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Endometriosis

Endometriosis is a condition in which the inner layer of the uterus, called the endometrium, is dispersed throughout the pelvis. Treatment aims to target symptoms or remove the disease.

Incidence

Endometriosis Australia estimates that 1 in 10 menstruating women suffer from endometriosis. Studies show that there can be a significant delay of around 7 years in the diagnosis of endometriosis.

Risk factors include women who: have not had children, are overweight, have heavy or prolonged periods, had their first period at an early age (before 12 years), or who have a first-degree family member (mother, sister) with endometriosis.

Symptoms

Endometriosis symptoms may vary. The main symptoms include: chronic and severe pelvic pain that affect normal activities; pain during your periods (dysmenorrhea); ovulation pain; pain with intercourse; heavy, irregular or long periods; pain with bowel movements or urination; and infertility.

Generally, oestrogen stimulates the growth of endometriosis (“fuel into the fire”).

Diagnosis

A definitive diagnosis can only be made by laparoscopy. A laparoscopy is a surgical procedure, which is performed under a general anaesthetic where a thin telescope is placed through a small incision through the belly button. This allows your doctor to see if there is any endometriotic lesions within the pelvis. Endometriotic lesions are the stray endometrial tissue outside the uterus. Some of those endometriotic lesions need to be removed for examination under a microscope to confirm a diagnosis of endometriosis.

There are three types of endometriosis which refer to where it is located (i) superficial endometriosis (ii) cystic ovarian endometriosis (sometimes referred to as ovarian endometrioma or ‘chocolate cysts') and (iii) deep infiltrating endometriosis. A woman may have more than one type.

Superficial endometriosis can be found in the pelvis, on the outside of the ovaries, on the ligaments that support the uterus, in the Pouch of Douglas (the area between the uterus and rectum), fallopian tubes, outside of the uterus, bowel, cervix, vulva, vagina, ureters and bladder. Superficial lesions can become irritated and can cause adhesions resulting in the organs in the pelvic region to stick together causing pain.

Cystic ovarian endometriosis involves one or both ovaries (endometrioma). Ovarian endometriomas are also known as chocolate cysts, because they contain old blood which is brown in appearance.

Deep infiltrating endometriosis presents as nodules which infiltrate the pelvic organs, most commonly the uterine ligaments, vagina, bowel, bladder and rectum.

A transvaginal ultrasound or MRI may show endometrioma or deep infiltrating endometriosis, however ultrasound and MRI cannot detect superficial endometriosis.

The type of endometriosis does not correlate with the severity of pain.

Treatment options

Once a diagnosis has been established though laparoscopy, there are several different treatment options for endometriosis available. Generally, we will recommend trying less invasive and hormonal treatments first, before opting for invasive surgery.

  1. Pain medication (analgesics) - Pain medications may be an option only if your pain or other symptoms are mild.  
  2. Hormone and Progestogen treatment - This may help slow the growth and local activity of the endometriotic lesions, and alleviate pain. However, women can experience a return of symptoms after stopping the treatment. Hormonal treatments also include the oral contraceptive pill. A progestin-only contraceptive, such as an intrauterine device may also relieve pain. Hormonal treatments will not be suitable for women trying to get pregnant and may have some unwanted side effects that need to be discussed with patients.
  3. Drug treatment – There are drugs available that can block the production of oestrogen and stop periods, thus alleviating symptoms and preventing further endometriotic lesions from growing. Danazol is a mild anabolic steroid that contains a testosterone and stops the release of hormones involved in the menstrual cycle. It is important not to fall pregnant on Danazol. GnRH agonists are an alternative that creates an artificial menopause, but is reversible.
  4. Surgery - If the pain is affecting quality of life or normal activities despite the use of analgesics (pain killers) and hormonal treatment (or if hormonal treatment is not suitable or working), then surgery may be required. Laparoscopic (keyhole) surgery is used to remove as much endometriotic lesions as possible while preserving your uterus and ovaries. Superficial endometriosis can easily be removed laparoscopically as a day surgical procedure. I am often asked to treat severe forms of endometrioses that may require complex and advanced surgery, including dividing adhesions (inner scarring) and managing issues that arise from endometriosis involving parts of the bowel, the bladder or the ureters.

Hysterectomy should always be the last resort option after all other methods have failed. Hysterectomy should be done vaginally or laparoscopically (key hole or minimally invasive surgery); if the opening of the abdomen is recommended, I recommend that patients look for a second opinion. Information on hysterectomy can be found here.

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