Endometriosis is a common chronic inflammatory condition. Its cause, associated symptoms, diagnosis and treatment are explored here.
Endometriosis is a chronic inflammatory condition driven by the hormones oestrogen and progesterone.
In women with endometriosis, cells from the womb lining (the endometrium) are found in other parts of the body, most commonly in the pelvis (e.g. on the lining of the wall of the pelvis; or in the ovaries, Fallopian tubes, bladder, bowel or ligaments supporting the womb). Cells can also be found between the womb and rectum, or between the rectum and the vagina.
These cells attach themselves to the lining of the pelvis and undergo cyclical changes (related to the menstrual cycle), where patches of endometriosis thicken and are shed but there is no way for them to leave the body. This causes inflammation and can cause scar tissue to form.
The body’s responses to the inflammation and scar tissue are pain and discomfort.
How common is endometriosis?
1.5 million women suffer from endometriosis in the U.K., which is 1 in 10 women of reproductive age. This is equal to the number of women with diabetes.
What are the symptoms?
- Pelvic pain which is cyclical (related to the menstrual cycle) or non-cyclical (unrelated)
- Excessive pain before/during/after periods
- Pain when having sex
- Fertility problems
- Persistent tiredness
- Pain when urinating
- Abnormal bleeding
- Pain with bowel movements
Some patients experience few or none of these symptoms, so diagnosing endometriosis can be difficult. This can be very frustrating for patients who can end up waiting several years without explanation for their pain.
Types of endometriosis
Ovarian endometriosis: Nodules implant in the lining of ovaries. When tissue around these areas hardens it can develop and spread into the Fallopian tubes and bowels.
Deep infiltrating endometriosis: The nodules implant at least 5mm below the peritoneum. Structures penetrated can include the uterosacral ligaments (ligaments supporting the womb), bowel, bladder and ureters.
Peritoneal endometriosis: The peritoneum is the lining of the pelvis. Peritoneal endometriosis occurs when endometrial cells travel to and implant in the peritoneal wall.
What is thought to cause endometriosis?
Retrograde menstruation: Occurs during the menstrual cycle when cells travel in the opposite direction to blood flow. Blood carries the cells to areas outside the womb where they implant and cause inflammation, leading to pain. It’s still possible to develop endometriosis after a hysterectomy, which questions this theory.
Genetic inheritance: Some genes may make it more likely that a person suffers from endometriosis.
Autoimmune reaction: The condition may persist due to the body’s inability to fight against the cells.
Spread through blood or lymphatic vessels: Explains the appearance of endometriosis in organs away from the pelvis including the lung and eye.
How is endometriosis diagnosed?
Endometriosis can only be truly diagnosed by having a diagnostic laparoscopy (keyhole surgery) which involves a small telescope being passed through a small cut in your umbilicus (navel) connected to a video camera and television so that the inside of the pelvis can be seen. This procedure requires a general anaesthetic.
How is endometriosis treated?
Endometriosis is treated by medical or surgical methods.
Medical therapies include:
A) Painkillers (paracetamol, ibuprofen) and/or drugs that change the way our bodies handle pain (amitriptyline, gabapentin, pregabalin)
B) Hormone treatments that fool the body into a false pregnancy state (combined oral contraceptive pill, progesterone mini-pill, Depo-Provera™ injection, Nexplanon™ implant and Mirena™ coil) or fool the body into a false menopause state (Zoladex™, Decapeptyl™)
Surgical management involves the removal or destruction of the deposits. This is generally performed laparoscopically (under general anaesthetic).