What is endometriosis?
It is a condition where endometriosis gland cells are unusually found outside the uterus, growing onto and sometimes into other organs. For reasons not fully understood, the normal mechanisms that everyone has to remove abnormal tissue like this do not work properly, and these cells continue to grow slowly and progressively.
How common is endometriosis?
Approximately 10% of all women between the ages of 15 and 45 have this condition. It does not occur in girls who are yet to have their first period, and it does not increase in severity in women who are approaching menopause. Needless to say, men do not suffer from this condition (alas!).
What causes endometriosis?
This is a really good question. There is no doubt that genetics, or more specifically inheritable genes, are a strong influence in developing endometriosis – perhaps 30% to 50% of women with a first degree relative (mother, sister) will develop similar progressive changes. Additionally, there is a well-recognised immune component, where deposits are simply not easily removed from the body. What is certain is this; so-called ‘retrograde menstruation’, where blood flows from the uterus into the pelvis, does NOT explain the deep disease seen in most women with advanced endometriosis.
How is endometriosis classified?
There is a staging system that can be used to classify endometriosis based on number and size of deposits, the degree of adhesion formation, and even where organs are fused together. The original staging system was on a scale of 1 to 4, with 4 being the worst. Unfortunately there are women with severe disease who fall outside this classification, particularly where organs such as the bowel or lung have been penetrated by endometriosis, or where a kidney has been lost due to chronic obstruction of a ureter by unrecognised scar tissue.
What is the effect of untreated endometriosis?
The abnormal cells bleed, inflammation occurs and eventually scar tissue forms. Depending on which organs are involved some organs stick together, which creates fixed hard tissue; women with moderate endometriosis then start to experience sex pain, bowel pain, back pain, ovulation pain and infertility. These symptoms worsen progressively over years until the condition is recognised and treated.
Can endometriosis cause heavy periods?
Yes, but usually only when there are changes involving the uterus wall as well. Endometriosis that invades the myometrium (muscle of uterus wall) is called adenomyosis. Removing deposits of endometriosis only is unlikely to reduce a woman’s experience of heavy periods.
Can endometriosis cause infertility?
Unfortunately, yes. As many as 50% of women with symptomatic endometriosis will experience a significant delay when attempting to conceive. Careful removal of endometriosis by an experienced surgeon will restore a woman’s fertility to normal for her age.
What factors contribute to endometriosis?
It has been well established that women who are overweight, who have never had children and who commenced periods before the age of 12 have a statistically greater chance of developing important endometriosis. The key here is exposure to estrogen, where the glandular cells have no ‘checking mechanism’. The average time frame for a woman to present with Grade 4 endometriosis is around seven years. It is not uncommon for young women to be discouraged from seeking help for chronic period pain, usually on the basis of age or non-specific scan findings.
Will hysterectomy cure endometriosis?
If only it were that simple! Endometriosis is a multi-facet disease; deep seated deposits outside the uterus are not removed by a simple hysterectomy. However, removal of all these deposits and the uterus of a woman with proven adenomyosis will address pain issues. Hysterectomy generally refers to removing the uterus and cervix. Additionally, removing the fallopian tubes and ovaries is an option for women with a completed family, severe disease with proven deeply invasive ovartian endometriosis. Removing the ovaries creates a condition called ‘surgical menopause’.
Do medications cure endometriosis?
Unfortunately no, but they can make the symptoms less of a problem. Simple pain relief and the oral contraceptive pill are good starting points for most women. Similarly, the use of Chinese medications may assist with symptom control, but unfortunately will not change the disease process that is already well established. The use of the oral contraceptive pill post-surgery is often helpful in reducing the potential risk of recurrence.
What if the pill or hormone treatment is not taking away the pain?
This is where surgery becomes important. In the hands of an experienced surgeon, the risk of recurrence of any pathology is reduced to <20% over three to five years. The essence of endometriosis surgery is to remove ALL the active deposits by careful excision.
Can pain continue despite excellent surgery?
Yes, occasionally. This is more likely to be the case in women who have had multiple prior surgeries with diathermy to ablate (burn) tissues, resulting in the possibility of leaving abnormal tissue behind, or worse, to cause nerve damage resulting in chronic pain. Usually this can be addressed by a more thorough surgery where ALL the abnormal tissue has been removed and nerve pressure is relieved. Some young women may also have adenomyosis, which contributes to pain, and may be best suppressed with a hormone device such as Mirena.
All patients after surgery will have some degree of post operative pain, largely managed with the use of Panadol Osteo (slow release paracetamol), an Anti-inflammatory (eg Celebrex, Mobic, Voltaren etc), as well as either Tramadol or even Tapentadol IR/SR. These medications will be used generally in the first week after surgery, with a view to reducing over 7-10 days. Some of these medications (anti-inflammatories in particular) must only be taken with food.
In rare circumstances, women may need nerve modulating agents (Pregabalin, Lyrica, Endep) or narcotic medications (Endone, Oxycodone) to temporarily suppress pain until the correct surgical option can be established.
What is Mirena?
Mirena is a hormone implant placed inside the uterus that releases a low dose of progestin (levonorgestrel). It provides contraception, lighter periods and a degree of pain control for uterine adenomyosis. It can be easily removed by a GP or specialist at any time within the five years after it is installed. Mirena is completely reversible, with no long term side effects.
What is Zoladex?
This is a class of medications called GnRH analogues. They effectively remove virtually all oestrogen from a woman’s body and induce a state of ‘medical menopause’. They are reversible but not curative. Over a period of three to six months, endometriosis deposits can shrink considerably, which helps in managing pre-operative pain.
What are the risks of surgery for endometriosis?
Broadly speaking, these can be classified into two categories:
- anaesthetic risks: (medical history, BMI, heart and thyroid conditions all need to be discussed with an anaesthetist on the day of surgery)
- surgical risks: The risk of harm to adjacent structures (bowel, vessels, ureters and bladder) during surgery is very small. The risk of harm is further minimised by having a meticulous and thorough surgeon, such as Dr Gordon, who has almost 20 years of experience in both Public and Private practice. For the complexity and range of advanced laparoscopic procedures that Dr Gordon undertakes for the restoration of fertility and resolution of pain, the actual risk of any complication occurring is substantially lower than the generally quoted average risk of 1:1000.
Further information about endometriosis:
Disclaimer: I have utilised commonly branded medications in this FAQ section, as these are names familiar to most patients. I have absolutely no financial interest or stakes in any Pharmaceutical company. Where possible I have tried to provide similar alternative medications, so as to not be seen to be favouring one company’s products over another.