What is Endometriosis?
This is a common condition which affects around 1 in 10 women across the world. Endometriosis occurs when tissue grows in places outside of the uterus where it does not belong and acts in the same way as the tissue which naturally lines the womb (endometrium).
This means that whenever a woman gets her period that tissue sheds and bleeds much in the same way as normal womb tissue. However, unlike a normal period, this tissue cannot escape from the vagina and, because it grows in abnormal places like the ovaries, fallopian tubes, bladder, bowel and stomach, it frequently causes intense pain, inflammation and sometimes scarring.
What treatment options exist?
Endometriosis is a chronic, long-term condition which can seriously affect the lives of its sufferers. The symptoms are diverse and wide-ranging, though the most common complaints are of intense pain which cannot be relieved by normal painkillers, heavy periods, pelvic pain, abdominal pain, inability to have sexual intercourse, tiredness and fertility problems.
Though endometriosis has no cure, there are several treatment options which aim to help relieve the symptoms and make life more manageable. There are several reasons for undergoing endometriosis treatment, including; pain relief, to slow down the growth of endometrial tissue, to help improve fertility and to prevent the endometriosis from returning.
Your GP or gynaecologist will discuss the options with you while outlining the benefits and risks associated with each so that you can determine the best option for you. Factors to consider include medical history, age (e.g. if you are approaching menopause), the severity of symptoms, whether you want to have children and any past treatments.
The most common symptom associated with endometriosis is that of chronic pain. For some of its sufferers, pain is debilitating, constant and essentially controls their life. As such, pain medication is used to help try to alleviate some of the pain.
Non-steroidal anti-inflammatories (NSAIDs) such as Ibuprofen are recommended since they also help in minimising inflammation caused by endometrial growths. Taking the pain relief for a few days before your period is normally due can sometimes help.
In a large number of endometriosis sufferers, pain is severe and so stronger medication, like Codeine, can be prescribed. However, this medication is known to cause constipation which can, in many people, worsen endometriosis symptoms.
Hormonal Treatment for Endometriosis
Hormone treatments are used to try and stop the production of oestrogen, which encourages the shed of endometrial tissue. Some evidence suggests that each hormone treatment can be just as effective as the other at treating endometriosis symptoms, though side effects and individual suitability differ (for example, with cases of persistent severe pain).
Several hormone-based treatments exist:
Combined oral pill or contraceptive patch
This treatment is referred to as the ‘combined pill’ because it contains both oestrogen and progestogen hormones. Many of us will know this as “the pill” and will associate it with an effective contraceptive birth control method.
However, in cases of mild endometriosis, the combined pill can be used to help relieve symptoms, by acting to stop ovulation and therefore hopefully make periods lighter and less painful.
Women with endometriosis are often advised to take the contraceptive pill continuously for three or more months, allowing for fewer periods and therefore less pain and bleeding. It is worth pointing out that hormonal contraceptives are generally much more effective in women who do not complain of severe pain.
Levonorgestrel-releasing intrauterine system (LNG-IUS)
This may also be known as The Mirena. It is a T-shaped contraceptive device which is fitted inside a woman’s womb by a doctor or nurse and is then effective for up to five years. It releases levonorgestrel, a progestogen hormone and works to prevent the womb lining from rapidly growing, thus also decreasing pain and periods; sometimes even stopping them altogether.
Side effects can include irregular bleeding for over six months, tender breasts and skin acne.
Gonadotrophin-releasing hormone (GnRH) analogues
GnRH analogues are synthetic hormones which work to cause a temporary menopause, by decreasing the production of oestrogen in the ovaries and therefore shrinking endometrial tissue as a result.
According to reports, this treatment reduces pain in over 80% of women, including those with severe pain.
There are several types, including:
- Nafarelin (Synarel) – nasal spray taken twice per day
- Leuprorelin (Lupron) – injection once every one or three months
- Goserelin (Zoladex) – injection once every 28 days
There are several common side effects of using GnRH analogues and these are generally the same symptoms of normal menopause, such as hot flushes, night sweats, vaginal dryness, decreased libido, mood swings and insomnia. However, your doctor may prescribe you with Hormone Replacement Therapy (HRT) to help combat menopause symptoms.
Adult women can take a GnRH analogue for up to 6-12 months, meaning this is only a short-term solution. There are concerns over using GnRH analogues for more than 12 months, such as bone density loss. One way to minimise bone density loss and treat the side effects is to take hormonal “add-back” treatment (adding very small amounts of either oestrogen or a synthetic progestin) in addition to the GnRH analogue.
These are synthetic forms of a natural hormone called progesterone and work to prevent the womb lining and endometrial tissue from rapidly growing. They are usually taken daily via oral tablet on days 5-26 of the menstrual cycle. Your doctor can explain this to you, as it may be a little complicated to understand.
Progestogens are recommended for women have not managed to get pain relief from the contraceptive options above, or who have been advised against taking hormonal contraception which contains oestrogen (such as smokers). However, there are several common side effects including bloating, weight gain, mood swings and irregular bleeding.
While laparoscopic surgery, also known as keyhole surgery, is the only way to reach a definitive endometriosis diagnosis, it can also be used to help treat the condition, by removing or destroying as much of the endometrial tissue as possible.
A doctor might recommend that laparoscopic surgery is the best option in cases where a woman has severe and constant pain which cannot be lessened by pain medications, or where they are having trouble getting pregnant and it is suspected that endometriosis is the cause. Additionally, if they have a growth or mass in the pelvic area, then surgery may be necessary to remove it and again determine if endometriosis is causing it.
The goal of laparoscopic surgery is to remove the troublesome endometriosis tissue. More than 80% of women who have surgery have reported a decrease in pain for several months after surgery. However, since endometriosis is a chronic condition with no cure, there is a good chance that the pain will come back. The best way to reduce the likelihood of this happening is to ensure you continue with some form of treatment after surgery, such as hormone treatment.
During the laparoscopy, a surgeon will make several small cuts in the abdomen to allow them to insert a laparoscope and look inside and view the organs on a screen. The doctor will use a tube to pump gas into the abdomen so that they have more space to examine and operate. Either heat, laser or electric current is applied to the endometrial tissue in order to remove or destroy them.
This surgery is minimally invasive and carried out under general anaesthetic. Most people can go home following a laparoscopy, though some could be asked to stay overnight.
This surgery is more extreme than a laparoscopy and would only be recommended where endometriosis is widespread and much more severe. In some cases, endometriosis can cause organs to become stuck together, so for these, a laparotomy is used.
During a laparotomy, the surgeon will make a big incision along the bikini line to open up the area and gain access to the organs affected by endometrial tissue. Again, the aim is to remove as much of the tissue as possible.
As this is a major surgery, the recovery time is longer than that of a laparoscopy.
A hysterectomy is a major surgery which cannot be reversed and will result in significant changes to your body, so the decision to have one needs to be properly discussed with your gynaecologist.
A hysterectomy involves the removal of the uterus or ovaries. This type of treatment will usually only be carried out as a last resort, in very severe endometriosis cases and where all other treatment options have been exhausted. A woman will no longer be able to have children following a hysterectomy, so future children will be a deciding factor when deciding whether it is right for you.
Your doctor might recommend surgery to remove your uterus or ovaries, or both if:
- You have tried other treatments but continue to suffer severe symptoms
- You do not want to become pregnant in the future
- You want a permanent treatment
It is important to note that even after a hysterectomy there is no absolute guarantee that endometriosis will not return, though this is unlikely.