Endometriosis is a puzzling hormonal and immune disease that affects girls and women from the age of eight till after menopause. The name comes from the word, ‘endometrium’, which is the tissue that lines the inside of the uterus, builds up and sheds itself each month in the menstrual cycle.
The age of 27 is the average age when a woman is first diagnosed with endometriosis. It is the third most common cause of female infertility. We have had cause to be concerned about this disorder because of the alarming increase in the number of patients presenting with endometriosis in our clinic. Hence, I am focusing on this preventable disease.
In endometriosis, a tissue like the endometrium is found outside the uterus in other parts of the body. In those areas outside the uterus, the tissues develop into what are called nodules, tumours, lesions, implants or growths.
The most common locations of growths are in the abdomen, involving the ovaries, fallopian tubes, ligaments supporting the uterus vagina, bladder, rectum and the lining of the pelvic cavity.
Sometimes these growths can also be found in the uterine muscle, termed adenomyosis and following abdominal scar surgeries, umbilicus (laparoscopy). They can also be spotted in distant sites, such as the heart, lungs and pleura, but this is uncommon.
Endometriosis presents usually as a clinical suspicion based on the symptoms, such as chronic pelvic pain (low abdominal pain), worsening dysmenorrhea (painful menstruation), acquired dyspareunia (painful intercourse), premenstrual spotting, infertility, painful defecation with bleeding and a host of other non-specific symptoms.
It occurs in about 20 per cent to 25 per cent of females in the reproductive age (15-45 years).
Risk factors for this disease include first-degree relatives’ affected, short menstrual cycles, light complexioned women, long duration of menstrual flow, low parity, environmental toxins and infertility.
The causes of endometriosis are not clear, but some theories serve as pointers to it.
One of them is the retrograde menstruation or trans-tubal migration theory. This proposes that during menstruation; some menstrual tissues back up through the fallopian tubes, implant in the abdomen and grow. This happens in most women, if not all, but an immune system problem and/or hormonal problem allows this tissue to take root and grow.
Another theory suggests that those tissues are distributed from the uterus to other parts of the body through the lymphatic system or blood.
There is also the genetic theory, which suggests that certain families have some predisposing factors for the disease. A coelomic metaplasia theory suggests that embryonic cells can transform to tissues similar to that of the uterus and respond to the monthly hormonal stimulation.
Surgical transplantation has also been cited as a cause of endometriosis, especially in cases where growths were found in abdominal surgery scars.
However, it can be found in some scars where direct accidental implantation is unlikely.
In 1992, a research done by the endometriosis association showed that environmental toxins, such as dioxin and PCBs (Printed Circuit Boards), which act like hormones in the body and damage the immune system, can cause endometriosis.
Dioxins are highly toxic chemicals that come from the production and use of pesticides, and herbicides; municipal, medical and hazardous waste incineration; chemical and plastic manufacturing; pulp and paper production.
Dioxins readily concentrate in the food chain, contaminating animals, fish; thus food is the primary source of dioxin exposure for humans.
The incidence of endometriosis in women of reproductive age ranges between two and four per cent with higher prevalence in women with infertility (25 to 50 per cent). Many theories have been proposed to explain why it is harder for women with endometriosis to conceive.
However, as of today, none of the theories has been proved. It is possible that there are several causes and that different causes are relevant in different women. Some of the theories include:
- Pelvic adhesions inhibit the movement of the egg down the fallopian tube
- Eggs are of poor quality.
- Chemicals produced by the endometriosis inhibit the movement of the egg down the fallopian tube.
- Inflammation in the pelvis caused by endometriosis stimulates the production of cells that attack the sperm and shorten their life span.
- Endometriomas occupy space, thereby reducing the amount of functional ovarian tissue and eventually the number of eggs produced.
- Eggs are not released from the ovaries each month (also known as anovulation, which may also occur in women without endometriosis).
Diagnosis of endometriosis can be done clinically; examination of the pelvic region may reveal fixed retroverted uterus, pain around the pelvic region, fixed enlarged ovaries, painful uterosacral nodules.
Diagnosis is considered uncertain without laparoscopy. Laparoscopy is a surgical procedure done under anaesthesia. It helps the surgeon to visualise the condition of the abdominal organs and, if careful and thorough, see the growths.
Ultrasound can be used to visualise these growths on the ovary, it usually appears as a fine homogenous, uniform, granular echoes, single or multiple, on one or both ovaries.
On Doppler ultrasound, there is no vascularity (blood flow) within the mass. MRI can also be used to diagnose the condition. The ca-125 hormone can be assayed in severe cases.
Treatment of endometriosis has changed over the years, but no sure cure has yet been found. There is no cure for endometriosis, but treatment can help to reduce pain and infertility. Treatment depends on how severe your symptoms are and whether you want to get pregnant.
If you have pain only, hormone therapy to lower your body’s estrogen levels and shrink the implants/growths may reduce the pain. If you want to become pregnant, having surgery, infertility treatment, or both may help.
Not all women with endometriosis have pain and it doesn’t always get worse over time. During pregnancy, it usually improves, as it does after menopause. Menopause is also believed to end the activity of mild to moderate endometriosis.
Women with mild pain, who have no plans for a future pregnancy or are near menopause (around age 50), may not feel a need for treatment. The decision is up to them.
However, if there is pain or bleeding and they aren’t planning to get pregnant soon, birth control hormones (patch, pills, or ring) or anti-inflammatories may be all that is needed to control pain.
Birth control pills
Pills are likely to keep endometriosis from getting worse. Women who have severe symptoms or if birth control hormones and NSAIDs don’t work may try a stronger hormone therapy. Besides medicine, other things can be tried at home to help with the pain. For example, apply heat to your belly, or exercising regularly.
Conservative surgery, either major or through the laparoscope, involving removal or destruction of the growths, is a treatment option that can relieve symptoms and allow the spontaneous pregnancy to occur some cases.
Radical surgery, involving hysterectomy (removal of the uterus) and removal of all growths and the ovaries (to prevent further hormonal stimulation), may become necessary in cases of long standing, troublesome disease and for women who are no longer desirous of pregnancy.
If there is trouble becoming pregnant (infertility) even after surgery, you can consider trying fertility drugs with insemination or In Vitro Fertilization (IVF).
Complementary treatments including nutritional approaches, immunotherapy, detoxification via MAYR therapy, allergy management techniques are being used by women with endometriosis. Some of these treatments have been found to be successful in terms of pregnancy and pain relief.
You can also read this article in Punch