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The term endometriosis refers to a benign and common disease in which cells like
the ones that line the inside of the womb (endometrial tissue), grows outside
the uterus and attaches to other organs in the abdominal cavity such as the
ovaries and fallopian tubes. These cells, like the endometrium, respond to the
monthly hormonal changes. When the woman with endometriosis menstruates, the
endometrium is shed in the form of a period. The endometriosis breaks down in
the same way but these cells are trapped inside and cannot escape. Early
implants look like small, flat dark patches or flecks of blue or black paint (
"powder-burns" ) sprinkled on the pelvic surfaces. Later, they form swellings
filled with blood called endometriomas . With time, this blood darkens to a
deep, reddish brown colour, giving rise to the description "chocolate cyst."
These may be smaller than a pea or larger than a grapefruit . They occur most
frequently in the ovary but can form anywhere in the pelvis. Endometriosis also
causes an inflammation that forms scar tissue and adhesions which can block the
fallopian tubes or interfere with ovulation.
No one knows for sure what causes this disease. One theory is that during
menstruation some of the menstrual tissue backs up through the fallopian tubes
into the abdomen, where it implants and grows. Another theory suggests that
endometriosis may be genetic, or runs in families.
Endometriosis tends to occur in women who are in their 30s and early 40s, but
occasionally occurs in those under 30 years of age. It is more commonly seen in
patients who have not borne a child . 30-40% of women with endometriosis may
have difficulties in becoming pregnant. Though endometriosis prevents
conception, when treated the patient can conceive.
The disease is highly unpredictable. Some women may have just a few isolated
implants that never spread or grow, while in others the disease may spread
throughout the pelvis. Endometriosis is usually a progressive disease that
tends to get worse over time and can reoccur after treatment. When it will
recur cannot be predicted. However a full term pregnancy may prevent recurrence
or delay it. Endometriosis recurs in about 20 percent of cases over 5 years in
patients who have been treated for endometriosis
Some patients with endometriosis may have no symptoms. Symptoms include severe
menstrual cramps, pain during intercourse, and infertility. . Occasionally,
however, the disease is accompanied by vaginal bleeding at irregular intervals;
or by premenstrual spotting. There is little correlation between the severity
of symptoms and extent of the endometriosis.
The anatomical distortion caused by endometriosis, specially when it is moderate
and severe, could explain a mechanical cause of infertility. The precise
mechanism by which minimal and mild endometriosis affects fertility is not
fully understood. It is possible that endometriosis adversely affects the egg
development, sperm binding to the egg, fertilization, tubal function and embryo
implantation.
The only means to confirm a diagnosis of endometriosis after a medical history ,
pelvic exam and a sonography is by
laparoscopy. Laparoscopy assesses the severity of endometriosis and the
condition of the Fallopian tubes.
The treatment is planned based on the stage of endometriosis ( mild to
extensive), and may include medication or surgery or IVF, or a combination.
Treatment Options
Hormone medication
The goal of hormonal treatment is to simulate pregnancy ( progesterone drugs) or
menopause (danazole and GnRH agonists), two natural conditions known to inhibit
the disease. In each case, the normal endometrium is no longer stimulated to
grow and regresses with each monthly cycle. This action prevents menstruation
and causes endometrial implants to shrink. To be effective against
endometriosis, the pills / injections must be taken continuously for 3 – 6
months, without pausing for withdrawal bleeding.
Gonadotropin-releasing hormone (Gn-RH) agonists. These drugs
block the production of ovarian-stimulating hormones.. It can force
endometriosis into remission during the time of treatment and sometimes for
months or years afterward. These drugs create an artificial menopause that can
sometimes lead to troublesome side effects such as hot flashes and vaginal
dryness. These drugs can be given in the form of special injections called
depot preparations, which release small quantities of the drug daily, allowing
administration at monthly intervals.
Danazol(a testosterone derivative), may not be the first choice because it
can cause unwanted side effects, such as acne and facial hair.
Progesterone drugs, given in the form of daily oral medication, are much cheaper
but may not be tolerated well as its side effects include weight gain and a
depressed mood.
Surgery
Hormonal therapy may be prescribed along with conservative surgery.
Medication usually controls mild or moderate pain and may eliminate small
patches of the disease. But large chocolate cysts in the ovary are less likely
to respond, and drugs cannot remove scar tissue. This is why surgery may be
needed to improve fertility by removing adhesions, lesions, nodules or
endometriomas.
Conservative surgery seeks to remove or destroy the growths, relieve pain, and
allow pregnancy to occur if desired. Conservative surgery can involve
laparoscopy or laparotomy. Most cases can be successfully treated through the
laparoscope. Open surgery (laparotomy) is needed only very rarely and may be
required with advanced disease that involves large areas of the rectum or
larger lesions.
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Simple puncture - This procedure is completed by draining the chocolate
material/fluid from the endometriotic cyst. It is the procedure of choice for
infertile patients who need to undergo an IVF/ICSI procedure as a laparoscopy
can be avoided. GnRH agonists are given for 3 months prior to the
IVF/ICSI cycle and the cyst drained under anaesthesia and
ultrasound guidance after the first menstrual bleed. Fertilisation rates in
some patients with endometriosis can be a little lower perhaps because of an
intrinsic oocyte abnormality. ICSI is usually recommended.
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Early Endometrial lesions or superficial implants of endometriosis can be
burned away using a high-energy heat source or an electric current called
diathermy during a laparoscopy.
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Ablation - Another approach is to drain the cyst and destroy or burn its base
with electrosurgery – usually done as a laparoscopic procedure.
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Cutting away of the cyst wall - This is the procedure of choice to
decrease recurrence of disease and is done laparoscopically.
Radical surgery, which may be necessary in severe cases, involves hysterectomy,
removal of all growths, and removal of ovaries. For women nearing 40 and who
have finished childbearing, removal of uterus and both ovaries is the only
option to prevent reccurence.
Adenomyosis
With adenomyosis, the tissue that lines the uterus (endometrium) grows within
the uterus' muscular outer walls. This is most likely to happen in the late
childbearing years and after having had children.
Adenomyosis isn't the same as endometriosis, Although the cause of adenomyosis
remains unknown, the disease typically disappears after menopause. For women
who experience severe discomfort from adenomyosis, there are treatments that
can help, but
hysterectomy is the only cure.
When it occurs in younger patients who desire pregnancy and is localised to a single
area of the uterus, It can be excised laparoscopically without having to remove the uterus.
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