Endometriosis is a gynaecological disorder in which the endometrial mucosa (tissues lining the inside of the uterus) is implanted in sites other than the uterine cavity. It affects up to 50% of patients attending infertility clinics but majority of cases don’t have any symptoms.
To understand how Endometriosis works, we need to first understand the menstrual cycle because both are mediated by the same hormones. In simple terms, when a woman menstruates, a part of her endometrium is shed and this comes out from her body as “menstrual blood”. This happens in cycles of approximately one month intervals. Now, imagine this blood not coming out of the body, but instead bleeding within the body (such as inside the abdomen, lungs, etc). This is what happens in Endometriosis.
The most disturbing part of the disease is pain. When the bleeding occurs inside the body (you can call it a form of subtle “internal bleeding”), it results in inflammation, pain, scars and more pain. Initially, the pain is a more severe version of the “menstrual pain” but with time, it becomes a chronic, unrelenting pain. The site of the pain also varies according to the site of the Endometriosis. For example, patients may complain of painful defecation, painful sex, painful urination and of course, painful menses.
Other symptoms of Endometriosis are also related to the affected sites. For example, if it occurs in the bladder, the patient may pass blood in her urine (around the time of her menses), and if it is in the rectum, the patient may pass blood in her stool. Bleeding and scaring within the pelvis results in infertility, affecting about 30-40% of sufferers of Endometriosis, due to blockage of the fallopian tubes and severe adhesions in the abdominal cavity.
So, what causes Endometriosis exactly?
The cause of Endometriosis is not fully understood, however certain theories have been used to explain the possible origin of this disorder. There seem to be a combination of factors involved. There is the “retrograde menstruation” theory, in which it is thought that menstrual blood flows backwards through the tubes, and endometrial tissues are carried through blood vessels or lymphatic channels, and then implanted into several sites.
Factors that increase the risk of developing Endometriosis include:
*Family history of Endometriosis
*Early age at starting menses
*Short menstrual cycle (less than 27 days)
*Long duration of menstrual flow ( >7 days)
*Delay in childbearing or having fewer children
*Anatomical defects in the uterus and tubes
*Iron deficiency and low oxygenation
Management of Endometriosis
Proper management begins with making the correct diagnosis. It is important to note that there are diseases that can mimic Endometriosis. These diseases (such as appendicitis, irritable bowel syndrome, etc) must be ruled out while confirming the diagnosis of Endometriosis. A few laboratory investigations may be required but the mainstay of investigating the disease is using Laparoscopy. This is a minimally invasive procedure whereby a “scope” is inserted through a tiny hole in the abdomen, to visualize the inside of the body, in this case looking out for classical signs of Endometriosis.
Treatment is mainly based on the severity of the disease and the patient’s desire for fertility. This can be divided into:
Conservative medical treatment involves the use of painkillers and hormones that counteract the effects of the menstrual hormones, thereby lessening the severity of the disease.
Minimally invasive procedures, like Laparoscopy as mentioned above, can be used to remove Endometriotic lesions or cauterize them. Open surgery can also be performed in cases where laparoscopy is inadequate or lack of equipment/expertise. In both situations, the woman’s fertility could be conserved.
Radical procedures aim at removing the source of the Endometriosis and the supporting hormones altogether – hysterectomy and oophorectomy (removal of the uterus and ovaries). This is the ultimate cure and is desirable for women who have completed their family size.