Endometriosis is a relatively common disease that can cause significant pain and suffering.  At the other end of the scale, it can exist without any sign of it's presence.  Approximately 3-10% of women aged 14-45 have endometriosis

What is Endometriosis

Endometriosis is small deposits of the womb lining that are located outside of the womb cavity.  Commonly found on the ovary, back of the uterus and on the ligaments that hold the uterus in position.  However, it can also be found on the thin lining of the pelvic organs (peritoneum) on the tubes, between the vagina and rectum, in or on the bladder and in abdominal scars from previous surgery.  Although, it can appear anywhere and has been found of the lungs of some women.

When you have a period, so does the endometriosis which leads to cyclical swelling, stretching of tissues, inflammation and scarring.  Eventually all the scarring and inflammation can lead to symptoms even when you are not having a period.

What causes it?

Unfortunately, this is not known but there are theories why it occurs:

Problems it can cause

Pelvic pain - this can be variable. You may experience a dull ache in the lower abdomen or at the other end of the spectrum very severe. It can be more localised in the rectum or cause urinary problems.  The degree of pain can be unrelated to the extent of the disease.  Some women with severe endometriosis have no pain at all, whereas women with just a few spots and the pain is very disabling.  Sometimes pain is experienced in areas in the body where no endometriosis exists.

Painful Periods - often the first sign that endometriosis is present.  Pain usually begins a few days before the period is due and can continue throughout the period.  Symptoms can include, constant back pain, abdominal cramps, pain in the legs and clotting.

Painful Sex - can be worse in certain positions and especially with deep penetration.  Many women experience aching in the pelvis afterwards.

Infertility - In severe cases there can be scarring round the tubes or ovarian cysts so it's no surprise these could affect fertility. A few spots of endometriosis however can still be detrimental to conception.

There are many other problems it may cause including painful bowel movements, bloating, constipation, painful pelvic examinations and painful frequent urination.

The body produces a hormone called Prostaglandin which makes the uterus contract and is the same hormone which causes labour pains during childbirth. 

Diagnosis

Definite diagnosis can only be made by a laparoscopy.  A small telescope is inserted through the belly button to view the pelvis on a TV.  The abdomen is inflated with carbon dioxide to separate the organs and provide a clearer view and a catheter is used to drain the bladder.  Endometriosis is diagnosed as stage one upwards. Stage one and two being the least severe.  In more severe cases (stages three and four) there may be web-like scar tissue, adhesions which can affect the natural position of the uterus.  The ovary may be affected by benign ovarian cysts (endometriomas) which can be as small as a grape or as large as a grapefruit. Women may feel sudden pain if there is bleeding into these endometriomas.  They may also burst which can lead to irritation and the development of adhesions.  These adhesions can 'glue' internal organs together.

Treatment

Symptom management - Use of painkillers to make period pains more tolerable.  Ibruprofen and mefanamic acid are used to try and reduce Prostaglandin levels.  These may not work and then hormone treatment may be used to try and shrink the Endometriosis.

Medical treatment in the form of hormones delays the chance of pregnancy.  It also suppresses endometriosis rather than removing it and is only effective for short term management as it usually returns after stopping treatment within a varying timescale.

Contraceptive Pill - one of the most commonly used treatment used to ease painful periods. This can be prescribed normally with a  7 day withdrawal at the end of each packet long term. It may also be prescribed continually without breaks for 6-12 months. 

Progestogens - the most common form of treatment, used to try and shrink the endometriosis.

GnRH agonists - Given by nasal spray or in injection form. This works by lowering oestrogen levels putting the body in a pseudo menopausal state.  Side affects therefore can be hot flushes, reduced sex drive, depression, vaginal dryness, headaches and emotional symptoms.  HRT can be used to ease these side-effects but as with all drugs may produce side-effects of it's own.

Danazol - Though to be as effective as GnRH agonists but can have some unpleasant side-effects, such as weight gain, water retention, tiredness, decreased breast size, hot flushes, acne, oily skin, growth of facial hair, irreversible deepening voice.  Additional contraception should be used as accidental use in early pregnancy can masculinise a female foetus. A rare but possible side-effect can be liver damage. 

When all else fails - Surgery

Mild to moderate disease can be removed under laparoscopy by using a laser. An excellent surgeon may be able to remove all of the endometriosis. Moderate to severe endometriosis may also benefit from this procedure and be used to remove smaller endometriomas (see Diagnosis).  Open surgery may be carried out to remove endometriomas which are particularly large.

Hysterectomy is usually a last resort. The ovaries may be removed (Surgical menopause) if the women has completed her family and over 40, or if the disease is quite severe.

None of the treatments described above are guaranteed to prevent endometriosis returning, even after a hysterectomy with removal of the ovaries.  It can return and then affect other organs such as the bowels.

There is no definitive cure!!!