Endometriosis

Endometriosis – what exactly is it?

Endometriosis is a relatively common condition that affects young females giving them chronic pelvic pain and severe dysmenorrhoea (period pains). It affects 10 – 30% of women between the ages of 25 – 35 years but, as it is difficult to diagnose, it is often under-reported.

 

In endometriosis, some of the cells that line the inside of the uterus – the endometrium – find their way into the pelvis. This probably happens through retrograde menstruation, where the period blood, instead of flowing out of the vagina, goes from the uterus, through the tubes into the pelvis and settles on the ovaries or on the peritoneal lining of the abdominal cavity. An altered immune response ensures that these cells remain alive and respond to the cyclical hormonal changes of the month just like the endometrium in the uterus does.  Naturally, this causes irritation and inflammation and leads to the severe period pains. In addition, the inflammation  around these delicate pelvic organs results in scar tissue formation leading to adhesions. Structures like the tubes, the ovaries or the colon, that should be free and mobile, stick to each other. Otherwise, if the site of the endometriosis is the ovary, ovarian cysts result. These are called ‘chocolcate cysts’ as they are full of altered, old blood that has become dark brown in colour.

 

The commonest symptom of endometriosis is pain. Period pains that start before the blood flow, are increasing in severity and are not responding well to pain killers should alert the woman to visit a gynaecologist. Pain however does not directly reflect the severity of the disease as very severe disease can sometimes be pain-free while a few spots of endometriosis can lead to disabling pain. The cyclical nature of the pain may be lost after a time and instead the woman experiences chronic pelvic pain occasionally with deep pelvic pain on sexual intercourse.

Usually there are no abnormal findings on examination although scarring can be felt on vaginal examination sometimes. A pelvic ultrasound and an estimation of the tumor marker CA 125 may indicate that the woman is suffering from endometriosis. Unfortunately, both these tests can miss the condition completely and if the symptoms persist after treatment with pain killers, a diagnostic laparoscopy should be suggested. This is a procedure, performed under general anaesthetic, where 2 small cuts are made, one inside the umbilicus and another 5mm cut lower down, the abdomen is filled up with gas and a telescope is inserted inside the abdomen to have a good look around. Any brown endometriotic spots found can be excised or ‘burnt’ off and the adhesions divided. Ovarian cysts can also be removed while conserving as much of the ovarian tissue as possible. This means that the laparoscopy can also be curative besides diagnostic and the patient can still go home on the same day! Another way of reaching a definitive diagnosis is by open surgery – a laparotomy – where a larger incision is made at the pubic hair line necessitating a longer recovery period.

Besides pain, endometrioses can also lead to infertility. This can happen both as a result of the adhesions that trap the tubes and prevent them from picking up the egg from the ovary as well as from the biochemical changes that occur inside the peritoneal cavity due to the presence of the endometriotic spots. Therefore, adequate treatment is critical and close follow-up is needed as the condition can recur later on in life.

Although surgical treatment is the preferred treatment for endometriosis and the only way to treat ovarian cysts, if the endometriotic spots are few or as an adjunct to surgical treatment, medical treatment can be considered. A ‘period-free’ state is induced through monthly injections that induce an artificial menopause. The side-effects can be quite annoying but lift off once the injections are stopped.

Endometriosis is under-reported as doctors are reluctant to suggest a laparoscopy. Instead, women are asked to pursue pregnancy which may not be acceptable for the woman at the time or may be difficult to achieve. Therefore it is wise for women to take the matter further rather than simply accept a life of disabling pelvic pain until the right time comes for a family! Endometriosis can be very effectively managed in this day and age!