Endometriosis

Endometriosis is defined as the presence of normal tissue in an abnormal place. The endometrium (lining) of the uterus spreads to the pelvis through the tubes and settles most commonly in the pelvis. Like the lining of the uterus, the endometrium grows under the influence of the major female hormone oestrogen. The most common sites in the pelvis are on and below the ovaries, and deep in the pelvis behind the uterus, called the Pouch of Douglas. Here the endometriosis grows on the ligaments behind the uterus and on the vagina and rectum. It also may grow on the bladder, appendix, abdominal wall and even sometimes in the upper abdomen.

Remember:- Endometriosis is an abnormal occurrence with no definite reason.

The risk of endometriosis increases with the early onset of periods, heavy prolonged, frequent periods and family history of endometriosis. A daily exercise regime and the use of oral contraceptive pills helps reduce the risk of the disease. Additionally, pregnancy has been proved to reduce the risk too.

Usually, your menstrual history itself is enough to make a diagnosis. Any cyclical symptom may indicate the presence of the disease. Please note:-

• Increasing menstrual pain is a common indication of the development of endometriosis. The pain may prevent normal work or social activities
• The pain may be different from the more common form of menstrual pain which tends to decrease as one grows older
• The pain may be present both in the middle and sides of the abdomen and may not respond well to any painkillers

You should seek medical advice whenever:-

• You experience lower abdominal pain at ovulation or before the period
• Bowel and bladder pain particularly around the time of menstruation
• Frequent need to empty the bladder along with diarrhoea or constipation, particularly around the time of menstruation
• Tenderness in the lower abdomen
• Pain during intercourse
• Unable to conceive (infertility)

Laparoscopy with removal and examination of the affected tissue is the only definitive way of diagnosing endometriosis.

Ultrasonography can detect only ovarian cysts whereas CT and MRI cannot detect the condition fully.

Infertility may be the only symptom in women with endometriosis. Though the disease often commences in the teens, unfortunately diagnosis in young women is often delayed because of difficulty in distinguishing endometriosis from the more common type of menstrual pain. Excess of prostaglandins and the hesitation of doctors to perform a laparoscopy to detect the disease contribute to delayed diagnosis

Endometriosis is commonly associated with 30% of women who have infertility. Endometriosis causes infertility in different ways.

• If the endometriosis damages the tubes and the ovaries then this will significantly reduce the womans ability to conceive as the movement of egg and sperms will not be normal.
• Even if the tubes and ovaries are not damaged, endometriosis can still affect the movement of sperms, egg pick up by the tube, egg fertilisation, embryo growth and implantation.
• Key points
• There are many women who live with symptoms for many years before diagnosis of endometriosis is made.
• If endometriosis remains undetected and untreated for long, it may cause severe damage to the pelvic tissues.
• It is important to seek medical help as early as possible whenever you suspect suffering from any of the symptoms of endometriosis.
• Diagnosis through laparoscopy and treatment of endometriosis is the best way to prevent infertility.

• Medical therapy (oral contraceptive pills, GnRh agonist injections) has a role in controlling the symptoms, but do not offer longstanding regression or cure. They also cannot improve chances of conception and carry the risk of unwanted side effects.
• The surgical philosophy in recent times has moved towards a complete removal rather than simple burning of the lesion. To a certain extent endometriosis may be likened to an iceberg and burning treats superficially leaving residual disease deep in the tissue.
• Excisional surgery has a 70% to 80% chance of substantial pain relief with an increase in fertility rates with the best results even in the most severe conditions. Most of these procedures can be done via laparoscopy.

• Severe pain during periods requiring multiple pain killers could be endometriosis
• Definitive diagnosis of endometriosis is only done by laparoscopy
• Fertility rates improve after surgical management
• Laparoscopic excisional surgery for endometriosis has better results for pain and infertility