Endometriosis

What is Endometriosis?

Endometriosis is a life-long condition that affects more than one in ten women during their reproductive years. It typically starts in a woman’s late twenties, and it’s a condition where tissue that usually lines the uterus (endometrium) grows outside of the uterus.

  • The endometrial-like tissue develops into growths or cysts on the ovaries, fallopian tubes, and tissues lining the pelvis.

  • These growths bleed and break down during the menstrual cycle but the blood cannot exit the body. This abnormal process leads to inflammation, scar tissue formation and adhesions between tissues.

  • Endometriosis is a chronic, often progressive condition. The exact cause is unknown, but genetic, hormonal, and immunological factors are likely contributors.

Symptoms of endometriosis

Endometriosis can cause distressing symptoms, including:

  • Heavy and painful periods
  • Severe cramping pain before a period
  • Spotting and bleeding in between periods
  • Painful ovulation
  • Painful sex
  • Pelvic pain
  • Pain when passing urine
  • Painful bowel movements
  • Blood in stool
  • Irritable bowel-like symptoms, such as bloating
  • Back pain
  • Leg pain
  • Infertility
  • Fatigue
  • Depression

How is endometriosis diagnosed?

Many women have suffered with symptoms for years before they come to see me in the clinic, and often, they’ve experienced a considerable delay before a diagnosis of endometriosis is confirmed. This is because endometriosis symptoms overlap with many other conditions and can manifest in different ways.

Laparoscopy (a surgical procedure to look inside the abdomen with a camera) is the gold-standard technique to make the diagnosis of endometriosis definitively. Scans and internal examination are not sufficient to make the diagnosis. Sometimes, however, an MRI may be helpful and may be required to rule out other conditions.

Endometriosis and fertility

Many women are concerned that endometriosis will affect their fertility, and whilst there is indeed an association between endometriosis and fertility problems, it’s thought that around two-thirds of women with endometriosis can get pregnant without medical intervention.

We don’t fully understand why endometriosis can cause infertility, but it may be because the disease process creates scarring, which can affect the fallopian tubes and the womb.

Sometimes, surgery to treat the affected areas can improve fertility in women who have mild endometriosis, and many women benefit from assisted reproduction techniques, such as IVF.

Treatment of endometriosis

We don’t yet have a cure for endometriosis, but much can be done to help manage it. Endometriosis treatment consists of medications (such as hormone treatments and pain relief) and surgery.

Hormonal treatment for endometriosis

Endometriosis is oestrogen-dependent; in other words, blocking the action of oestrogen on the areas of endometriosis prevents tissue growth and reduces pain. The treatment ceases to work when stopped, and it can’t reverse scarring (adhesions) or improve fertility.

Hormonal treatments can include:

Progesterone medications

Oral medications such as medroxyprogesterone, Norethisterone and Dydrogesterone work by suppressing the growth of the areas of endometriosis, but their effect is temporary. Depo-Provera, which is an injectable contraceptive, also has a suppressive action, but it can delay a return to fertility.

Mirena coil

The Mirena coil contains progesterone, which counteracts the effect of oestrogen on areas of endometriosis and reduces menstrual bleeding. Plus, it’s a contraceptive, which makes it a good choice for many women with endometriosis.

Dienogest

Dienogest (Zalkya TM) is a new-generation progesterone-like drug which inhibits the production of oestradiol and, thus, the growth of endometriosis lesions. It also has an anti-inflammatory effect. It’s taken for 6 to 9 months (in tablet form), and at that stage, we can re-examine its efficacy with a follow-up ultrasound scan. Changing to a different medication or the Mirena coil may then be possible.

Dienogest may cause some side effects, such as irregular spotting, breast tenderness, headache and nausea, but it’s generally well tolerated. As with all progesterone-like medications, if taken long-term, it can lead to reduced bone mineral density.

GnRH analogues

Gonadotrophin-releasing hormone is produced in an area of the brain called the hypothalamus. It stimulates the pituitary gland to release FSH (follicle-stimulating hormone) and LH (luteinising hormone), which control the menstrual cycle. GnRH analogue medications (such as Goserelin and Leuprorelin) indirectly suppress oestrogen formation, stopping the growth and activity of endometrial deposits. It also induces a temporary menopausal state, and a small amount of HRT may given along with it to reduce side effects.

Testosterone Derivatives

Women naturally produce a small amount of testosterone, but large amounts decrease the production of oestrogen and progesterone. Synthetic testosterone derivative medications, including Gestrinone and Danazol, have the advantage of treating endometriosis whilst preventing loss of bone density. Still, they may produce unfavourable side effects such as acne, weight gain and headaches.

Endometriosis surgery

The goal of surgery for endometriosis is to help reduce pain or to improve fertility.

Laparoscopy, a minimally invasive, keyhole surgical technique, can remove or destroy endometrial patches (with diathermy). Whilst further patches may grow, this kind of surgery can reduce pain by around two-thirds and also double conception rates in women who have mild endometriosis.

Hysterectomy to remove the womb (with or without the removal of the fallopian tubes and ovaries) may be an option for women whose symptoms haven’t been sufficiently improved after other treatments, mainly where the endometriosis lesions are growing within the wall of the uterus, known as adenomyosis.

Some patients have advanced or widespread endometriosis, which may involve parts of the bowel, and major surgery involving bowel resection may be needed. Such surgery is carried out via a large incision on the abdomen, involving a multidisciplinary team of clinicians. I refer my patients to specialist endometriosis centres in this situation.

Living with endometriosis

There’s no doubt that endometriosis can impact a woman’s quality of life. Living with pain not only brings physical distress but there’s also an emotional toll, which affects both the individual and those around her. It can feel isolating, and women may be financially impacted because of time off work.

I believe in a holistic approach to helping women with endometriosis, and this may include the help of other professionals, such as physiotherapists and pain management experts.

If you think you may have endometriosis, or if you’re looking for help after a recent diagnosis, do come to see me.