Endometriosis: Pain & Infertility

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Endometriosis is a common disease affecting women in the child bearing period. It is a condition where small deposits of the womb lining are located outside of the womb cavity. The most common place to find it is on the ovary, the back of the womb and the ligaments that hold the womb in its normal position. It can also be found on the thin lining of the pelvic organs (the peritoneum), on the tubes, between the vagina and rectum (recto-vaginal septum), in or on the bladder, in abdominal scars from previous surgery and even far away from the pelvis.

It is more common in women whose relatives have endometriosis, in women who have cycles shorter than 28 days and those who typically have a period lasting longer than a week. Many cases occur in women without these associations, of course, and not all women who fit into the above categories necessarily get endometriosis.

Causes of Endometriosis

There are several theories; one possible cause is called retrograde menstruation. In around 85% of women, a small amount of blood flows backwards down the fallopian tubes and into the pelvic cavity. This blood contains tiny pieces of the lining of the womb (endometrium). It is not known why in some women this might lead to endometriosis, but not in others – it may have something to do with woman’s immune response and its ability to fight off and remove these pieces.

Another theory suggests that because the uterus, tubes, peritoneum and part of the ovary are all developed from the same area in the fetus, endometriosis might be caused by some cells taking the wrong turn during development. Endometriosis may be transported by blood which would explain the rare finding of endometriosis in sites such as the lung, umbilicus or even the nose.

The Symptoms of Endometriosis

Endometriosis may result in pelvic pain, painful periods, pain during intercourse and infertility. The pelvic pain caused by endometriosis can be very variable. It may be like a dull ache located generally over the lower abdomen, or may be more severe. It can be more localized into the rectum (back passage) or cause urinary symptoms. Sometimes the degree of pain felt by a woman is not related to the extent of disease found when the endometriosis is diagnosed. It is estimated that endometriosis is present in 60-70% of women with chronic pelvic pain.  Painful periods are often the first sign a woman might have that endometriosis is present. The pain usually begins a few days before the period is due and continues throughout the period. It is typically located in the centre of the pelvis, but can be one-sided. It may go into the back or down the legs.

Pain on intercourse is often worse with a particular position and especially with deep penetration. Many women experience an aching in the pelvis after intercourse; this may last sometimes up to 48 hours.

Endometriosis has been found in one third of infertile women. In sever cases there is much scarring around the tubes, or there are ovarian cysts, it is not surprising that this might interfere with normal fertility. It is less clear how a few small spots of endometriosis might have a detrimental effect on attempts at pregnancy. Nevertheless, studies have found that endometriosis is more common in women who have difficulty conceiving. It has been shown that treating mild to moderate endometriosis increases the chances of conceiving.

Diagnosing Endometriosis

Detailed history taking and pelvic examination can sometimes suggest the presence of endometriosis. Typical findings depend on the severity of the disease and where it is located. A normal uterus is quite mobile, but the scarring of endometriosis can make it tender and fixed in the pelvis. There may be a swelling felt on one of the ovaries because of an endometriosis cyst.

Ultrasound scans are useful to help diagnose endometriosis cysts affecting the ovary, but diagnostic laparoscopy is the gold standard way for diagnosing and treating endometriosis. With the patient asleep a small telescope is passed through the umbilicus to gain access to the pelvis. A picture of the pelvis is viewed on a TV screen and the presence of endometriosis and its stage can be assessed.

An experienced surgeon should be able to identify this disease in all its various forms and undertake treatment at the time of diagnosis, where appropriate. This is the most effective form of treatment for mild to moderate endometriosis and should be considered the first-line approach. More advanced endometriosis will normally need a separately planned operation. The patient needs to be fully counseled as regards the risks of surgery.

Treating Endometriosis

Not all endometriosis needs to be treated, only if it is causing symptoms or if fertility is an issue.

There are several options for treating endometriosis, and each has its place for different women’s disease. Treatment may be medical or surgical.

Medical Treatment

There are a variety of pain killers as Mefanamic Acid and Ibuprofen which reduce the levels of prostaglandin (substance responsible for pain).  If there is no improvement in symptoms, then hormonal treatment may be used. It can shrink endometriotic tissues and thus improve symptoms. There are a variety of hormones that can be used they all aim at reducing the levels of certain hormones thus stop stimulating endometriosis.

Surgical Treatment of Endometriosis

Surgery can either be conservative or radical. The aim of conservative surgery is to return the appearance of the pelvis to as normal as possible. This means destroying any endometriotic deposits, removing ovarian cysts, dividing adhesions and removing as little healthy tissue as possible.

Assisted Conception

In cases of infertility, in-vitro fertilization (IVF), sometimes called ‘test-tube baby’ may be recommended. This won’t deal with the endometriosis, but the approach might be suitable for a woman with minimal pain, who is older and doesn’t have as much time to undergo prolonged treatments. Also, if other treatments have failed and infertility persists, assisted conception is usually the only remaining option.


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