The uterus is made up of three special layered linings of tissue and muscle. The innermost layer is called the endometrium, the second layer- myometrium and the third layer- the serosa. Endometriosis is a condition where the innermost layer of uterus-endometrium, grows in locations outside the uterus. Endometriosis may cause adhesions on the uterus. The uterus can become stuck to the ovaries, fallopian tubes and bowel. Although many patients experience extreme pain, some women with endometriosis do not experience any symptoms (asymptomatic). Usually it causes pain around the time of your period but, for some women, the pain is almost constant.
The symptoms of endometriosis vary widely and the severity of symptoms is not necessarily related to the severity of the endometriosis. While some women have few or no symptoms, others experience severe and incapacitating pain that recurs each month for many years.
Many women think that painful periods are normal. If you have bad period pain, you should seek medical advice.
- Period pain (dysmenorrhoea)
- Pain during sexual intercourse (dyspareunia)
- Pelvic and abdominal pain outside of menstruation
- Abnormal bleeding – including heavy bleeding, clotting, prolonged bleeding, irregular bleeding, premenstrual spotting
- Difficulty in getting pregnant
- Painful bowel motions, diarrhoea, constipation, bleeding from the bowel
- Painful urination
- Lower back, thigh and/or leg pain
- Premenstrual syndrome
The diagnosis of endometriosis can be difficult. Some women have had symptoms for many years before the diagnosis was made. Diagnosis is usually based on:
- A woman’s symptoms
- A physical examination of the pelvic cavity
- Ultrasound Imaging, which may provide evidence of endometriotic cysts, adhesions, or nodules
- An examination of the inside of the abdomen and pelvic cavity using an instrument called a laparoscope, during a procedure called laparoscopy. The examination of a tissue sample (usually obtained during laparoscopy) is the only way of diagnosing endometriosis for certain.
Treatment for endometriosis depends on a number of factors including
- The severity of symptoms
- The extent of the endometriosis
- The woman’s age and her outcome requirements (e.g. reduction in pain, improved fertility)
Studies have estimated that, of every 100 women (with mild or no symptoms) who do not have treatment:
- Endometriosis will get worse in 50
- It will remain unchanged in 25
- It will shrink or disappear in 25
No treatment can absolutely prevent endometriosis from recurring but a combination of regular medical follow-up, hormone medication and/or surgery can control the condition.
Some women with mild endometriosis are not greatly troubled by symptoms, and treatment may not be needed. If symptoms are chronic or severe, then a variety of treatments may be required, including:
- Surgical treatment
- Hormonal therapies
- Combinations of the above treatments.
All of the following treatments have risks, benefits and limitations.
Anti-inflammatory medications and Painkillers
Only control minimal pain
Should be considered for
- Women with early stages who are not having adequate pain relief with these drugs
- Women with recurrent mild endometriosis and pain
Hormonal therapies are particularly effective in treating the pain associated with endometriosis. In cases of severe endometriosis, hormonal therapies usually do not work as well.
They may be used on their own, or in combination with surgical treatment. Hormones have the advantage of treating small lesions that surgery may miss.
As with all medicines, hormonal therapies have possible side effects. Side effects for the medicines are different and vary from woman to woman, and medicine to medicine. While side effects may be minor in some women, other women may want to stop treatment because of unpleasant or serious side effects. Some women find a gradual return of symptoms some months after treatment stops.
Treatment with the contraceptive pill
The contraceptive pill can help to relieve the pain of endometriosis. This is especially so if the tablets are taken continually for several months so that a period does not occur. This method is not suitable for women who are trying to become pregnant, as the contraceptive pill prevents pregnancy.
Treatment with a Progestagen
Taken every day, Progestagens usually help to relieve symptoms. Side effects are usually minor, but the pills may cause irregular bleeding, weight gain, tiredness and depression in some women. Progestagens can also be given as an injection once every 12 weeks. As with the contraceptive pill, Progestagens are not suitable for women who want to become pregnant. After a woman stops having Progestagen injections, the effects may take several months to wear off and pregnancy may not be possible during that time.
Treatment with other medicines
Other medicines have been effective in treating endometriosis, including:
Gestrinone or Danazol. These work by stopping periods. Side effects may include weight gain, increased hair growth, skin rash, and rarely, voice change.
Gonadotropin-releasing hormone (GnRH) agonists, for example, Goserelin or Naferelin. GnRH agonists prevent the release of oestrogen from the ovaries and suppress menstruation. This usually reduces the pain associated with endometriosis and the number and size of patches. As GnRH agonists cause oestrogen in the body to fall to very low levels, the side effects can be similar to symptoms of menopause and postmenopause, which may include:
- A small loss of bone density
- Changes in libido
- Hot flushes and night sweats
- Vaginal dryness
- Decreased breast size
- Mood changes
- Muscle pains.
Surgery can be effective for women who have mild, moderate or severe Endometriosis. The aim of laparoscopic surgery is to remove patches, cysts and adhesions. It may be helpful in reducing pain and improving fertility. Most endometriosis can be treated laparoscopically without the need to remove pelvic organs such as the ovaries or uterus.
Laparotomy (open surgery):
In some cases of severe endometriosis, a Laparotomy may be necessary. The advantage of a Laparotomy is that the large incision may be helpful for the surgeon if the disease is severe or a bowel resection is needed. A Laparotomy is major surgery.
In severe cases of long term and painful endometriosis in older patients, the woman may choose to have her uterus removed (hysterectomy). This is only done in women who are not planning any further pregnancies. One or both ovaries and fallopian tubes may also have to be removed to:
- Cure the endometriosis
- Remove endometriosis involving the ovaries, or
- Eliminate the source of oestrogen (ovaries)
- Cure the pain from adhesions constricting the ovaries.
- A hysterectomy is not usually recommended unless other treatments have failed.
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