Endometriosis is a condition in which tissue that normally lines the uterus grows outside the uterus. This condition leads to painful periods.
The most common symptoms of endometriosis are pain and menstrual irregularities
HIGHLIGHTS
- Endometriosis is a painful disorder that affects women
- It leads to extremely painful periods
- Endometriosis commonly involves your ovaries, fallopian tubes and pelvis
Endometriosis is a chronic disorder characterized mainly by pain. This pain occurs during periods and intercourse. In severe cases there is pain during passing stools as well as during urination and a host of other problems like irregular or heavy periods, extreme fatigue, pain in the legs and even intractable backache.
Almost 1 in 10 women suffer varying degrees of endometriosis and it often runs in families. It affects women in the reproductive age group and tends to be a chronic long term illness with a profound impact on general health and emotional wellbeing. Long term impact also includes infertility which adds to the emotional distress and in some rare cases endometriosis especially in the ovaries can lead to a type of cancer called the clear cell carcinoma of the ovaries
The inner lining of the uterus (womb) is called the endometrium and has endometrial cells and endometrial glands. This lining responds to the variations in hormonal levels, such that it gets thicker and vascular during the month and in the absence of pregnancy at the end of the month it gets shed off as a period (menstruation).
Unfortunately, we do not know the exact cause of endometriosis as yet, but we do know that it is hormone dependent. In endometriosis, tissues, similar to the inner lining of the uterus are found everywhere. These tissues could be on or around the uterus, on the ovaries and fallopian tubes. Rarely these tissues are also found on the rectum and behind the uterus, also on the lining of the abdomen and pelvis (peritoneum).
All these areas respond to the monthly hormonal changes, become vascular and at the end of the month, they tend to bleed and form blood clots. This is what causes the extreme pain of endometriosis. Healing of these areas occurs by tissues getting fibrosed or cicatrized, basically scar tissue forms inside the body at various places. This scar tissue, then adds onto the pain and other symptoms. Scar tissue destroys the pelvic organs and contributes to infertility. The same process repeats every month.
Occasionally blood- filled ovarian cysts form, and these are called "chocolate cysts". Endometrial tissue found within the muscle of the uterus (adenomyosis), causes the uterus to grow larger and more inflamed and adds to the monthly pain. Symptoms of irritable bowel disease and pelvic inflammatory conditions tend to overlap with those of endometriosis.
Diagnosis is based on a careful history of symptoms and investigations. The first line investigation almost always is an ultrasound scan of the pelvis. If needed an MRI scan may also be helpful. Most often, a laparoscopy (procedure done under anaesthesia) wherein a telescope is introduced inside the abdomen to actually see and record the endometriotic areas may also be needed to achieve a diagnosis.
Treatment is mainly a combination of hormonal regimes and surgery. Most commonly given tablets are the combined oral contraceptives that contain a balanced amount of estrogen and progesterone. This is given continuously or cyclically. The aim is to maintain a balance between estrogen and progesterone and keep the estrogenic influence low. Often, progesterone itself is administered. This can be in the form of progesterone only pills, injection or an implant under the skin. Another popular and effective method is the intra uterine system that releases progesterone inside the uterus. This reduces pain and makes the periods lighter.
GnRHa (gonadotrophin releasing hormone agonists) are extremely effective because they act by shutting down the ovaries, thereby reducing the hormonal levels in the body and hence reducing endometriosis. GnRHa can result in bone loss and menopausal symptoms and can only be used for a limited time frame.
Surgery involves removal of endometriotic deposits, cysts and other areas. The type and extent of surgery depends on the extensiveness of endometriosis. Success rate are variable and often repeat surgeries are needed. Commonest route of surgery is the laparoscopic (key hole) method. Laparotomy is reserved for more severe cases and involves a cut in the abdomen.
Though, the attempt is to do a conservative surgery and restore normal anatomy of the uterus and ovaries, ultimate relief is achieved once both ovaries are removed. In severe cases, this may be the only option. In case the uterus is also enlarged and diseased, hysterectomy (removal of uterus) is necessary. In extremely severe cases involving the bowel or bladder, appropriate specialist surgeon may be a part of the team to carry out extensive surgery. In case infertility is also an issue along with pain and other symptoms, a fertility expert becomes an integral part of the team. Occasionally for severe pain, experts from the field of pain management are also consulted for their advice.
Psychological therapies, counseling, healthy diet with a regulated lifestyle and adequate exercise go a long way in reducing the symptoms of endometriosis.
Patients often resort to alternative therapies which include homeopathy, ayurveda, refloxology, acupuncture, acupressure, vitamin supplements, TENS (transcutaneous electrical nerve stimulation). These have variable success rates.
In short, endometriosis is a chronic debilitating condition that affects women in the reproductive age group and has multiple somatic, psychologic and social ramifications. Therefore treatment requires a patient and long term treatment approach and team work to determine what modality or combination of modalities will benefit the patient the best.
(Dr. Samar Gupte is MD, Consultant Gynaecologic Onco surgeon)
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