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Endometriosis is a benign gynecological disease, characterised by the presence of endometrial tissue (tissue normally lines the inside of the uterine cavity) outside the uterine cavity. Clinically associated with pelvic pain, especially with bleeding, and it could be one of the causes of female infertility. The endometrial tissue in the Endometriosis is commonly implanted and attached to the organs within the female pelvis, such as the ovaries and fallopian tubes. On odd occasions, endometrial tissue may even spread beyond the pelvic region.

The endometrial tissue in the endometriosis commonly is implanted and attached to the organs within the female pelvis such as ovaries and fallopian tubes. On odd occasions, endometrial tissue may even spread beyond the pelvic region.

The endometrial tissue outside the uterus continues to act as it normally would- it thickens, swells and sheds to mark the beginning of the cycle.

Causes

The exact mechanism of endometriosis is still unknown. However, there are several possible explanations:

  • Retrograde Menstruation: In almost all women, part of the menstrual blood, which contains endometrial cells flows back through the fallopian tube into the pelvis instead of out of the uterus. In some women, the displaced endometrial cells can attach to the organs of the pelvis. Once attached, this tissue can implant, grows, continues to thicken and bleed during every menstrual cycle.
  • Coelomic metaplasia theory: Endometriosis develops from an abnormal change in the nature of the cells that line the plelvis due to infections and hormonal or other inductive stimuli.
  • Induction theory: Is an extension of previous theory (coelomic metaplasia theory) and proposes that internal biochemical or immunological factors can induce undifferentiated cells into endometrial tissue.
  • Embryonic rest theory: Cell rests of Mullerian ducts (embryologic origin) could be activated to differentiate into endometrium in the presence of a specific stimulus.
  • Lymphatic and vascular spread theory: Endometriotic cells can develop and grow at the distance spread through the lymphatic system or blood vessels.
  • Surgical Scar Implant After surgery, endometrial cells may attach to a surgical incision (Eg. C-section, hysterectomy).

Diagnosis

Endometriosis is a complex condition that is difficult to diagnose by evaluating the symptoms alone. It is possible that you have endometriosis if you are having fertility problems, severe menstrual cramps, pain during intercourse, or chronic pelvic pain. If you have a persistent ovarian cyst, then there is a possibility of you having endometriosis. It is often found that endometriosis is a condition that is in related family members i.e. mother or sister. But, there are instances where women with endometriosis show no symptoms at all.

Pelvic Exam

A doctor during a vaginal exam combined with a rectal exam may feel a tender nodule behind the cervix. Sometimes, the uterus may be tilted back or retroverted, and one or both ovaries may be enlarged or fixed in a particular position. In certain cases, the endometriosis implants may even be visible in the vagina or the cervix.

Although clinical and family history, results of the pelvic exam may all be used to evaluate a suspect case of endometriosis, a laparoscopy is needed to confirm the diagnosis.

Laparoscopy

Laparoscopy is a simple procedure that allows the doctors to see the pelvic organs in detail and examine signs of endometriosis. A laparoscope is a thin specialised instrument that has a camera attached to it. This camera inserted into the abdomen through a small incision near the navel. Therefore, this allows the surgeon to see and analyse the uterus, fallopian tubes, ovaries and other pelvic organs.

Laparoscopy helps evaluate the extent and spread of endometriosis in the pelvis. A clinical staging system is used to describe the extent of endometriosis, adhesions and endometrioma cysts in the ovary. This system, however, is not an exact measure of a woman’s chance of conceiving with fertility treatment or the degree of pain she experiences.

Depending on the findings, endometriosis may be treated during the laparoscopy. Additional small incisions allow insertion of surgical instruments. Endometriosis may be coagulated, vapourised, burned or excised and scar tissue or ovarian cysts may be removed. During laparoscopy, it can be determined if the fallopian tubes are open by injecting dye through the cervix into the uterus. If the tubes are open, the dye will flow out the ends of the fallopian tubes.

However, it is very important that the patient being diagnosed with endometriosis does not have very aggressive ovarian surgery since that would accelerate the destruction of the ovarian reserve and decrease further the infertility problem.

Symptoms

  • Painful Periods: Most women normally experience mild cramps during menses. But, some experience severe cramps, called as dysmenorrhea. These may be a symptom of endometriosis or other problems like uterine fibroids or adenomyosis.
    Primary dysmenorrhea usually happens in the early years of menstruation and tends to improve with age or after childbearing. It is usually not related to endometriosis. Secondary dysmenorrhea is a condition that occurs later in life and may increase with age. These may be a warning sign of endometriosis. But in some cases women having endometriosis may not feel any cramping at all.
  • Lower back and abdominal pain may occur at any time
  • Pain during intercourse
  • Excessive bleeding or bleeding between periods (menometrorrhagia)
  • Difficulty of becoming pregnant, infertility- Displaced endometrial tissue can cause severe inflammation in the tubes and the endometrium preventing fertilisation and implantation of an embryo
  • Pain when passing urine and very rarely blood in the urine
  • Pain during bowel movement

Treatment

Treatment of endometriosis will depend on the desire to conceive, the age, the severity of the symptoms and whether the fertility should be maintained. In this case, one has to be as conservative as possible and avoid major surgery since this will reduce significantly the ovarian reserve (= number of eggs in the ovaries) and the chance of possible conception.

Treatment options are:

Pain Medication- To help ease the painful menses, the doctor will recommend adequate pain treatment. It is best to take the painkiller regularly over the time of the period rather than “then and now”.

Hormone Therapy- These medicines will suppress your hormone production and will decrease/ stop the progress of endometriosis. Following options are available:

  • The Combined Contraceptive Pill: This pill (contains Estrogen and Progesterone) reduces the production of a hormone (FSH and LH) in the pituitary gland, thus also the production of estradiol and progesterone in the ovaries.
    Periods are also less painful and lighter because of a thinner lining of the uterus due to changes in the hormonal balance. Other symptoms like painful intercourse or pain in the pelvic area may also improve. However, it does not prevent scarring or treat any damage that has already occurred.
  • The Progesterone tablet or Injection: It is effective in reducing the effect of estrogen in the endometrial cells which causes the cells to “shrink”. However, the side effects can include ongoing spotting through the cycle, weight gain, bloating and mood changes like depression and headache.
  • Aromatase inhibitors: Reduced the production of estradiol and endometriotic tissue, which needs estradiol as fuel to grow. Therefore, it has been proposed to treat severe endometriosis.
  • Gonadotropin-Releasing Hormone (GnRH) Analogue: This medication stops your ovaries from producing estrogen that causes endometrial cells to shrink, causes a menopausal-like state. Side effects can include hot flushes, vaginal dryness, decreased libido, and mood changes like depression, difficulty in sleeping and mild headaches. This medication cannot be given for more than six months, as the risk of osteoporosis (weak bones and bone fractures) will increase by time.

Surgery- the doctor may recommend a surgery to remove some large patches of endometriosis. However, one must be very careful of not destroying the ovarian reserve. Based on the stage and previous history of the patient, a physician might decide to go for laparoscopic procedure or laparotomy (a surgical incision into the abdominal cavity for major surgery).

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