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Endometriosis and infertility by Prof Oladapo Ashiru

Endometriosis is a puzzling hormonal and immune disease affecting girls and women from the age of eight to post-menopausal. The name is from the word endometrium, the tissue that lines the inside of the uterus. And builds up and sheds each month in the menstrual cycle.

  One in 10 women gets affected by endometriosis during their reproductive years (ages 15 to 49). 176 million women in the world have endometriosis. It represents six to 10 per cent of women of childbearing age; 30 per cent to 50 per cent of women with endometriosis may experience infertility. The average age a woman presents with endometriosis is 27. It is the third most common cause of female infertility.

In endometriosis, tissue like the endometrium is outside the uterus in other areas of the body. In those areas outside the womb, the tissues develop into what are called nodules, tumors, 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, the lining of the pelvic cavity. Sometimes the growths can also be found in the uterine muscle, termed adenomyosis. It can also be noted in distant sites such as the heart, lungs, pleura, but this is uncommon.

 Endometriosis usually presents 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.

Risk factors for this disease include; first degree relatives’ affected, short menstrual cycles, fair-complexioned women, long duration of menstrual flow, low parity, environmental toxins, and infertility.

The causes of endometriosis are not clear, but some theory has been proposed that serves as a pointer.

 One of the theories is that of retrograde menstruation or trans-tubal migration theory. This theory proposes that during menstruation, some menstrual tissue backs up through the fallopian tubes, implants in the abdomen, and grows. It happens in most women, if not all, but an immune system problem and hormonal problem allows this tissue to take root and grow.

Another of those theories suggests that those tissues are distributed from the uterus to other parts of the body through the lymphatic system or blood.

Genetic theory suggests that individual families have some predisposing factors for the disease.

The coelomic metaplasia theory suggests that embryonic cells can transform into 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; in cases where those growths are found in abdominal surgery scars, it can be found in some injuries where direct accidental implantation is unlikely.

 In 1992, a research done by the endometriosis association had shown that environmental toxins such as dioxin and PCBs (Printed Circuit Boards), which act like a hormone in the body and damage the immune system, that 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.

Many theories have been proposed to explain why it is harder for women with endometriosis to conceive. However, as yet, none have been proven. It is possible that there are several causes and that different reasons 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 impede the progress 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

-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 made clinically; examination of the pelvic region may reveal fixed retroverted uterus, pain around the pelvic area, fixed enlarged ovaries, painful uterosacral nodules.

Diagnosis is considered uncertain without laparoscopy. Laparoscopy is a surgical procedure done under anesthesia, helps the surgeon visualize the condition of the abdominal organs, and, if careful and thorough, see the growths.

Ultrasound can be used to visualize these growths on the ovary; it usually appears as a beautiful homogeneous, uniform, granular echoes, single or multiple, on one or both ovaries.

Treatment of endometriosis has varied over the years, but no sure cure has yet been found.

There is no cure for endometriosis, but treatment can help with 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 will shrink the implants/growths and reduce pain. If you want to become pregnant, having surgery, infertility treatment, or both may help.

Not all women with endometriosis have pain. And endometriosis 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 have no plans for a future pregnancy or are near menopause, may not feel a need for treatment. The decision is up to them.

 However, if there is pain or bleeding, a woman who is not planning to get pregnant soon, birth control hormones or anti-inflammatories may be all that is needed to control the pain. Birth control hormones are likely to keep endometriosis from getting worse.

 Women who have severe symptoms or if birth control hormones and NSAIDs did not work may try more potent hormone therapies. 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 pregnancy to occur in 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.

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