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Endometriosis
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Endometriosis is a common disorder that affects women during the reproductive period. The endometrium is the hormonally-sensitive innermost layer of the uterus or womb. Endometriosis occurs when the endometrial tissue grows outside the uterine cavity. This misplaced tissue may implant and grow anywhere in the pelvis, abdominal cavity, and sometimes even in distant sites like lungs and navel. |
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What happens in endometriosis? |
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The misplaced endometrial tissue, though outside the uterus, reacts to the ovarian hormones similarly as it would in the endometrium. When hormone levels drop, the tissue may bleed. Unlike the normally situated endometrium, which bleeds and is shed off from the body as menstrual discharge, this misplaced endometrial tissue situated outside the uterus has no outlet. Thus, the bleed from the misplaced tissue remains in the same site and irritates the surrounding tissues. |
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How does an endometriosis look like? |
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The misplaced endometrial tissue may be present as small, superficial flat patches called implants, or as thicker penetrating nodules, or may form blood-filled cysts in the ovary (Endometrioma). These endometriotic cysts are often described as chocolate cysts. As the endometriotic tissue irritates the surrounding tissues, it may form web-like growths of scar tissue called adhesions, which bind the pelvic organs such as fallopian tubes, ovaries, and intestines to one another, or may sometimes spread over the entire pelvis. When the endometrial tissue invades deep into the uterine wall, it is known as Adenomyosis. |
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What causes endometriosis? |
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Several theories have been postulated to know how endometriosis begins. The leading theory explains that the backward flow of the menstrual blood (retrograde menstruation) through the fallopian tubes into the pelvis implants the endometrial tissue outside the uterus anywhere in the pelvic cavity.
Another explanation in vogue is that certain subtle changes occurring in the immune system are responsible for clearing the abnormal cells and bacteria from the body. But the retrograde menstrual blood may overwhelm the body’s ability to get rid of the misplaced endometrial tissue cells, thus resulting in the implantation of the endometrial tissue outside the uterus.
There is a probable involvement of genetic factors. That is, women whose sister or mother have endometriosis, have a greater incidence of the disease.
In spite of decades of research, the reason why some women develop endometriosis while some do not is not yet completely known. |
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What are the symptoms of endometriosis? |
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Many women who have endometriosis may experience few or no symptoms. Most often, it is diagnosed during pelvic surgery done for other reasons. In some women, endometriosis may cause severe menstrual cramps, abnormal uterine bleeding, pain during intercourse, or even infertility. Some women may even experience bowel disturbances if endometriosis exists in the intestines. The important symptoms are discussed below. |
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Menstrual Cramps |
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Many women with endometriosis have severe menstrual cramps or dysmenorrhoea. In some women, dysmenorrhoea occurs before the onset of menstruation, persists throughout the bleeding phase, and even continues after the bleeding stops. Menstrual cramps are caused by contractions of the uterine muscle initiated by prostaglandins released from the endometrial tissue. When prostaglandins are released from the misplaced endometrial tissue in the pelvic cavity during menstruation, the pain is intensified because the pelvic tissues are more sensitive to the effects of prostaglandins. |
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Abnormal Uterine Bleeding |
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Some women may experience bleeding abnormalities like menstrual bleeding occurring at irregular intervals. |
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Pain during Intercourse |
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Some women may complain of pain during intercourse, known as Dyspaurenia. The thrusting motion during intercourse may cause pain due to the following reasons:
 The ovary may be bound to the vagina with adhesions (resulting in pain in the ovary)
A tender nodule on the uterosacral ligaments attached to uterus
Tender implants in the pouch of douglas present near the surface of the vagina |
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Infertility |
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Infertility can also develop due to endometriosis. Adhesions may interfere with the normal process of the ovum pick-up by the fallopian tube and hamper the tubal motility function. Presence of chocolate cysts (especially of larger size) for a prolonged period may reduce the available normal functional ovarian tissue, thus decreasing the ovarian reserve. Endometriosis alone may be the cause of infertility or may be a contributing factor, based on the severity and extent of the endometriotic tissue. |
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How is endometriosis diagnosed? |
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The physician can suspect the disease based on the history of complaints, but cannot diagnose endometriosis by the symptoms alone. On pelvic examination, certain findings like nodularity felt in the pouch of douglas or presence of an adnexal mass or fixity of pelvic structures may strengthen the suspicion, but the diagnosis of endometriosis is confirmed by laparoscopy.
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Laparoscopy is a surgical procedure that enables the physician to diagnose the presence of endometriotic lesions to assess |
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and score the severity of the disease, involvement of the adjacent organs like intestines, bladder, etc., and even to correct the lesions (release of adhesions, fulguration of the superficial implants, excision of the endometriotic cysts) to the possible extent at the same time. Sometimes, biopsy is conducted on the tissue and sent for histopathological confirmation. |
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Ultrasound imaging of the pelvis can help in diagnosing the endometrioma. An ultrasound scan gives useful information like |
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which ovary is involved, size and number of endometrioma present. This information helps to plan for operative laparoscopy. |
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In special cases, Computerized Tomography (CT scan) or Magnetic Resonance Imaging (MRI) of the pelvis may be required to |
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get more information about the extent of the disease. |
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Though non-specific, serum CA-125 levels (a blood test) are estimated in few cases. |
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What are the available options to treat endometriosis? |
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The doctor shall consider your symptoms, the clinical findings of examination, test results, and your concerns before planning the treatment. Women with few or no symptoms may not require treatment. Women with endometriosis and associated infertility are advised to plan for conception as early as possible. The treatment modalities available are hormonal medication and surgery. |
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Hormonal Medication |
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The goal of hormonal treatment is to simulate pregnancy or menopause, the two natural conditions known to inhibit the disease, as the normal endometrium is no longer stimulated to grow and shed with each monthly cycle, and menstruation ceases (pseudomenopause state). Thus the growth of misplaced endometrial tissue will usually be suppressed.
Hormonal medication is useful in treating mild to moderate endometriosis with limitations. Hormonal medication usually prescribed includes oral contraceptive pills, progestins, danazol and GnRH analogues. |
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Surgery |
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Women with endometriotic cysts (especially the larger endometriomas), severe grade endometriosis with adhesions benefit more with surgical correction as it gives relief from pain and also improves fertility. Sometimes, all endometriotic lesions may not be corrected even with surgery. In such cases, postoperative medical therapy is advised.
Laparoscopy is useful in ablation of the superficial endometriotic implants by laser or electric diathermy, release of adhesions, and excision of endometriotic cysts. In infertile patients, simultaneous tubal evaluation can also be done. Sometimes, operative laparoscopy may be converted into laparotomy, owing to technical difficulties in cases of severe endometriosis. |
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Management of Endometriosis Induced Infertility |
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The management of infertility is based on the period of infertility, previous treatment taken, associated other factors of infertility, and the severity of endometriosis.
Following the correction of endometriotic lesions by laparoscopy and documentation of tubal patency, ovulation induction along with timed intercourse/IUI can be planned if male factor is normal.
In couples with severe grade endometriosis and associated tubal pathology, or male factor infertility, or those who do not conceive within 3-4 cycles of IUI following correction of endometriotic lesions, assisted reproductive techniques (ART) can be a good option. |
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Endometriosis |
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