Endometriosis 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.
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
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.
Symptoms 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 of endometriosis worsen progressively over years until the condition is recognised and treated.
How to diagnose endometriosis
Endometriosis is commonly diagnosed using the following methods, including non-surgical options:
1. Patient history: classical, cyclical period-related pain with, in most severe cases, the experience of debilitating sex pain or bowel habit changes, chronic back pain, etc.
– Grade 1-3 endometriosis: findings are often “soft” or indistinct
– Grade 4-5 endometriosis: usual to see more definite ovarian pathology, vaginal or bowel involvement
3. MRI scan: where a transvaginal scan is not tolerated
4. Surgery: definitive photographic, tactile and histological evidence to explain chronic symptoms
The stages of endometriosis
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 best-known classification system for endometriosis is the Revised American Society for Reproductive Medicine Classification (R. ASRM) in which there are 4 stages, with 4 being the worst.
There are newer classification systems (ENZIAN by Keckstein et al 2003) and Endometriosis Fertility Index (Adamson 2010) which are able to describe deep infiltrating endometriosis (DIE) more accurately, so that a better correlation can be made between observed disease and prognosis.
To date, there is no single classification system that has been adopted that can accurately predict both fertility outcome and pelvic pain, as well as important issues such as quality of life improvement, risk of occurrence and potential response to new and emerging therapies.
As a general rule, patients with the higher stage endometriosis have reduced fertility and increased pelvic pain.
Following complete excisional surgery it would be my expectation that within weeks of surgery, the experience of pain secondary to endometriosis will be negligible in most cases.
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 does endometriosis pain feel like?
Pain with endometriosis can be variable, deep and constant. Nociception (the experience of pain) requires nerve stimulation, so it is generally true that the patients with larger, deeper or more fixed deposits of endometriosis will “experience” a deeper level of pain. This pain will be more midcycle if ovaries are fixed, and more severe with an approaching period if the Pouch of Douglas is fixed/fused by endometriosis.
Contact Endo Health today to get an accurate diagnosis and discuss your treatment options.
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 ovarian endometriosis. Removing the ovaries creates a condition called ‘surgical menopause’.
Can 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 natural 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 medicinal treatment is not taking away the pain?
This is where endometriosis 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.