Introduction
ENDOMETRIOSIS- A Chronic Gynaecologic Disease
Women of reproductive age are at a risk of suffering from several health conditions that affect their reproduction and reproductive capacity. Endometriosis is a common, painful condition that can affect daily activities of women and people assigned female at birth (AFAB). Apart from fertility issues, endometriosis can cause painful, heavy menses.
In endometriosis, tissues similar to lining of the uterus grow outside the uterus, causing severe pelvic pain and difficulty conceiving. The tissue can lead to inflammation and development of scar tissue in the pelvic are and rarely, elsewhere in the body. This condition affects women aged between 25-40 years old. This chronic disease is associated with severe, life-impacting pain during periods, sex and bowel movements. Also, there might be nausea, fatigue, depression, anxiety, abdominal bloating and pain during urination.
Endometriosis causes a chronic inflammatory reaction which may lead to development/ formation of scar tissue(adhesions, fibrosis) within the pelvis and other body regions. Various forms of lesions have been described, such as:
- Endometrioma (cystic ovarian endometriosis) in the ovaries.
- Superficial endometriosis. This is found on the pelvic peritoneum.
- Deep endometriosis. This is found in the bladder, bowel and recto-vaginal septum.
- Endometriosis outside the pelvis, though this is a rare occurrence.
Endometriosis can cause harm/ injury to extra-pelvic structures such as the pleura, the pericardium and the central nervous system.
Key Facts & Statistics
ENDOMETRIOSIS
- Endometriosis affects roughly 190 million women and girls of reproductive age in the entire world. This figure translates to around 10% of reproductive women.
- A lot of women remain asymptomatic, and go undiagnosed.
- This disease has a high burden in Europe and US
Risk Factors
What are the risk factors for ENDOMETRIOSIS?
Several factors can increase the likelihood of developing endometriosis by an individual. These are;
- Positive family history of endometriosis.
- Race and ethnicity. Endometriosis is more likely to develop in white women, as compared to hispanic and black women.
- Age at which menarche (onset of the first period) occurred. Individuals who start having menstruations before 11 years old may be at higher risk.
- Going through menopause at an older ager.
- Low body mass index(BMI).
- Short menstrual cycles. For example, less than 27 days.
- Higher estrogen levels in the body.
- Anatomical defects in the uterus or oviducts.
- Length of menstrual cycle and duration of flow(days).
Causes & Theories for Pathogenesis
What are the causes of ENDOMETRIOSIS?
The exact cause of endometriosis is unknown.
Currently, endometriosis is thought to arise from:
- Retrograde menstruation. Menstrual blood which carries with it endometrial cells flows upwards to oviducts and pelvic cavity at the moment when blood is flowing through the cervix and vagina out of the body during periods.
- Cellular metaplasia. The cells outside the uterus change into endometrial-like cells, then they start to grow.
- Stem cells can lead to development of endometriosis, which develops throughout the body via blood and lymphatic vessels. Theories for Pathogenesis
- Immune system conditions. These can make the body unable to recognize and destroy endometriosis tissue.
- Surgical scar complication. Endometrial cells may get attached onto scar tissue from a cut made during surgical procedures such as caesarean delivery.
Theories for Pathogenesis
There are several theories that are used to explain the pathogenesis of endometriosis. These include:
- Sampson’s theory
- Coeleomic metaplastic theory
- Stem cell theory
- Vascular and lymphatic metastasis theory
- The Mullerian remnant theory
Signs & Symptoms
What are the signs and symptoms of ENDOMETRIOSIS?
- Pain during intercourse.
- Infertility (difficulty conceiving)
- Painful bowel movements.
- Heavy menses.
- Bloating and nausea.
- Abdominal or back pains during and in between the periods.
- Depression and anxiety.
Diagnostic Procedures & Tests
How is ENDOMETRIOSIS diagnosed?
The condition is best diagnosed by obstetrics and gynaecologists- specialists in reproductive healthcare.
Procedure involves;
- Personal medical history(number of pregnancies, or previous positive family history of endometriosis)
- Pelvic examination. Performance of pelvic imaging using ultrasound.
- MRI scan. Magnetic resonance imaging scans may be ordered depending on the symptoms present, physical examination and results from the ultrasound scan.
- Laparascopy. Apart from definitive diagnosis of endometriosis, a laparascopy test can be used for treatment. Laparoscopy test involves obtaining a biopys, which is a small sample of tissue that is taken and sent to the lab.
Sometimes, your doctor can accidentally discover endometriosis during a different unrelated procedure.
Differential Diagnosis
Genital system:
- Pelvic inflammatory disease (PID).
- Adhesions
- Endometritis.
- Primary dysmenorrhea.
- Secondary dysmenorrhea.
GIT:
- Irritable bowel syndrome (IBS).
- Inflammatory bowel disease (IBD).
- Constipation.
Urinary system:
- Chronic urinary inflammation.
- Interstitial cystitis.
Treatment and Management
Does ENDOMETRIOSIS have a cure?
Currently, there is no known cure for endometriosis. Treatment is focused at controlling signs and symptoms.
How is ENDOMETRIOSIS treated?
Treatment plan for endometriosis is based upon various factors. These are;
- Severity of the condition.
- Any plans regarding to future pregnancies.
- Age of the patient.
- Severity of the symptoms, especially pain.
Most often, the treatment plan aims at primarily managing pain and improving fertility. These can be achieved through surgical procedures and administering medications. Medications often utilised to aid in controlling symptoms of endometriosis include pain medications and hormone therapies.
Endometriosis pain relievers can be;
- Non-steroidal anti-inflammatory drugs(NSAIDs)
- Over-the-counter (OTC/ analgesic pain relievers
Hormonal options that can suppress the condition are;
- Birth control medicines
- Gonadotropin-releasing hormone medications
- Danazol
Birth control drugs.
There are various forms of hormonal suppression options. They include combination options using estrogen and progesterone or progesterone-only choices. For example oral birth control pills, patch, vaginal ring, birth control shot, intrauterine device. These hormonal controls can aid patients to have lighter periods, that are also less painful. These choices are contraindicated in patients who are attempting to conceive.
GnRH medications.
GnRH is gonadotropin-releasing hormone. GnRH medications stop the hormones which are responsible for menstrual cycles. They relieve pain by halting the menstrual cycle. These medications can be taken by mouth, shots or nasal sprays.
Danazol.
It is a hormonal drug which aims at inhibiting the action of hormones that cause an individual to experience periods. While on this drug, there may be occassional menstrual periods or they might stop completely.
Surgical procedures to treat endometriosis are;
- Laparoscopy
- Hysterectomy
Laparoscopy.
A surgeon makes a small cut in the abdomen, usually less than 1 centimeter, and inserts a laparascope ( a thin tube-like tool) that aids in viewing the inside of the body and identify endometriosis using a high-definition camera.
Hysterectomy.
The uterus is removed based on the amount of endometriosis and scar tissue present.
Complications
What are the complications of ENDOMETRIOSIS ?
- Difficulty getting pregnant (infertility and subfertility. People who have endometriosis and are trying to conceive should consider in-vitro fertilization (IVF)
- Endometrial-like tissue can grow outside the uterus causing cysts and scar tissue.
- Chronic pelvic pain.
- Cancer. Some studies suggest that endometriosis increases the likelihood of developing ovarian cancer.
Prevention
How do we prevent ENDOMETRIOSIS?
Several factors can help in preventing the risk of developing endometriosis. These are;
- Pregnancy
- Breastfeeding
- Healthy weight
- Menstruation beginning at later ages, 12 years and above.