Endometriosis Frequently Asked Questions
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What causes endometriosis?
The simple answer is that nobody knows for sure, but there are at least two popular theories. One such theory is called Sampson’s implantation theory, which suggests that during menses some of the tissue (endometrium) being shed flows backwards through the fallopian tubes and into the pelvis, where it implants and grows.
The other theory is called Meyer’s coelemic metaplasia theory, which suggests that cells that should normally develop inot different tissue types, under the influence of female hormones, develop into endometrium instead.
Yet other people think that bit of endometrium float off into the blood stream to aother parts of the body instead of being shed – such a theory would explain the occurrence of endometriosis in distant parts such as the brain or lung.
How common is endometriosis?
It is found in approximately 3-5% of women of child-bearing age. It is associated with infertility, since it occurs ten times more frequently in infertile women.
Who gets endometriosis?
Endometriosis usually occurs 2 - 8 years after a woman starts having menses (the menarche). Symptoms resolve spontaneously in the menopause, but if women take HRT then symptoms can persist as the endometriosis is sustained by the oestrogen in the HRT. Women with endometriosis who fall pregnancy often find that the disease improves. Endometriosis is therefore more common in women who have never had children or who are infertile.
It used to be thought that endometriosis in more common in Western women, but this is more likely due to the fact that Western women are more likely to access medical treatment when the disease is made. Also, the small family sizes may mean that Western women are more exposed to the risk of development of the disease.
How would I know if I have endometriosis, what are the symptoms?
Painful menses are the classic symptom. Typically the pain starts with the onset of menses but does not necessarily last for the duration of menstruation.
Some women experience additional pelvic pain unrelated to menses, and this may be due to adhesions (scar tissue) that has formed due to endometriosis, or may be due to cysts of endometriosis.
Painful intercourse is another classic symptom of endometriosis. The pain may vary during the menstrual, and may also vary depending on the site of endometriosis or its severity.
Women with endometriosis are more likely to complain of heavy menses.
Endometriosis at unusual locations such as the lung or belly button causes cyclical pain, with complete remission of symptoms away from menses. Some women my bleed from the belly button, or see blood in their stool when endometriosis involves the bowel, or cough up blood around the time of their menses.
How will the diagnosis of endometriosis be made? What tests will I have to have?
History - often the presenting symptoms described above will raise suspicion.
Examination - an internal examination may reveal tenderness in particular parts of the pelvis, or may reveal an enlarged ovary suggesting an endometriotic cyst.
Ultrasound may show an endometrioma, but most endometriosis is not visible on ultrasound. Subtle signs caused by endometriosis are sometimes visible to the trained eye such as reduced mobility of pelvic organs.
MRI can occasionally identify large nodules deep in the rectovaginal septum, but most endometriosis is not visible on MRI scans.
Laparoscopy is the mainstay for diagnosing endometriosis. Endometriotic lesions can be seen as black spots, ‘chocolate cysts’, reddened areas, new vessel formation, and clear ‘sago’ blisters. Classical sites include the ovary, para-ovarian fossae, Pouch of Douglas, utero-sacral ligaments, other pelvic surfaces.
Why does endometriosis cause infertility?
Scar tissue (adhesions) may form around the tubes and ovaries, interfering with their normal function. The presence of endometriosis in the pelvis may cause chemical changes in the pelvic that adversely affect the eggs and aperm, and thereby interfere with fertilsation. The presence of large endometriotic cysts may interfere with ovulation. Painful intercourse may result in a reduced frequency of coitus and therefore sub-fertility.
What medical treatments are available for women with endometriosis?
All medical treatments suppress ovulation and are unsuitable for women wishing to conceive. The medical treatments commonly used are the following:
Combined oral contraceptive pill
The combined pill often helps with symptoms from endometriosis. Monophasic pills (those with the same dose of oestrogen and progesterone for the 21 pill days) can be taken continuously (without a seven day break for 3 or even 6 months) to prevent the occurrence of withdrawal bleeds.
Progesterones
High dose progesterones such as Provera or Norethisrerone can be taken to obliterate the menstrual cycle. This causes he endometriotic deposits to “desolve”, and also helps by removing cyclical symptoms.
GnRH analogues
GnRH analogues can be taken as a nasal spray or as an injection. They cause a temporary medical menopause by preventing the release of gonadotrophins. Their side-effects include hot flushes and night sweats which can be relieved by taking hormone replacement therapy at the same time.
Aromatase inhibitors
Examples of these drugs are anastrozole and letrozole. They work by withdrawal of the oestrogen stimulus to endometriosis, and they are usually prescribed in conjunction with GnRH analogues.
Danazol & Gestrinone
Danozol and Gestrinone act against oestrogen but also have male-hormone type actions. They have side effects ofcausing excessive body hair and voice deepening and are rarely used nowadays.
What surgical treatments are available for endometriosis?
With surgery, treatment involves either direct destruction /excision of the endometriosis, or removal of the hormonal stimulus. Most surgical treatments are performed via the laparoscope (key hole surgery).
Laparoscopic Ablation
This involves destruction of the endometriosis and can be done by LASER or diathermy. Repeat treatments over the years are often required.
Laparoscopic Excision
When large nodules of endometriosis exist, they can be excised and sent for histology.
Ovarian Cystectomy
Endometriomas can be removed by key hole surgery too. If the endometrioma is drained, it invariably recurs and the base of the cyst should either be ablated or excised.
Hysterectomy and Bilateral Salpingoophorectomy
Removal of the uterus (Hysterectomy) and both ovaries and tubes (bilateral salpingo-oophorectomy) removes local endometriosis and the hormonal stimulus from the ovaries.
What is the long term outlook in women with endometriosis?
Endometriosis is a self-limiting condition that resolves during the menopause.
If you have any queries regarding topic raised within this article please do not hesistate to contact the Women's Health Clinic via the email form at the bottom of the page or by calling our London clinic on 020 8947 9877.
