Endometriosis: Questions Answered

Endometriosis is a condition that affects some women in their reproductive years. It occurs when the tissue that normally lines the uterus is found outside it. The areas where it is commonly found are the surface of the ovaries, the fallopian tubes, and the tissue lining the pelvis.

It is believed that these tissues grow and cause inflammation, scarring and sometimes adhesions. Similar to the lining of the uterus, these implants respond to female hormones such as estrogen. It is not fully understood why it can cause so much pain in some women; however, it is thought that sometimes the implants bleed and the blood cannot escape from the body during the period, so it bleeds directly onto the surface of the surrounding organs and tissues.

There are many theories that try to explain the origin of endometriosis. One of them explains it via a process known as “retrograde menstruation”. This backward flow of menstrual bleeding through the fallopian tubes and into the pelvis might cause the endometrial cells to implant on abdominal organs. Research also suggests altered immunity, coelomic metaplasia, and metastatic spread. Newer research is also proposing genetic origins of the disease. A 2013 study from the National Institute of Health also supports this*. For instance, women who have a first-degree relative affected by the disease have a seven-times-higher risk of developing it than women who do not have a family history of the condition.

While some women with endometriosis experience very little pain and no symptoms at all, others have severe pain and several symptoms. The most commonly reported symptoms are:

• Pain before and during a period.
• Pain during or after sexual intercourse.
• Abdominal, back and/or pelvic pain outside of menstruation.
• Painful bowel movements or urination.
• Abdominal pain at the time of ovulation.
• Heavy or irregular bleeding with or without clots.
• Premenstrual spotting.
• Extreme tiredness.
• Difficulty falling pregnant.

To find out whether you have endometriosis, the first step is to discuss it with your GP. If required, your GP may then refer you to a gynaecologist for further investigations. Sometimes an ultrasound will detect the endometriosis; however, the only definitive method of diagnosis is through a laparoscopy.

When considering the treatment plan for endometriosis, you will need to decide whether your primary goal is to treat pain or maximise fertility.

• Drug treatment – Hormone therapies are suitable for mild endometriosis, or before or after surgery. The aim is to suppress the growth of endometrial cells. Hormone therapies should be used only if you are currently not trying to fall pregnant.
• Surgical treatment – A laparoscopy can surgically remove endometrial implants or adhesions that have resulted from endometriosis. Research suggests that removing endometriosis surgically can sometimes improve the chances of becoming pregnant.

In many cases, the presence of endometriosis impacts on a female’s chances of falling pregnant because of altered ovulation and oocyte (egg) production, luteal phase disruption, the effect on fallopian tubes and in turn embryo transport, and detrimental effects on the endometrium.

However, some women with endometriosis have fallen pregnant easily.

If surgical treatment does not help, fertility medication and treatments can be considered. Commonly, ovulation-stimulating medication combined with Intra-Uterine Insemination (IUI) is all that is needed to further enhance fertility.

If surgery and IUI have not helped achieve a pregnancy, In Vitro Fertilisation (IVF) can be considered. IVF procedures are often effective in improving fertility, and the decision about whether to opt for this must take into account the age of the patient, the severity of the endometriosis, the presence of other infertility factors and the results and duration of past treatments. Thorough consultation with a fertility doctor is always advisable.