation
- Heavy bleeding—occasional heavy periods or spotting between periods
- Infertility—sometimes endometriosis is first diagnosed when seeking treatment for infertility
Causes
Despite being a common and persistent problem, there is not yet a clear understanding of what causes endometriosis. Some women report not being taken seriously when relating the symptoms they experience. This results in delayed diagnosis and prolonged suffering. Some prejudice among healthcare professionals remains, however the situation is steadily improving.
Possible causes include:
- Transformation of peritoneal cells. Hormones or immune factors may promote the transformation of peritoneal cells—the inner lining of the abdomen—into endometrial-like cells.
- Transformation of embryonic cells. Hormones such as estrogen may transform embryonic cells—cells in the earliest stages of development—into endometrial-like cell implants during puberty.
- Surgery. During a surgery, such as a hysterectomy or C-section, endometrial cells may be transported by accident and attach to a surgical incision.
- Endometrial cell travel. The blood vessels or lymphatic system may carry endometrial cells to other parts of the body, e.g. during retrograde menstruation (blood flowing back into the pelvis during menstruation), something that occurs to most women to some extent.
- Genetic factors. Because endometriosis runs in families, it may be an inherited condition.
- Hormones. The hormone estrogen appears to promote endometriosis. Studies are looking into whether endometriosis is caused by a problem with the body's hormonal system.
Endometriosis usually develops several years after the onset of menstruation. It is thought that there may be an increased risk for women who start menstruating at an early age. The length and intensity of the menstrual cycle may also be linked to the development of the disorder, but further research is needed.
Some conditions exacerbate endometriosis, while others temporarily soothe symptoms. For example, a weakened immune system may be unable to recognize and destroy endometrial-like tissues growing outside the uterus, leaving them to grow and cause problems. Having higher levels of estrogen or a greater lifetime exposure to estrogen produced in the body are also considered possible risk factors.
On the flip side, symptoms temporarily lessen during pregnancy, and women who have given birth have a lower risk of developing the disorder. Going through menopause at a later age (60–65) increases the risk of endometriosis as the body continues to produce estrogen, but symptoms have been known to disappear completely after menopause.
Possible complications
The most common side effect of endometriosis is infertility. This can present itself in a number of ways: damage to the fallopian tubes, hormonal changes, pelvic inflammation, adhesions, an impaired immune system, or damage to the eggs.
Even so, many women suffering from endometriosis can still conceive and carry a pregnancy to term. As the condition can worsen over time, a woman is more likely to have a successful pregnancy when she is young.
Endometriosis itself is benign, however links have been made between endometriosis and ovarian cancer. Although rare, endometriosis-associated adenocarcinomas can develop later in life.
Diagnosis
Endometriosis can go untreated for years if improperly diagnosed. There are some tests that can help identify existing endometriosis.
Pelvic exams
During a pelvic exam, your doctor checks the pelvis for abnormalities, such as cysts or scars. Small areas of endometriosis may go unnoticed unless they have caused a cyst to form.
Ultrasound uses high-frequency sound waves to create images of the inside of your body. To capture the images, a device called a transducer is either pressed against the abdomen or inserted into the vagina. For a more complete view of the reproductive organs both types of ultrasound may be used. Standard ultrasound imaging test won’t provide a definitive diagnosis, but it can identify cysts associated with endometriosis, known as endometriomas.
Magnetic resonance imaging
An MRI uses a magnetic field and radio waves to create detailed images of the organs and tissues within the body. An MRI can help with surgical planning, providing detailed information about the location and size of endometrial implants.
Laparoscopy is a type of surgery, and the only way to be completely sure whether or not you have endometriosis. During a laparoscopy, a surgeon makes a tiny incision next to the navel and inserts a slender viewing instrument, or laparoscope, that can identify signs of endometrial tissue outside the uterus.
A laparoscopy can show the location, extent and size of endometrial implants. Your surgeon may take a tissue sample for further testing. Often, with proper surgical planning, endometriosis can be fully excised during the laparoscopy.
Treatment
A crucial step in relieving the symptoms of endometriosis is to maintain a healthy lifestyle. Many women with chronic pelvic pain find relief in regular physical activity.
Some foods have been shown to increase the symptoms, such as:
- Foods high in trans fatty acids, a form of unsaturated fat found mostly in fried or highly processed food;
- Red meat. Some studies have indicated that a high intake of red meat causes increased risk of endometriosis;
- Gluten.
Over-the-counter pain medication, such as ibuprofen or naproxen, are sometimes recommended to ease the symptoms.
Another option is hormone therapy.
The rise and fall of hormones during the menstrual cycle causes endometrial tissue to thicken, break down, and release. Hormone medication may slow the growth of endometrial tissue and prevent new growth. This is not a permanent solution—once the treatment is stopped, the pain is likely to return.
A combination of pain medication and hormone therapy can be effective in relieving or eliminating pain caused by endometriosis. However, this isn't recommended if you’re trying to conceive.
Hormonal contraceptives (such as birth control pills, vaginal rings, or patches) help control the hormones responsible for the accumulation of endometrial tissue. Many women report lighter and shorter menstrual flow when using a hormonal contraceptive. Continuous cycle regimens in particular may reduce or eliminate pain.
Gonadotropin-releasing hormone (Gn-RH) agonists and antagonists are drugs that block the production of ovarian-stimulating hormones, lowering estrogen levels and preventing menstruation. This causes endometrial tissue to shrink. As these drugs create an artificial menopause, taking a low dose of estrogen or progestin along with Gn-RH agonists and antagonists may decrease menopausal side effects (such as hot flashes, vaginal dryness, and a decrease in bone density). Monthly bleeding and the ability to get pregnant return when the therapy is discontinued.
A variety of progestin therapies, including contraceptive injections, contraceptive implants, IUDs with levonorgestrel, or progestin pills can stop menstruation, which also stops the growth of endometrial implants, relieving symptoms.
Aromatase inhibitors are a class of medicines that reduce the amount of estrogen in the body. Your doctor may recommend using an aromatase inhibitor together with progestin or a combination hormonal contraceptive to treat endometriosis.
Surgery is usually recommended if pain medication cannot relieve the symptoms or if the patient is unable to take the recommended medication. In more severe cases, especially if the condition affects the intestines, bladder, ureters, or pelvic nerves, surgery is usually suggested.
Surgery may be the preferred treatment if:
- Your diagnosis of endometriosis is too uncertain to start another kind of treatment;
- You are experiencing problems conceiving;
- You have, or are believed to have, an ovarian endometrioma.
Your doctor may perform a laparoscopy or, in more severe cases, traditional abdominal surgery. Most people can be treated with laparoscopic surgery.
The takeaway
As with any condition, your best chance of recovery is with early diagnosis. Regular check-ups and a good gynecologist can help with this. Endometriosis can be hard to manage, and finding the treatment that is best suited to your needs can take some time, but knowing your options is an important first step.
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