What to do? Endometriosis

Endometriosis can cause painful periods, persistent pain in the pelvic area, infertility, and other symptoms. The symptoms can range from mild to severe. Treatment options include painkillers, hormone treatments, and surgery.

What is endometriosis?

The endometrium is the tissue that lines the inside of the womb (uterus). Endometriosis is a condition where endometrial tissue is found outside the uterus. It is ‘trapped’ in the pelvic area and lower tummy (abdomen) and, rarely, in other areas in the body.

endometriosos

Who gets endometriosis?

The exact number of women who develop endometriosis is not known. This is because many women have endometriosis without symptoms, or with mild symptoms, and are never diagnosed.

Investigations to diagnose endometriosis are only done if symptoms become troublesome and are not eased by initial treatments (see below). Estimates vary so that from about 1 in 10 to as many as 5 in 10 of all women develop some degree of endometriosis.

If symptoms develop they typically begin between the ages of 25-40. Sometimes symptoms begin in the teenage years. Endometriosis can affect any woman. However:

  • Sometimes it runs in families. Therefore, endometriosis is more common in close blood relatives of affected women.
  • Endometriosis is rare in women past the menopause, as to develop endometriosis you need oestrogen, the female hormone. Oestrogen levels fall after the menopause.
  • The combined oral contraceptive pill (often called ‘the pill’) reduces the risk of developing endometriosis. This protective effect may persist for up to a year after stopping ‘the pill’.

What causes endometriosis?

There have been several theories over the years. One theory was that some cells from the womb (uterus) lining (the endometrium) get outside the uterus into the pelvic area. They get there by spilling backwards along the Fallopian tubes when you have a period.

Currently we do not know what causes endometriosis. Most experts agree that there are many responsible factors, possibly including genetic, immunological, and hormonal reasons.

Patches of endometriosis tend to be ‘sticky’ and may join organs to each other. The medical term for this is adhesions. For example, the bladder or bowel may ‘stick’ to the uterus. Large patches of endometriosis may form into cysts which bleed each month when you have a period. The cysts can fill with dark blood; this is known as ‘chocolate cysts’.

What are the symptoms of endometriosis?

Patches of endometriosis can vary in size from the size of a pinhead to large clumps. Many women with endometriosis have no symptoms. If symptoms develop they can vary, and include those listed below.

In general, the bigger the patches of endometriosis, the worse the symptoms. However, this is not always the case. Some women have large patches of endometriosis with no symptoms. Some women have just a few spots of endometriosis, but have bad symptoms.

  • Painful periods: The pain typically begins a few days before the period and usually lasts the whole of the period. It is different to normal period pain, which is usually not as severe, and doesn’t last as long.
  • Painful sex. The pain is typically felt deep inside, and may last a few hours after sex.
  • Pain in the lower abdomen and pelvis: the pain is constant, but is usually worse on the days just before and during a period.
  • Difficulty becoming pregnant: This may be due to clumps of endometriosis blocking the passage of the egg from an ovary to the Fallopian tube. Sometimes, the reason for reduced fertility is not clear.
  • Other symptoms include pain on passing poo (faeces), pain in the lower abdomen when you pass urine, and, rarely, blood in the urine or faeces. Very rarely, patches of endometriosis occur in other sites of the body. This can cause unusual pains in parts of the body that occur at the same time as period pains.

How is the diagnosis of endometriosis confirmed?

The symptoms caused by endometriosis can be caused by other conditions. Therefore, if any of the above symptoms become persistent then tests are usually advised to find the cause of the symptoms. Endometriosis is usually confirmed by laparoscopy (key hole surgery). This is a small operation that involves making a small cut, under anaesthetic, in the tummy (abdominal) wall below the tummy button (umbilicus). A thin telescope-like instrument (a laparoscope) is pushed through the skin to look inside. Patches of endometriosis can be seen by the doctor.

How does endometriosis progress?

If endometriosis is left untreated, it becomes worse in about 4 in 10 cases. It gets better without treatment in about 2 in 10 cases. For the rest it stays about the same. Endometriosis is not a cancerous condition.

Complications sometimes occur in women with severe untreated endometriosis.

For example, large patches of endometriosis can sometimes cause a blockage (obstruction) of the bowel or of the tube from the kidney to the bladder (the ureter).

What are the aims of treatment?

The main aims of treatment are to improve symptoms such as pain and heavy periods, and to improve fertility if this is affected. There are various treatment options and I make these decision in close consultation with patients depending on the pain symptoms, fertility plans and quality of life.

Not treating as an option

If symptoms are mild and fertility is not an issue for you then you may not want any treatment. In about 2 in 10 cases, symptoms go without any treatment. You can always change your mind and opt for treatment if symptoms do not go, or become worse.

Medical treatment for endometriosis

  • Paracetamol, Ibuprofen, codeine are acceptable pain relief.
  • Hormonal treatment can also be given to help with symptoms and will include combined oral contraceptive pills, Mirena Intrauterine system, and GnRH analogue.

Surgical treatment for endometriosis

A key-hole surgery is the gold standard for the correct diagnosis of this problem. This is the only way currently to look inside the abdomen and take a biopsy to confirm endometriosis. Surgery also provides the opportunity to remove the visible disease from inside. There are randomized trails conforming that removal of endometriosis helps to reduce the pelvic pain, pain with sex and also improves the fertility rate.

Severity and type of symptoms may influence the choice of treatment.

Some women with endometriosis have no symptoms, and need no treatment. If symptoms are mild, painkillers alone may be fine. Hormone treatments usually work well to ease pain, but do not improve fertility. Surgery may be needed if infertility is caused by endometriosis.

Age and plans for pregnancy

Symptoms often improve during pregnancy. Also, the longer you have endometriosis, the greater the chance of reduced fertility. You may need to take this into account if you have plans for having children. If your family is complete, your treatment options will be wider.

Mr Raza is a highly experienced Gynaecologist surgeon to carry out key-hole surgery for endometriosis. If you have any further question or want to arrange an appointment, please email pa@chelseawellwomen.co.uk