ENDOMETRIOSIS 101

Endometriosis is a progressive, chronic condition in which cells like those that line the uterus are found in other parts of the body.

Studies suggest that endometriosis affects 1 in 10 women of reproductive age, with an estimated 176 million women worldwide having the condition. Unfortunately, for many of these women, there is often a delay in diagnosis of endometriosis resulting in unnecessary suffering and reduced quality of life. In patients aged 18-45 years, the average delay is 6.7 years. As most women with endometriosis report the onset of symptoms during adolescence, early referral, diagnosis, identification of disease, and treatment may mitigate pain, prevent disease progression, and thus preserve fertility.

Endometriosis should be viewed as a chronic disease that requires a life-long management plan with the goal of maximising the use of medical treatment and avoiding repeat surgical procedures

SYMPTOMS

The symptoms vary from woman to woman. Some experience symptoms of severe pains, others have no symptoms at all.

PAIN:

The most common symptom of endometriosis is chronic pelvic pain especially just before, or during the menstrual period. Pain may also occur during sexual intercourse. If endometriosis is present on the bowel, pain during bowel movements can occur. If the bladder is affected, pain may be felt during urination.

Heavy bleeding can occur with or without clots. Bleeding may be irregular, continue for a long period, or spotting may occur before the menstrual period.

SEVERE MENSTRUAL CRAMPS:

Many women experience mild menstrual cramps, which are considered normal. When cramping is more severe it is called dysmenorrhoea. Severe cramping may occasionally cause nausea, vomiting, or diarrhoea. Primary dysmenorrhoea occurs during the early years of menstruation, tends to improve with age, and is usually not related to endometriosis. Secondary dysmenorrhea occurs after the early years of menstruation and may continue to worsen with age. This may be a warning sign of endometriosis, although some women with endometriosis feel no cramping at all and many women with dysmenorrhoea don’t have endometriosis.

BLADDER AND BOWEL PROBLEMS:

Changes in the pattern of bowel habit such as constipation or diarrhoea, feeling the need to urinate more frequently, and increased abdominal bloating with or without pain at the time of the period.

INFERTILITY:

There is a large body of evidence that demonstrates an association between endometriosis and infertility. Almost 40% of women with infertility problems have endometriosis. Inflammation from endometriosis may damage the sperm or egg or interfere with their movement through the fallopian tubes and uterus. In severe cases of endometriosis, the fallopian tubes may be blocked by adhesions or scar tissues.

COMPLICATIONS

Common in women with endometriosis, long-term complications include:

• Adhesion formations and ovarian failure post-surgery. The bleeding can form bonds of scar tissue that can attach to organs in the pelvis and abdomen.

• Reduced fertility that may have no obvious cause or may be caused by adhesions forming on or near the ovaries or fallopian tubes.

• An increased risk of miscarriage or giving birth prematurely.

• Cysts can bleed or rupture, causing severe pain.

• Endometriosis of the intestine can cause the bowel to become blocked or twisted.

• An increased risk of certain types of cancer, particularly ovarian.

TREATMENT

The optimal management of endometriosis is unclear. The main aims of treatment are therefore to relieve symptoms of pain and infertility and to treat endometriomas.

• Combined oestrogen and progestin therapy: Oral contraceptives (OCs) that combine oestrogen and progestin are considered as first-line treatment for pelvic pain associated with endometriosis.

• Progestogens are effective for the treatment of pelvic pain associated with endometriosis. They also induce decidualisation and atrophy of endometriotic tissue and inhibit gonadotrophin secretion, with resultant reduction in the production of ovarian hormones. Medroxyprogesterone acetate and norethindrone acetate are both commonly used for the treatment of pain in endometriosis. The use of progestogens is limited by side-effects, including weight gain, irregular bleeding, and mood changes.

• Gonadotrophin-releasing hormone agonists (GnRH agnostics) should be considered as the first line of treatment for endometriosis and particularly in women who are unresponsive to combined OCs or progestins or have a recurrence of symptoms after initial improvement. GnRH agonist treatment coupled with induced hypoestrogenism is effective in managing endometriosis.

• Surgical treatment is reserved for patients with incapacitating symptoms who do not respond to medical treatment, who cannot tolerate medical treatment owing to side-effects, for those with endometriomas, and for those with symptoms and signs of urinary or bowel obstruction. The modalities of surgery include laparoscopy and laparotomy. There is better visualisation of endometrial lesions with laparoscopy compared with laparotomy. The latter is therefore reserved for women with extensive diseases. Surgical management of endometriosis requires careful consideration of the indications of surgery, preoperative evaluation, surgical techniques, surgeon’s experience, and ancillary techniques and procedures.