What is endometriosis?
The lining of your uterus is called your endometrium. Endometriosis is when cells similar to the cells from your endometrium are found growing elsewhere, usually in the pelvis. Endometriosis can affect women at any age from puberty to menopause. It is a long-term condition that can have an impact on your general physical health, emotional wellbeing and daily routine.
Endometriosis can be found:
- on the peritoneum (the lining of the pelvis and abdomen),
- on the ovaries where it can form cysts (often referred to as ‘chocolate cyst’ or endometriomas),
- on, or around the uterus
- on, or within the fallopian tubes
- in the area between the vagina, the bladder or the bowel.
Endometriosis may sometimes be found in other parts of the body including scars following surgery, the belly button and the chest, but these are less common.
What are the common symptoms to look out for?
Symptoms of endometriosis vary between women. Your symptoms will depend on where your endometriosis is, and some may have no symptoms at all.
Common symptoms can include:
- pelvic pain which may change throughout your menstrual cycle,
- very painful periods,
- pain when you open your bowels or pass urine, which is often worse during your period,
- bleeding from your bowels or bladder during your period,
- pain during or after sex,
- difficulty in getting pregnant,
- fatigue.
Sometimes, the symptoms can be similar to pain caused by other conditions such as irritable bowel syndrome (IBS) or pelvic inflammatory disease (PID).
There is no correlation between severity of endometriosis and severity of symptoms.
How common is endometriosis in women?
It is a common condition, affecting up to 10 in 100 women. You are more likely to develop endometriosis if your mother or sister has had it.
Why is endometriosis difficult to diagnose?
Firstly, there are number of ways to diagnose endometriosis.
Your doctor takes a detailed history by asking about your symptoms in detail.
Your doctor may carry out an internal examination with your consent. This helps to find where the pelvic pain is and allows the doctor to feel for any lumps or tender areas.
Depending on your symptoms, you may be offered the following investigations:
A transvaginal (internal) ultrasound scan – this may show whether there are any cysts on your ovaries or may show other evidence of endometriosis in your pelvis.
An MRI scan – this can be useful if you have more extensive endometriosis including involvement of your bowel or bladder.
Laparoscopy – this is keyhole surgery and is carried out under a general anaesthetic. It can be used to diagnose and to treat endometriosis. You may be offered this surgery if initial treatment to help your symptoms is not effective.
A normal result from an ultrasound or MRI scan does not rule out endometriosis, however it will help guide suitable treatment options.
Endometriosis may be difficult to diagnose if there are no characteristic symptoms like painful periods and result of ultrasound scan or MRI is normal. Very small deposits of endometriosis may not be seen on ultrasound scan etc.
What are the current treatments available for endometriosis?
The treatment of endometriosis depends on a variety of factors, including:
- the type and severity of your symptoms,
- how much endometriosis you have, and where it is,
- whether you are planning a pregnancy,
- whether you wish to use contraception,
- your personal preferences for treatment.
You may be offered a combination of medical, hormonal and surgical treatment.
If you have extensive endometriosis, for example on your bowel or bladder, you should be referred to an endometriosis specialist service which could include a gyanecologist, a nurse specialist, a bowel surgeon, a bladder surgeon and specialists in pain management.
Pain-relieving medication
There are several different medications that may treat your pain. Some medications relieve pain while others may help to reduce inflammation caused by endometriosis.
Hormone treatments
Hormone treatments can help control your symptoms. It is recommended that you give it at least 3–6 months to work. Most hormone treatments that may be offered are contraceptive. They do not affect your fertility in the longer term. Hormone treatments include:
The combined oral contraceptive pill or patch given continuously without the normal pill-free break; this usually stops ovulation and aims to temporarily stop your periods or makes them lighter and less painful.
A progestogen releasing intrauterine device, which aims to reduce the pain and make periods lighter; some women using this get no periods at all.
Progestogens in the form of an injection, the mini pill or the contraceptive implant.
If these hormonal methods do not improve your symptoms, then gonadotropin-releasing hormone agonists, which are injections designed to temporarily stop your ovaries from producing estrogen and progesterone hormones. This causes a temporary menopause, with similar symptoms to when someone’s periods come to an end naturally.
Surgery
The type of surgery you may be offered for endometriosis will depend on your individual situation. Most women can be treated by laparoscopic (keyhole) surgery. Small incisions are made in your abdomen and a small camera called a laparoscope is inserted to look at your pelvis. This is used to see the areas of endometriosis.
Surgery for extensive or deep endometriosis can be more complex. This is usually done in specialist centres, with support from bladder and bowel specialists.
Depending on your circumstances, sometimes a hysterectomy with or without removal of the ovaries can be considered. This will not necessarily cure your endometriosis, but may help with other symptoms.
Fertility treatment
While many women with endometriosis will be able to conceive naturally, for some endometriosis means it can take longer or be more difficult to get pregnant. If you are having difficulties becoming pregnant, your healthcare professional will provide you with information about your options and may refer you to a fertility specialist for further investigations and treatment if needed. The treatment you may need and the options available to you will depend on your individual circumstances.
How does endometriosis typically affect a woman’s fertility?
Endometriosis affects your fertility in many ways. It causes pain during vaginal sex. It affects the lining of the womb thereby reducing the chance of implantation. Fallopian tubes may be damaged in number of ways leading to tubal blockage. Severe endometriosis with associated tubal damage may impair egg capture and transport. Up to 30% of women with endometriosis have tubal abnormality (obstruction, scarring or fluid filled tube). Quality of the eggs in endometriosis is affected and physical presence of endometrioma (chocolate cysts) on ovaries may cause oxidative stress to eggs and physical presence of cysts may reduce the number of eggs. Endometriomas are found in 17–44% of women with endometriosis, and almost one-third of those affected have bilateral cysts. Endometriomas can also be a significant cause of pain during sex, which can lead to impairment of sexual function, relationships and psychological wellbeing.
How can fertility treatment such as IVF help navigate endometriosis?
For many women with endometriosis and infertility, IVF will provide your best chance to achieve parenthood. IVF is a beneficial approach for many women with endometriomas. Endometriosis causes damage to tubes and if both tubes are blocked then IVF is recommended as natural conception cannot happen.
In young women who have mild disease and a good ovarian reserve, surgery may allow time for natural conception or less invasive treatments such as ovulation induction and IUI but for the management of older women, or those with more severe disease, IVF is likely to offer their best chance of achieving a live birth. Individualising management to the patient, the stage of their disease, their symptoms and their fertility wishes is essential.
Is a woman with endometriosis at greater risk of embryo implantation failure?
Latest research has shown that women with endometriosis are at risk of implantation failure. Endometriosis is a chronic inflammatory condition that results in systemic and local inflammatory changes and chronic inflammation is cause for concern as it is associated with subfertility by affecting the lining of the womb, eggs and environment in pelvis.
Endometriosis is also associated with reduced hormonal (progesterone) sensitivity in the endometrium, which in turn leads to imbalance in the endometrial environment so reducing the chance of implantation.
If a woman suspects that she may have endometriosis, what are the first steps she should take to seeking medical help?
You should contact your GP who will refer you to the gynaecologist depending on the presenting symptoms. Gynaecologist will take detailed history and examine you. Ultrasound scan is mostly the first line investigations. If fertility is desired then ovarian reserve is assessed by ultrasound scan and by blood test called AMH. Nevertheless, assessment of the male partner including semen analysis is mandatory if a couple wishes to conceive. Depending on severity of symptoms, various treatment options are available and discussed in detail on individualized basis.
My personal belief is that every woman is unique and needs a tailored approach to their endometriosis management. I help many women at Bridge Clinic London to manage their endometriosis and I guide them regarding the most appropriate fertility treatments available to achieve a successful pregnancy.
