Endometriosis is a disease affecting millions of women worldwide. It is the second most common gynaecological disorder after uterine fibroids.
Symptoms range from mild abdominal discomfort to debilitating pelvic pain.
Women with the condition often find all areas of their life significantly affected, including education, work and social life.
If may also disrupt relationship with partners, children, friends and colleagues. Endometriosis makes it difficult for a woman to get pregnant.
This chronic condition is often undiagnosed for many years; leaving women in pain.
Diagnosis and Treatment
Endometriosis is a common benign disorder defined as the presence of endometrial glands and stroma (inner layer of the wall of the womb) outside its normal location. These endometriotic tissue deposits found outside are called “Growths”, “Implants”, “Lesions” or “Nodules”.
These endometriotic implants are most often found in the pelvic peritoneal layer which covers the inner aspect of the abdominal cavity and organs. Also, these endometrial implants are commonly found behind the uterus, in the ovaries, uterosacral ligaments, bladder, bowels and other organs. These implants may be superficial or it may be found as deep infiltrating Endometriosis.
It is an eostrogen dependent disease and it responds to hormone based treatment. However, some patients may not respond to medical treatment and will need surgical intervention.
The extent of endometriosis can vary widely between individuals and primary method of diagnosis is visualization of endometriosis lesions by laparoscopy with or without histology.
American Society of Reproductive Medicine has categorized the endometriosis as Stage I (minimal), Stage II (mild), Stage III (moderate), and Stage IV (severe). But this classification has some limitations as it poorly correlates with infertility and pain.
How pain can occur in patients with endometriosis?
As the pain is highly subjective, patients with endometriosis may feel pain to varying degrees which may not correlate with spread or the stage of disease.
Endometriosis is commonly associated with chronic pelvic pain, dysmenorrhea (Pain during menstruation), dyspareunia (pain during sexual act) & noncyclical Pain.
Uncommonly they may have dyschezia (pain with Defecation), dysuria (burning sensation during urination) or abdominal wall pain.
For the initial assessment and evaluation, pain scoring tools such as a numerical rating scale may be used.
Endometriosis Associated dysmenorrhea typically proceeds menstrual bleeding by 24 to 48 hours. Compared to primary dysmenorrhea this pain is thought to be more severe and responds less to pain killers.
Endometriosis associated pain during intercourse often correlate with stretching of vaginal walls ligaments which have been affected by the disease. If the pain develops after years of pain free intercourse, endometriosis may be a possibility.
The prevalence of endometriosis amongst women with subfertility is around 30%.
Explanations for infertility in these patients may be due to adhesions which may impair oocytes (Female eggs) pick up and transport by Fallopian tubes. In patients with severe endometriosis, tubo-ovarian architecture is often distorted.
Patients with severe disease who undergo In Vitro Fertilization (IVF) has poorer implantation rates and pregnancy out comes.
The doctor will begin by asking about your symptoms and will conduct a clinical examination which includes a pelvic examination.
Pelvic examination may reveal nodularity of the posterior vaginal wall, a pelvic mass which may be a cyst due to endometriosis and a uterus which may be retroverted with impaired mobility.
Trans Vaginal Ultrasound scan (TVS) where the probe is inserted in to vagina will visualize the pelvic organs in great detail will help in the diagnosis of the diagnosis.
This is accurate in detecting endometriosis and aids in the exclusion of other causes of pelvic pain.
CT scan plays a limited role in the diagnosis and evaluation of endometriosis.
Laparoscopy is the gold standard method for diagnosing Endometriosis which is a surgical procedure to visualize the pelvic and the abdominal organs by a camera inserted through a tiny hole in the abdominal wall.
Laparoscopy is used for diagnosis, staging and treatment.
Pain and infertility are the commonest presentations in patients who seek treatment.
Treatment depends on the woman’s specific complaints, severity of symptoms, and location of endometriotic lesions and plans of future fertility.
Patients with pain without fertility wishes can use hormonal therapy which help to slow the growth of endometriosis, these include birth control pills, progestins, Danazole and the newer drugs like aromatase inhibitors which act by interrupting local estrogens formation and inhibiting the growth of endometrium. These agents are usually initiate on patients who are suffering from pain syndromes with suspected endometriosis or following confirmed endometriosis with laparoscopy. Surgery is also one promising method of pain relief for chronic sufferers.
If the infertility is the presenting symptom only option that is left with is surgery since all medical treatment interfere with hypothalamo pituitary ovarian axis, thus suppressing ovulation.
Surgery for endometriosis can be of several forms. The ultimate goal is to remove all ectopic endometrial glands, scar tissues, endometriomas and adhesions and to revert back the normal anatomy. This preserves the fertility as well as provides good symptom relief. Some who do not respond to these conservative surgical methods may need additional procedures. Interrupting pain pathways by means of presacral neurectomy provides good pain relief although this surgery is technically demanding. For severe disease with no fertility wishes hysterectomy with or without ovarian preservation is the final option of management.