Endometriosis is a common condition that can cause pelvic pain and fertility issues. According to Dr Adelene Esterhuizen, gynaecologist at Mediclinic Hermanus, “Globally, it is estimated that approximately 10% of reproductive-age females have endometriosis. While it may be challenging to determine the exact prevalence of endometriosis in a general population, some individuals are asymptomatic, those with symptoms can have varied and nonspecific presentations, and definitive diagnosis typically requires surgery.”
The endometrium is the name for the inner lining of the uterus. In people with endometriosis, cells like those normally found in the endometrium grow outside of the uterus, causing inflammation, which can lead to very specific symptoms. The most common places where endometriosis occur are the ovaries, the fallopian tubes, the bowel (large intestine), and the areas in front, in back, and to the sides of the uterus.
There are several medical and surgical treatment options for endometriosis. Dr Esterhuizen believes that the best treatment depends on your individual situation and that response to treatment is also highly variable.
Endometriosis causes
The cause of endometriosis is still not fully understood. A common theory is that some menstrual blood and endometrium flows backward from the uterus through the fallopian tubes and into the pelvis during the monthly menstrual period. This tissue then grows where it lands in the pelvis. This is called the "retrograde menstruation theory." Unfortunately, it doesn’t fully explain all cases. Another speculative cause is that it has an auto-immune component. There are several other theories as well, and research is ongoing to find a cause for this condition.
Endometriosis symptoms
Some people with endometriosis have no symptoms, while those with symptoms may vary according to the stage of the condition. The most common symptoms are very painful, heavy periods. Dr Esterhuizen warns that while periods may be painful, it should never be debilitating pain, impairing your day-to-day activities.
Pain — Pelvic pain caused by endometriosis can occur:
- Just before or during the menstrual period. In some cases, painful periods get worse over time.
- Between menstrual periods, with worsened pain during the period.
- During or after sex.
- With bowel movements or while urinating, especially during the period.
- If left untreated, it may cause chronic pain (autonomic nervous stimulation), even after excision. For this reason, endometriosis should not be left untreated.
Pelvic pain can be caused by many other conditions, including pelvic floor muscle spasm, pelvic infections, and irritable bowel syndrome. If you have pelvic pain, your healthcare provider can help to identify if endometriosis may be the cause.
Difficulty getting pregnant — Endometriosis can make it more difficult to become pregnant. This might be because endometriosis may cause scar tissue to develop, which can damage the ovaries and/or fallopian tubes. Even people with endometriosis who do not have scar tissue can have difficulty becoming pregnant. This is likely due to unbearable pain, making intercourse undesirable, leading to infertility as a secondary cause.
In individuals who do become pregnant, endometriosis does not harm the pregnancy. In addition, symptoms of endometriosis often improve after pregnancy, which is also an unexpected phenomenon – we know endometriosis thrives on estrogen. Both estrogen and progesterone increase significantly during pregnancy.
Endometriomas — Women with endometriosis can develop ovarian cysts containing endometriosis tissue; these are called endometriomas. Endometriomas are usually filled with old blood that resembles chocolate syrup; thus, they are sometimes called "chocolate cysts." Endometriomas are sometimes seen during a pelvic ultrasound. They are benign (not cancerous) but typically cause significant pelvic pain; if this happens, surgery is usually recommended to remove them, but medical management may have good results as well.
Endometriosis diagnosis
“If a patient presents with symptoms discussed, we already have a good clinical suspicion that a patient may have endometriosis,” she explains. “Sometimes we may see thickening of the uterine wall (suspected adenomyosis, which is endometriosis inside the uterine wall), or we may see an endometrioma. But most of the time, we can’t see any evidence of endometriosis on ultrasound. The Gold Standard is to do a diagnostic laparoscopy to find evidence of disease and excise it. The tissue is then sent for histological confirmation. It is during laparoscopy that we can also assess severity of disease and categorise it as stage 1-4. “
Although laparoscopic confirmation is the Gold Standard, many doctors opt for medical treatment first and evaluate response. This is especially applicable to younger patients (teenagers). If there is poor response to medical treatment, the next step is typically surgery.
For more on treatment options, please read this follow up article.
