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What is endometriosis?
Endometriosis is a relatively common condition that may be associated with pelvic pain and difficulty conceiving. The lining of the womb is called the endometrium and endometriosis is defined as the presence of tissue outside the womb which is very similar to endometrium. The causes of endometriosis are poorly understood but it appears that this abnormal distribution of endometrium-like tissue causes inflammation and scarring which may then lead to symptoms. The course of endometriosis is difficult to predict as it may spontaneously regress in up to a third although in 50% the disease is progressive – worsening with time.
What are the symptoms of endometriosis?
The main symptoms of endometriosis are:
- Pelvic pain
- Painful periods
- Pain during intercourse
- Subfertility (difficulty or delay in conceiving)
- Bowel pain and rectal bleeding during menstruation
- Abnormal vaginal bleeding
- Heavy periods
- Pain or bleeding when passing urine
Any woman with symptoms suggestive of endometriosis will be asked a comprehensive series of questions by their consultant and an examination will also be performed. Usually a pelvic ultrasound would be organised to help identify other causes of pelvic pain and in particular to look for endometriosis in the ovaries where it can cause cysts called endometriomas. In some cases (particularly where severe disease is suspected) a more detailed MRI scan may be helpful.
Currently the only sure way to make a definite diagnosis is to perform a laparoscopy (which is a surgical procedure using a small telescope which is placed through the belly button). This approach not only allows accurate assessment of the pelvis but also treatment at the same time. There are however risks with any surgical intervention and it may not be appropriate in all patients.
As endometriosis is driven by the cyclical hormonal changes of the menstrual cycle all medical treatments involve hormonal manipulation to some degree.
Most hormonal treatments are equally effective at controlling endometriosis and so the actual treatment used should depend on the individual needs of the woman and the side-effect profile of the medicine.
Treatments might include:
- Combined oral contraceptive pill
- Progesterone-only pill (‘mini pill’)
- Mirena coil (a progestasgen-releasing contraceptive coil)
- Implanon (progestagen implant)
In addition to the list above, there is a group of drugs called the GnRH analogues (eg zoladex, triptorelin, prostap) are often used in endometriosis. These drugs induce a temporary artificial menopause and are associated with side-effects including hot flushes and sweats and in the longer term – thinning of the bones. These should only be used where other treatments have failed or prior to surgery for severe disease.
Pain relief drugs will nearly always be suggested which would normally include anti-inflammatory medications.
When medical treatment has failed or is unacceptable or inappropriate, surgical treatment may be advised. In women trying to conceive medical treatment is almost always inappropriate as the drugs are generally contraceptive and there is no evidence that after drug treatment fertility is improved.
In principle all women with known or suspected endometriosis and difficulty conceiving should be offered surgery which should be by laparoscopy. Surgical treatment of endometriosis prior to fertility treatments such as IVF is also often recommended.
There is good evidence that surgical treatment of endometriosis reduces pain and improves quality of life. Even in the most severe cases of endometriosis the expectation should be that keyhole surgery can be performed to minimize the trauma of surgery and improve recovery.