Endometriosis

CONDITION

What is endometriosis?

Endometriosis is a condition where the endometrium that generally lines the uterus, grows in other locations. Endometriosis may cause adhesions on the uterus. The uterus can become stuck to the ovaries, fallopian tubes and bowel.

What is the percentage of population affected by endometriosis?

One in 10 women are affected by endometriosis.

How does endometriosis affect you?

The two main problems that endometriosis can cause are:

  • Pain
  • Infertility

Which part of the body is affected?

The female reproductive system is made up of the following parts:

  • Vagina: opening of the reproductive system, which allows the entry of sperm
  • Cervix: narrow region that connects the vagina to the uterus
  • Uterus: womb, where a fertilised egg implants and grows to develop into a baby
  • Ovaries: organs on either side of the uterus, which release an egg each month in the prospect of a pregnancy
  • Fallopian tubes: narrow tubes that open out at the ovaries to pick up the released egg for fertilisation

The uterus is made up of three layers – The innermost layer is called the endometrium, the second layer, myometrium and the third layer, the serosa. Every month, the endometrial layer is built and thickens in preparation to accept the fertilised egg for implantation and provide nourishment to the growing embryo, until birth. If the egg does not get fertilised, the layer of tissue that is formed sloughs off and passes out in the form of your monthly period.

What are the causes of endometriosis?

Although the exact cause is not certain, some of the possible explanations may include:

  • Retrograde menstruation: back flow of menstrual tissue
  • Transformation of peritoneal cells or cells that line the abdomen into endometrial cells
  • Transformation of embryonic cells during puberty
  • Attachment of endometrial cells to a surgical incision
  • Transport of endometrial cells by the blood or lymph system
  • Immune system disorder that fails to recognise endometrial cells growing in other organs as abnormal

Who is at risk of endometriosis?

Some of the common factors that could increase your risk of developing endometriosis are:

  • Never giving birth before
  • Early puberty (start of your first period)
  • Late menopause
  • Short menstrual cycles
  • Higher levels of oestrogen or greater exposure to oestrogen in your lifetime
  • Low body mass index (BMI)
  • Alcohol intake
  • Family history
  • Medical condition that stops the normal outflow of period
  • Uterine abnormalities

What are the signs and symptoms of endometriosis?

The symptoms of endometriosis vary widely from woman to woman and the severity of symptoms is not necessarily related to the severity of the condition. While some women have few or no symptoms, others experience severe and incapacitating pain that recurs each month for many years. Endometriosis is characterised by:

  • Pain during periods (dysmenorrhoea)
  • Pain with intercourse (dyspareunia)
  • Pain during urination or bowel movements
  • Heavy bleeding
  • Bowel disturbances – including painful bowel motions, diarrhoea, constipation, bleeding from the bowel
  • Difficulty getting pregnant
  • Painful urination
  • Lower back, thigh and/or leg pain
  • Premenstrual syndrome (PMS)

Many women think that painful periods are normal. If you have bad period pain, you should see Dr. Alex Polyakov. The anticipation of recurrent pain or discomfort each month may also lead to feelings of anxiety, stress and depression. It is important to acknowledge these emotional difficulties that may arise from endometriosis.

What are the related disorders that occur with endometriosis?

Endometriosis can be associated with infertility and ovarian cancer.

What are the stages of endometriosis?

There are four stages (stage I to IV) of endometriosis based on the location, size, depth and extent of its implantation into the foreign tissue, presence of scar tissue and its severity, and the presence and size of endometrial tissue in the ovaries. The stages do not determine the extent of pain or other symptoms, or chances of infertility.

Superficial implantation with mild scarring are classified under minimal or mild stage. Moderate and severe forms of endometriosis are characterised by cysts and severe scarring. Stage IV endometriosis is characterised by infertility.

How is endometriosis diagnosed?

When you present to your doctor’s clinic with severe pelvic pain, your medical history is reviewed and a thorough physical examination performed. Your doctor may perform a retrovaginal exam by inserting a gloved finger into your vagina to feel for cysts or scars. An ultrasound or transvaginal ultrasound may be ordered to view the reproductive organs for cysts.

The standard diagnosis for endometriosis is a laparoscopic procedure, where a lighted tube called a laparoscope is inserted into your pelvic region through your belly button. The images captured by the camera on the laparoscope are relayed on a big screen for your doctor to see clearly. A biopsy or a sample of the suspected tissue is removed for further examination and confirmation of endometriosis.

Is diagnosis needed?

Diagnosis with the laparoscopic method may not be required in most cases. Your doctor may diagnose endometriosis just by your symptoms, a physical exam and an ultrasound. If you do not intend to get pregnant immediately, you can discuss the need for an invasive procedure such as laparoscopy.

TREATMENT

What are the consequences of not treating endometriosis?

Left untreated, endometriosis can remain as it is or become more severe. Mild forms of endometriosis may improve with time and most often resolve after menopause. Your decision to treat or not to treat is based on balancing the effects of endometriosis on your life and the risks of treatment.

When should I consider watchful waiting of endometriosis?

Your doctor may suggest watchful waiting if you have mild endometriosis, to observe the course of the disease and if you are approaching menopause.

What are the treatment options for endometriosis?

There is no cure for endometriosis but pain relief and pregnancy can be achieved by the following methods:

  • Medication: these can be in the form of
    • Hormonal: oral contraceptive pills and progesterone (a female hormone) administered orally, as an injection, through an intrauterine device or device inserted under your skin
    • Non-hormonal: pain relievers, NSAIDs
  • Surgery:
    • Conservative surgery: to remove endometrial implantations
      • Laparoscopy
      • Laparotomy
    • Radical surgery: to remove the uterus, cervix and ovaries
      • Hysterectomy

Often, surgery is combined with medical therapy either before the procedure to decrease the size of the lesion or after, to lower the chances of recurrence.

What are the alternative treatments for endometriosis?

Some of the alternate treatments for endometriosis are:

  • Physiotherapy
  • Acupuncture
  • Herbal therapy
  • Nutritional approaches
  • Homeopathy
  • Psychology

Apart from medication and surgery, chronic pain also benefits from clinical psychology, where you can learn various strategies to cope with pain and manage associated problems such as anxiety, stress, mood swings and depression.

Am I candidate for surgery?

You may be considered for surgery to treat endometriosis if you

  • Suffer from severe pain that is not relieved with conservative methods
  • Suffer from infertility because of endometriosis and decide to get pregnant

What are the indications of the different types of surgeries?

Your surgeon will consider conservative surgery when you wish to get pregnant in the future. Laparoscopy is usually the first approach considered for conservative surgery. Laparotomy is suggested only if the endometriosis is extensive, severe and the anatomy is distorted as some of the organs get stuck together.

Radical surgery on the other hand is performed in severe cases, when you do not wish to have any children.

How do I prepare for surgery?

Before endometriosis surgery, you will be advised not to eat or drink anything for six hours prior to your procedure. You may be given a solution to drink to clear your bowels.

How is surgery performed?

Surgery can be performed by the following methods:

Laparoscopy

The laparoscopic procedure when performed for diagnosis can be continued to treat the endometriosis as well. This is a minimally invasive surgery that is performed with the help of a laparoscope, which is a thin long lighted tube with a camera attached. The laparoscope can be inserted at the surgical site through a tiny incision made on your skin. The images captured on the camera can be relayed on a large monitor for your surgeon to view. A harmless gas is injected to inflate the abdomen, allowing for a clear view of the organs.

Two more small incisions are made to allow the insertion of other surgical instruments such as a laser to excise or cauterise the endometrial implants (destroy with intense heat and seal off the blood vessels). Scar tissue may also be removed. Your surgeon ensures that the surrounding healthy organs are not harmed.

Laparotomy

This involves the removal of the endometriosis tissue through a long incision made along the bikini line. It is more invasive than the laparoscopic procedure. Sometimes, a laparoscopic procedure gets converted into a laparotomy in the event of a surgical complication.

Radical surgery

Hysterectomy is a radical surgery that involves the removal of the uterus. Oophorectomy is a radical surgery that involves the removal of the ovaries.

Bowel resection

Bowel resection is performed if the bowel has also developed endometriotic adhesions. Your surgeon may perform one of three depending on your condition:

  • If the endometriosis lesion is small, it can be shaved off, leaving the bowel intact.
  • A circular section of the bowel containing the endometriosis can be cut and the resulting hole closed.
  • For deeper endometriosis, a section or segment of affected bowel is excised and the remaining sections of the bowel are re-joined.
  • In case of complications such as leakage at the region of the bowel that is re-joined, a process called colostomy may be performed temporarily, where the excised end of the colon is diverted to an opening created in the abdominal wall.

Depending on the recurrence of endometriosis, you may require repeat surgeries.

What are the advantages and disadvantages of the different types of treatments?

While hormonal therapy can help easily relieve pain, many may not help you become pregnant and may be associated with side effects such as acne, cramps, hot flushes, mood swings and weight gain.

When considering surgery for the treatment of endometriosis, the minimally invasive laparoscopic procedure is associated with certain procedure-related advantages such as:

  • Smaller incisions
  • Less post-operative pain and discomfort
  • Faster recovery
  • Shorter hospital stay
  • Earlier return to normal activities
  • Smaller scars
  • Minimal internal scarring
  • Provides a definite diagnosis
  • Ascertains long-term relief in 70% of women
  • Does not require long-term use of medication

However, it may not be useful to treat all forms of endometriosis and it has a recurrence rate of 30%.

Laparotomy may be able to treat more extensive endometriosis and related complications but is associated with risks and complications of an open surgery and disadvantages such as:

  • Longer recovery
  • More post-operative pain
  • Larger scar formation when compared to laparoscopy

Hysterectomy helps achieve a 90% cure long-term, without the need for medications, but the biggest disadvantage is the inability to achieve pregnancy. You may also need hormone replacement therapy if your ovaries are also removed.

What are the outcomes of endometriosis surgery?

Surgery cannot cure endometriosis. It can offer significant but short-term pain relief. However, removal of deep endometriosis tissue can lead to long-term pain relief.

What are the potential complications of endometriosis treatment?

As with most treatments, the various treatments for endometriosis can be associated with certain side effects and complications such as:

  • Endometriosis medication can cause side effects such as bleeding, bloating, nausea, skin changes, elevation in BP, weight gain and depression.
  • Surgery can be associated with complications such as damage to nearby organs or large blood vessels, infection, bleeding or blood clots.

What is the prognosis of endometriosis treatment?

Endometriosis treatment cannot completely cure endometriosis, but long-term prognosis of endometriosis treatment should consider three important parameters:

  • Management of symptoms
  • Rate of recurrence
  • Achievement of pregnancy

Endometriosis can recur, necessitating repeat surgery or management with hormone therapy. However, most patients can experience a good quality of life and conceive with treatment. In some cases, you may have to consider IVF to help you get pregnant.

What is the cost of endometriosis surgery?

Any costs involved will be discussed with you prior to your surgery.

What is the likelihood of endometriosis recurrence? How can it be managed?

While surgery is effective in alleviating pain, endometriosis can recur 40% of the time after conservative surgery. Thus, ongoing medical treatment is recommended. The chance of recurrence is more in severe cases.

How can endometriosis be prevented?

Since the exact cause of endometriosis is not certain, it is not clear how the condition can be prevented.

What are the lifestyle recommendations to manage pain related to endometriosis?

Regular exercise, relaxation, rest, meditation, hot water bottle, warm baths and eating healthy to prevent constipation can help relieve pelvic cramping and pain.

What is the current research regarding endometriosis treatment?

Extensive research is being done to find better treatment options for endometriosis. Some of the recent studies are listed below:

  • Aznaurova YB, Zhumataev MB, Roberts TK, Aliper AM, Zhavoronkov AA. Molecular aspects of development and regulation of endometriosis. Reprod Biol Endocrinol. 2014; 12: 50.
  • Morotti M, Vincent K, Brawn J, Zondervan KT, Becker CM. Peripheral changes in endometriosis-associated pain. Hum Reprod Update. 2014 Sep-Oct; 20(5): 717–736.
  • Hughes CL, Foster WG, Agarwal SK. The Impact of Endometriosis across the Lifespan of Women: Foreseeable Research and Therapeutic Prospects. Biomed Res Int. 2015; 2015: 158490.