Introduction: Endometriosis is a disorder which seems to be on rise in the recent decade and a half. It has been there in our study armamentarium for long but was a rarity and always a condition considered as a last differential when no cause for the woman’s symptoms were found.
Today with increased awareness, access to care and better imaging techniques the disorder is much diagnosed making us wonder whether this has increased or is being increasingly detected due to better technology and a vast experience now in clinical practice. Typically women with pelvic pain and the ones who are finding it hard to conceive(infertility) are the ones who are diagnosed with this condition more often. Sometimes the disease may be silent or have a confusing presentation and may get diagnosed incidentally.
Figure 1
Endometriosis
Endometriosis. What is that? It’s a disorder which occurs as a result of the lining tissue of the womb called the endometrium growing in places outside the womb or the uterus .The endometrium is special and specific tissue which functions importantly in implantation of the embryo after fertilisation which is the first step of pregnancy. If no pregnancy occurs the endometrium is shed off and this is called as menstruation .Thus the menstrual blood is actually blood which is interspersed with the endometrial tissue. In endometriosis this tissue grows in places where it is not supposed to grow such as ovaries (forming chocolate cysts or endometriomas), fallopian tubes (altering the architecture of the fallopian tube and the tubo-ovarian relationship) or peritoneum which is a special layer covering the internal organs of the body. Rarely endometriosis has been located in the deeper structure such as the walls of the rectum (large bowel), scars of delivery and the caesarean section or even on the bowel or in the lungs giving rise to catamenial pneumothorax. This same tissue also is seen to be growing in the walls of the womb and causing a condition called as the adenomyosis causing swelling of the uterus and pain.
Why is endometriosis a disorder when your own tissues seem to be growing ?
Every tissue in the body has its own defined function and place. When the tissues traverse either due to internal lymphatic or blood channels or due to being in direct proximity it is not normal and this is what happens in endometriosis. This tissue will continue to grow, shed off similar to the normally placed tissue as it contains hormonal receptors which influence this. Additionally, it will initiate reactions from the adjacent tissues and structures and form adhesions causing distortion in the anatomy and symptoms of pain which can be distressing. The endometrial tissues can also grow inside the walls of the womb and the bowel and sometimes outside the pelvis in the thorax. Being in a closed space the tissue does not have an outflow access and is trapped within the structures where it implants.
What type of pain is there in endometriosis and why? Endometriosis takes the woman to the doctor usually for pelvic pain. The pain may get exaggerated during the menstrual cycle. The woman may experience chronic dull pain on and off, back age, leg pains, constipation, digestion problems and many other non-specific symptoms. The pain is due to the irritation of the peritoneum, stretch on the ovary or involvement of the nerve fibres by endometrial tissue.
What are the symptoms of endometriosis? The commonest symptom of endometriosis is specific or nonspecific pelvic pain and painful menses. Menstrual pain is many times worse than the usual cramping pain and may not be associated with heavy bleeding. Also the menses pain increases over the days of the menstruation and as the time passes by. Look out for a consult:
· Painful periods, before ,during and after
· Menses pain disrupting ones quality of life
· Pain with bowel movements
· Irregular and excessive menstrual bleeding
· Infertility
· Nonspecific : bloating , irritability , constipations , gases , nausea etc
· Painful sex especially on deep penetration or after pain
Symptoms of endometriosis : Self assessment checklist
When to consult a doctor? Any menstrual complaints or above mentioned symptoms or experience if present its better to be correctly investigated and guided. Early detection and treatments have known to help alleviate the symptoms and stall the disease from going into serious process. Severity doesn’t always mean a severe disease likewise severe disease may not present with severe symptoms.
Any other differentials ? Yes this is a sure challenge as the gold standard to diagnose the disease is only laparoscopy. Sonography may not reveal the disease in its early stages and therefore much time may be lost as women seek care from other specialists where the differential is either a urinary tract infection, Gastrocolitis (swelling of the bowel), IBS (irritable bowel syndrome). Endometriosis is sometimes mistaken for other conditions that can cause pelvic pain, such as pelvic inflammatory disease (PID) or ovarian cysts. It may be confused with (IBS), a condition that causes diarrhoea or pain and gases, constipation and abdominal cramping. Sometimes the endometriosis and these diseases can co-exist.
Why does endometriosis occur? It’s a disease of theories and therefore the exact cause seems illusive. But retrograde menstruation where the menstrual cells may flow back through the fallopian tubes and get implanted on the peritoneum may grow is one theory. It’s also possible that the peritoneal cells undergo transformation in endometrial cells as both have acommoncellular lineage in development. It can be possible thatpre-existing cells from the embryonic stage get activated later with the hormonessuch as oestrogen when the woman hits menarche and onwards. Endometrial cells also are believed to be transferred from the endometrial cavity into the lymphatics and deported. The severity of the disease also seems to be modified by lifestyle, stress and immunological efficiency.
What are the risk factors identified ? One can consider this as self-administered list to guide you to see a doctor well in time
Risk factors of endometriosis : self-audit list
· Early onset menstruation
· Late menopause
· Short menstrual cycles< 27 days
· Long duration menstrual bleeding : > 7 days
· Hyper estrogenicstatus
· Lean women with low body mass index
· Familyhistory of endometriosis
· Reproductive tract abnormalities especially the obstructive ones
Endometriosis usually develops many years after menarche (the first menstrual period).
What are the modifiers of the endometriosis disease pathogenesis? Taking combination pills for cycle regulation or for birth control can modify the disease progression. Pregnancy if achieved can also modify as it is a condition characterised with high levels of oestrogenandprogesteronehormones.
What investigations are done for endometriosis? Sonography especially the pelvic scan with transvaginal approach helps in identifying ovarian endometriomas and some adhesions to an extent, any uterine anomalies, haemorrhagic cysts etc are definitely diagnosed. Sometimes if the sonography has not been able to reflect correctly MRI can be suggested. Additional imaging such as chest roentgenogram or bone imaging may be advised. Menstruation and endometriosis are both dynamic so follow-ups and treatment responses can be studied by sonography. Laparoscopy is the gold standard of diagnosis but is considered weighing many factors. The treatment approach depends on the severity of symptoms and the disease, need for conception, age of the woman. Many medicines in the form of hormonal pills, modulators, intrauterine systems, injections, pain modifying medicines have been found to be effective. Important is to take the treatment early and on time and follow the instructions correctly. Lab tests may be advised for screening of anaemia, thyroid disorders or anyother comorbidities and CA125, a nonspecific marker is used for assessment of treatment efficacy.
What are the complications of endometriosis? Severe menstrual pain and adhesions. Rupture of the hematomas or large cysts necessitating surgery sometimes repeatedly. Infertility is a common complication due to various reasons : Table below
Endometriosis leading to infertility : the reasons why ?
1. Inability to have sex
2. Improper ovulation
3. Alteration in the tubo-ovarian relationship
4. Adhesions causing disturbance in the normal processes of transfer of the egg and sperm and implantation
5. Hormonal imbalance leading to implantation failure
6. Internal inflammatory processes preventing continuation of pregnancy causing miscarriage
6. Adenomyosis if present causing uterine squeezing leading to miscarriages .
How can we approach the issue of fertility with endometriosis?
Various ways can be considered
1. Diligently talking treatment with regular follow ups with the doctor
2. Consider early pregnancy planning before the disease becomes more profound
3. Regular check-ups withthe doctor even if not planning pregnancy immediately
4. Surgical clearance followed by immediate conception plan
5.Laparosopcic diagnosis if suggested
6. Consider ART ( IVF) if disease is severe without unnecessary delay
7. Oocyte freezing or embryo freezing can be considered before there is further loss offertility potential as these can be considered for surrogacy if your reproductive system is completely distorted
8. Have a balanced and a healthy life style looking at all the parameters such as diet , exercise and nutrition and harnessing a positive attitude.
Figure 2
Pregnancy mechanics peri-fertilization
For pregnancy to occur, an egg must be released from an ovary, travel through the neighbouring fallopian tube, become fertilized by a sperm cell and attach itself to the uterine wall to begin development. Endometriosis may obstruct the tube and keep the egg and sperm from uniting. But the condition also seems to affect fertility in less-direct ways, such as by damaging the sperm or egg.Even so, many with mild to moderate endometriosis can still conceive and carry a pregnancy to term. Doctors sometimes advise those with endometriosis not to delay having children because the condition may worsen with time.
The main complication of endometriosis is impaired fertility. Approximately one-third to one-half of women with endometriosis have difficulty getting pregnant.
Can there be cancer in association with endometriosis? Ovarian cancer does occur at higher than expected rates in those with endometriosis. But the overall lifetime risk of ovarian cancer is low to begin with. Some studies suggest that endometriosis increases that risk, but it's still relatively low. Although rare, another type of cancer — endometriosis-associated adenocarcinoma — can develop later in life in those who have had endometriosis.