Endometriosis

Overview

Endometriosis is a gynaecological disorder that causes the uterus's normal lining to grow abnormally. The painful chronic disease is common and occurs in 1/10th of the global female population. The disorder does not go away without treatment and can cause excruciating pelvic pain and infertility in women.

Women become susceptible to developing endometriosis after they reach reproductive age. It can even occur in women not having children or those having menopause at a later age. Shorter menstrual cycles (less than 27 days) can also be associated with the development of the disorder.

The disorder can remain undetected for years since it is often mistaken for menstrual pain. Other times, patients may suffer no visible symptoms. As the displaced uterine lining or endometrium attaches to other organs and grows, it can cause discomfort, leading to severe pain. The condition usually involves the fallopian tubes, pelvic tissue linings, and ovaries. Eventually, it can affect the bladder and bowel, causing painful sensations during urination and defecation.

Endometriosis is most likely caused by retrograde menstrual flow when the blood flows backwards instead of going out of the vagina. The blood moves through the fallopian tubes into the peritoneum in such cases. As the menstrual flow enters the pelvis, it deposits the endometrial cells outside the uterus. These cells can then grow in unusual locations and cause problems.

Types of Endometriosis:

Several lesion types have been described:

Superficial endometriosis: It is found mainly on the pelvic peritoneum;
Cystic ovarian endometriosis (endometrioma): It is found in the ovaries;
Deep endometriosis: It is found in the recto-vaginal septum, bladder, and bowel;
in rare cases, endometriosis has also been found outside the pelvis.

Symptoms of Endometriosis:

There are numerous symptoms associated with endometriosis. The primary symptom is pain. The pain can be severe or mild. It is typically felt in the abdomen, pelvis, and lower back. Endometriosis is a common condition, but not everyone develops symptoms. Endometriosis can sometimes go undetected until discovered during another infertility procedure or investigation.

People with endometriosis symptoms may have:

Extremely painful menstrual cramps.
Abdominal or back pain during or between periods.

Pain during sex.
Heavy bleeding during periods or spotting (light bleeding) in between cycles.
Infertility (difficulty getting pregnant).
Painful bowel movements.
The severity of endometriosis is unrelated to its symptoms. Some people may have only a few patches of endometriosis and still experience severe pain. Other people may have severe endometriosis without experiencing much pain.
 

Causes of Endometriosis:

Endometriosis does not have a known cause. Endometriosis occurs when tissue similar to your uterine lining grows in the wrong places. It can cause painful symptoms when it develops outside your uterus, fallopian tubes, ovaries, intestines, or within your pelvis. This pain is caused by increased inflammation, which is often accompanied by fibrosis and adhesions.

Scar tissue (adhesions) can be caused by endometrial-like tissue growing outside of your uterus. These scar tissue sections have the ability to fuse your organs, forming connections that would not otherwise exist. This can cause distress and pain.

Risk factors of Endometriosis:

Endometriosis is more likely to affect women who:

Have a mother, sister, or daughter who has endometriosis;
Started their periods at a young age (before the age of eleven);

Have short monthly cycles (less than 27 days);
Have heavy menstrual cycles that last more than seven days;
Are infertile;
According to some studies, having a lean body mass or low body fat increases a woman's risk of endometriosis.

Possible Complications:

• Chronic Pain: Rapid undetected or untreated development of endometrial implants can make the areas extremely painful. The painful sensation is much more severe than the usual menstrual cramps. As a result, the quality of life is affected, as the patient may feel fatigued all the time and experience pain during intercourse. Also, consistent diarrhoea and other gastrointestinal complications can make matters worse.

• Infertility: Untreated endometriosis is a known cause of infertility. The misplaced uterine growths can block the fallopian tubes, restricting the movement of eggs to the uterus. Moreover, scar tissue can make it challenging to become pregnant.

• Urination Problems: Untreated endometriosis can impact various surrounding organs, depending on the severity. One of the common side effects of long-term endometriosis is the feeling of pain while urinating. Patients may also find it difficult to clear their bowels while suffering from uterine pain.

• Ovarian Cysts: The unusual endometrial tissue growth on other organs like the pelvis and abdomen can cause ovarian cyst formation. This, in turn, can lead to rapidly growing and enlarged cysts that pressure the ovary. The ovarian cysts can even burst, causing sepsis.

• Cancer: Leaving endometriosis untreated for a long time can develop epithelial ovarian cancer. This common type of ovarian cancer includes primary peritoneal and high-grade serous ovarian cancer (HGSOC). The condition can even lead to low-grade endometrial endometrioid carcinomas. These tend to spread quickly; the only solution is debulking surgery on the tumours.

When to Consult a Doctor?

It is recommended to consult a gynaecologist under the following conditions:

On Symptoms: If patients are experiencing severe pelvic pain, consistent dull period pain, nausea, or excessive menstrual bleeding, they must consult a gynaecologist. These could be signs of endometriosis. Since the condition is complex and challenging, having an early diagnosis can help provide the necessary medical assistance required for the treatment.

Difficulties Regarding Pregnancy: Failing to conceive after several attempts can indicate endometriosis. Although it is not the only cause of infertility, a professional gynaecologist can find the root cause. Since endometriosis blocks the fallopian tubes, the eggs cannot reach the uterus. Also, scar tissues can form due to abnormal growth, making it more difficult to achieve pregnancy.

Delayed Periods: Although a delayed period is not a clear sign of endometriosis, it can help in early diagnosis. Usually, women experiencing endometriosis suffer from painful sensations similar to menstrual cramps. The pain due to endometriosis also increases with time.

Regular Pelvic Exams: Women reaching puberty should consult their gynaecologist at least once a year. Regular health check-ups like a pelvic examination can curb the chances of forming endometriosis. This early diagnosis also helps the doctor inspect the vulva, vagina, cervix, and other areas for lumps.

Diagnosis:

Physical Examination: A gynaecologist may perform a pelvic and rectal inspection of the areas to check for any unusual growth. Although the chances of detecting endometriosis through a physical examination are low, it can help in preliminary diagnosis. Reduced uterine mobility, tender uterosacral nodularity, cervical motion tenderness, or a retroverted uterus can all be signs of the disease.

Lab Tests

• Pelvic exam: Your healthcare provider will use one or two gloved fingers to feel for any unusual changes in your pelvis. Cysts on the reproductive organs, painful spots, irregular growths known as nodules, and scars behind the uterus are examples of such changes. Small areas of endometriosis are often difficult to detect unless a cyst has formed.

• Ultrasound: An ultrasound test is done using high-frequency waves that produce images of the inside of the body. A transducer device is pressed against the abdomen or inserted into the vagina. The former is a standard ultrasound, and the latter is a transvaginal ultrasound. However, none of these tests can confirm endometriosis. Instead, these tests can identify the cystic lesions associated with the disorder, called endometriomas.

• Magnetic Resonance Imaging (MRI): An MRI examination is another method that helps create a detailed image of the internal organs and tissues. The procedure involves using a magnetic field and radio waves to produce the picture. It is a helpful device to help your doctor in surgical planning.

Blood Tests: A CA125 test is a type of blood test that allows checking the levels of CA125 protein in the blood. This is a tumour marker for various gynaecological examinations as the protein level is high in endometriosis patients. The only drawback of this method is that the CA125 level is also high in pregnant women.

Advanced Test

• Laparoscopy: It is a minimally invasive procedure in which the surgeon makes small incisions and uses a laparoscope for diagnosis. Performing a laparoscopy lets the surgeon gather accurate information about the endometrial growth. It also allows the collection of tissue samples for testing (biopsy). It is also possible to treat endometriosis completely while performing laparoscopic surgery.

Treatment:

Home Care: If the pain due to endometriosis becomes too unbearable, few home remedies can help. Applying heat to the pelvic muscles is an excellent remedy, as it allows the muscles to relax. This can ease the pain and cramping. Taking over-the-counter inflammatory medication like ibuprofen can also provide quick relief from the painful sensations. However, it is recommended not to use them for more than a week. Consuming turmeric capsules or turmeric tea with ginger powder and honey thrice a day may also provide relief. Omega-3 fatty acids, found primarily in fish such as salmon and sardines but also in some plants, help your cells fight inflammation and pain. Reach for a steaming cup of ginger tea to warm your body and soothe your stomach. Ginger has been shown in studies to alleviate nausea and vomiting associated with pregnancy, and it may also help with endometrial nausea. A healthy diet and regular exercise can help prevent your body from becoming more inflamed.

Medication: Besides over-the-counter pain-relieving drugs, doctors may prescribe other medicines like hormone therapy. These medications are recommended only if the patient is not trying to conceive.

• Pain Therapy: Your health care team may recommend pain relievers that you can buy without a prescription. These medicines include the nonsteroidal anti-inflammatory drugs (NSAIDs) ibuprofen (Advil, Motrin IB, others) or naproxen sodium (Aleve). They can help ease painful menstrual cramps. Your care team may recommend hormone therapy along with pain relievers if you're not trying to get pregnant.

• Hormone therapy: Hormonal medicine can help alleviate or eliminate endometriosis pain. Endometriosis tissue thickens, breaks down, and bleeds as hormone levels fluctuate during the menstrual cycle. Hormones synthesized in the lab may slow the growth of this tissue and prevent new tissue formation. Hormone therapy does not provide a permanent cure for endometriosis. If you discontinue treatment, your symptoms may return. Hormone therapy include the following:
  
  Hormone contraceptives: Various contraceptives such as patches, vaginal rings, and birth control pills can moderate the hormones responsible for endometriosis build-up. Many patients are reported to have shorter and less painful menstrual flow while using these.

  Aromatase Inhibitors: These are a group of medications that reduce the oestrogen levels in the body. However, the gynaecologist may prescribe these medications along with some progestin or combination hormonal contraceptives.

  Gonadotropin-releasing Hormone (Gn-RH) Agonists and Antagonists: Gonadotropin-releasing hormone controls the release of follicle-stimulating and luteinising hormone. So, the Gn-RH agonists and antagonists drugs help prevent ovarian-stimulating hormone production. As a result, the oestrogen level drops, pausing menstruation artificially. This helps shrink the endometrial tissue. The doctor may even prescribe a small dose of progestin with the Gn-RH drugs to avoid any side effects.

  Progestin Therapy: Oral progestins can be an effective medication against endometriosis. Drugs like levonorgestrel or progestin pills can stop menstrual cycles and the growth of endometrial implants.

Surgical Treatment

• Conservative Surgery: Conservative surgery allows the surgical removal of the endometriosis implants without damaging the ovaries and uterus. So, this is beneficial for those trying to conceive. The procedure is usually performed laparoscopically. However, in more severe cases, abdominal surgery is unavoidable.

• Fertility Treatment: Since endometriosis directly impacts the ability to conceive, gynaecologists may recommend a fertility treatment. This is usually done in the presence of a fertility specialist. The process involves various steps, like ovary stimulation and in vitro fertilisation.

• Hysterectomy: Hysterectomy is another surgical method that helps remove the uterine lining that grows outside the uterus. Previously, removing the uterus (hysterectomy) and ovaries (oophorectomy) was the most popular treatment method. But now, alternate ways to preserve the uterus and ovaries are preferred.

Additional Information

• Effect of endometriosis on mental health: Apart from physical pain, patients with endometriosis can often succumb to mental distress. Dealing with chronic pain for too long can cause them to suffer from anxiety and depression. So, a patient may need to consult a mental health counsellor and a gynaecologist simultaneously.

• Pregnancy with endometriosis: Despite the complications that endometriosis causes, it is possible for patients with endometriosis to get pregnant. The disorder may damage the egg and cause inflammation, but women with the disease can still give birth. It is best to consult a gynaecologist regarding the treatment options, including medication and surgical procedures.

• Factors that may lower the risk of endometriosis: Research suggests that certain factors may reduce the risk of endometriosis, such as pregnancy, late adolescent periods, breastfeeding, and eating more citrus fruits.