Endometriosis is a condition where tissue, similar to the tissue which lines the womb (endometrium), grows outside of the uterus. This tissue may be found in several different places, including the ovaries, the fallopian tubes, the bowel, the bladder and the stomach. Each month when a woman gets her period, these growths will respond to the body’s hormones by shedding and bleeding in much the same way as normal womb tissue. Unlike the cells in the womb, which leave the body through the vagina (a normal period), this tissue has nowhere to escape, which often causes inflammation, scarring and intense pain.
Some women with endometriosis will have mild or no symptoms, while others complain of severe pain and difficulty in conceiving. Endometriosis is a chronic, long-term condition which currently has no cure. It can have a significant impact on the lives of its sufferers, though there are several treatment options available to help, depending on individual circumstances.
1 in 10 women are affected by endometriosis – that’s 176 million women worldwide. Despite it being a common gynaecological condition, unfortunately, the disease is still widely misunderstood, under-discussed and under-researched within the medical field. However, The London Women’s Centre have much expertise in diagnosing and helping manage the pain and other symptoms of endometriosis.
Symptoms of the condition are wide-ranging and diverse, meaning the disease can present itself in many different ways, varying from woman to woman. Endometriosis also shares its symptoms with several other health problems, which gives an indication as to why it is often so difficult to diagnose.
Symptoms can include:
- Painful periods
- Heavy, irregular periods
- Pelvic pain not related to the periods
- Pain during or after sexual intercourse
- Lower back pain
- Abdominal pain
- Pain when passing urine
- Pain when opening bowels
- Bleeding from the bowel or the bladder during menstruation
- Fertility problems
- Long-term fatigue
- Difficulty breathing
The condition usually affects girls and women during the reproductive years and the most common symptom is pain, which may occur at regular intervals or all the time, often worsening before or during the regular period. Pain may improve once a woman falls pregnant, or can disappear itself without treatment. For others, treatment may temporarily improve symptoms, but the disease can return at any point. The condition is less common in women who have already experienced the menopause.
Endometriosis is a difficult condition to diagnose for a variety of reasons. The symptoms of the condition are wide, varied and differ from woman to woman. Symptoms of endometriosis share characteristics with other conditions, such as irritable bowel syndrome (IBS) and pelvic inflammatory disease (PID). Symptoms are often atypical and many doctors may lack experience in diagnosing the condition. Moreover, the only way to give a conclusive diagnosis is through surgery.
A detailed medical history in combination with clinical examination will give us clues as to whether you have endometriosis. The gynaecologist will ask questions about your period, the location and severity of pain you experience, whether sex causes discomfort and whether you have bowel problems.
Traditional teaching states that endometriosis cannot be diagnosed via ultrasound, x-ray, or other non-invasive methods. However, when a transvaginal ultrasound is performed by a specialist gynaecologist, it can detect rectovaginal endometriotic nodules, endometriosis between the rectum and the uterus and also urinary tract endometriotic deposits. Currently, the only way to reach a definitive diagnosis is through laparoscopic surgery, also known as keyhole surgery, which allows the doctor to see the abnormal tissue inside the body.
A laparoscopy will be carried out under general anaesthetic. Small cuts are made in the abdomen and then a telescope is inserted into the body, allowing the doctor to look at the pelvis. A small biopsy may be carried out to confirm an endometriosis diagnosis.
The magnitude of the disease is categorised as mild, moderate, or severe, depending on the location, extent and type of tissues affected. However, women with mild endometriosis can have severe symptoms, while women with severe endometriosis can have little or no symptoms.
Endometriosis is a difficult condition to live with and can have a huge effect on its sufferers, both physically and mentally. Though there is no cure, there are several treatment options to help people manage their symptoms. Your doctor will help you determine the best treatment option for you.
A number of hormone treatments exist, with the aim of stopping the production of oestrogen. Oestrogen encourages the endometriosis tissue to grow and shed, so limiting its production may help in reducing the amount of endometrial tissue present.
Hormone-based treatments come in several forms including:
- The combined pill which is taken orally, or the contraceptive patch
- Levonorgestrel-releasing intrauterine system (LNG-IUS)
- Progestogens (though these are less used as they typically have negative side effects)
- Gonadotrophin-releasing hormone (GnRH) analogues
Hormone treatments are effective for some women, though they have no effect on the so-called “sticky” areas of endometrial tissue (adhesions), which can cause organs to fuse together.
For a great number of endometriosis sufferers, pain is a constant fact of life. As such, doctors will usually suggest using pain medication to try to help manage the symptoms. Non-steroidal anti-inflammatories (NSAIDs), like Ibuprofen, are usually provided, since they act against the swelling caused by the growths. Your doctor will recommend taking the pain relief for several days before your period pain is expected to begin.
Where pain is more severe, stronger medication may be prescribed, such as codeine. However, using this type of medication can cause constipation, often worsening the symptoms of endometriosis.
While laparoscopic surgery is used to make a definitive endometriosis diagnosis, it can also be used to help treat the disease. A laparoscopy is a type of minimally invasive surgery which is carried out to remove or destroy areas where endometrial tissue is present, with the aim of helping improve symptoms and hopefully fertility.
Other types of surgery used to treat the disease are laparotomy and hysterectomy (removal of the womb), both of which are major surgeries and will only be used where the endometriosis is more severe and widespread. After a hysterectomy, a woman will no longer be able to have children.
The type of surgery offered to the patient will depend on the placement of the endometrial tissue and other individual circumstances.
Some women with mild symptoms have found relief in other ways, including making lifestyle changes, such as regularly exercising and cutting out particular foods like wheat and dairy. Psychotherapy and counselling may provide relief from the mental effects caused by living with the chronic condition.
While not for everyone and although evidence of effectiveness is limited, some women have reported finding pain relief through alternative remedies, such as reflexology, acupuncture, Chinese medicine, herbal remedies, homoeopathy and vitamin B1 and magnesium supplements.
Mr. Athanasias is our consultant who specialises in the management of endometriosis.