Endometriosis: Symptoms and treatment

Endometriosis is a condition where cells of the lining of the uterus (the endometrium) are found in places outside the uterine cavity.

The uterus is made of three layers and the innermost layer that lines the cavity is called the endometrium. In some women, the cells of the endometrium may be found in the pelvis and around the uterus, ovaries and fallopian tubes.

Endometriosis can happen to any women in the reproductive years i.e. 15 to 45 years of age.

Women who have endometriosis may complain of pain in the lower abdomen and pelvic region, pain during or after sex (dyspareunia), painful and/or heavy periods (dysmenorrhoea) and, sometimes difficulty in getting pregnant ( infertility).

These symptoms may affect the quality of her life significantly. The pain during sex/periods and the chronic pain may be very distressing. It is also possible that the woman has endometriosis but may have no symptoms at all.

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We still do not know why endometriosis occurs but there are various theories that explain the pathology. The most commonly accepted theory is that, during a period, small amount of menstrual blood flows from the uterus into the pelvic area via the fallopian tubes. This is called `retrograde menstruation`. This tissue then implants inside the pelvis. During the cycle it responds to the hormones (estrogen and progesterone) just as the uterine lining does.

This tissue will also grow in response to them and then break down and bleed in the same way as the normal lining. This bleeding inside the pelvis remains inside and then causes inflammation, pain and finally leads to adhesions.

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Endometriosis on the ovaries can lead to cysts i.e. collection of dark brown chocolate colored fluid in and around the ovary. Occasionally endometriosis may occur on the bowel and bladder, or deep within the muscle wall of the uterus (adenomyosis) and in scars especially the caesarean.

Diagnosis is difficult as there is no definitive symptom. And there is no definitive test. The same set of symptoms may happen even in other conditions such as pelvic infections.

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Sonography can be done but it has its limitations. It may show the presence of cysts if any. But it may not necessarily tell the nature of cysts. Small endometriotic spots will not be seen on sonography.

Laparoscopy is the only way to get a definite diagnosis where we look inside the abdomen with a camera. This procedure is an operative procedure and has to be done under anesthesia.

If endometriosis is found on laparoscopy we will do therapeutic procedures at the same time; such as burning of the spots, cutting of adhesions and removal of chocolate cysts.

Normally before proceeding to laparoscopy one would have already tried painkillers and hormonal medication (Combined oral contraceptives, progesterone only drugs, the LNG – IUS GnRH agonists). Some of these may be used even after the laparoscopy once the diagnosis is clear.

Women who have difficulty in conceiving may require assisted reproductive techniques to conceive. Finally some women may even require to remove the uterus tubes and ovaries if the pain is very distressing.

Dr.Sangeeta Agarwal

The author is an Obstetrics and gynaecology expert, practising at Bombay Hospital

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