What is Endometriosis

Endometriosis is a chronic gynecologic condition characterized by the development and presence of tissue similar to the uterus lining (endometrium) outside the uterus, causing scarring, inflammation, and painful cysts that impact the menstrual cycle and daily life. 

Globally, it is affecting approximately 190 million (10%) of girls and women of reproductive age, affecting 1 in every 10 females and often diagnosed in their 30s and 40s.

Some of the common places that women can develop endometriosis include ovaries, the space behind the uterus, fallopian tubes, the peritoneum, the myometrium (a layer of the uterine wall), and less commonly, the lung, vagina, bladder, rectum, diaphragm, and intestines.

Causes of Endometriosis

The exact cause of endometriosis is still unknown. However, it is thought to be involved with the following theories:

• Genetics: As per many experts, it is concluded that there is a connection between a family history of endometriosis and an increased risk of developing it.
• Reverse menstruation or Retrograde menstruation: Endometrial tissue flows back through the fallopian tubes and into the pelvic cavity (abdomen) at the time, during the time that menstrual blood is flowing out of the body through the cervix and vagina, resulting in deposition of endometrial-like cells outside the uterus.
• Cellular metaplasia: Normal cells change from one form to another form, changing into endometrial-like cells and starting to grow.
• Blood or lymph system transport: Misplaced or abnormal stem cells may initiate and spread disease, whether it is endometriosis or cancer.
• Transformation: Other normal cells in the body may become endometrial cells and start growing outside the uterus.
• Direct transplantation: After surgery like a hysterectomy or C-section, endometrial cells may attach to the walls of the abdomen or other areas of the body.
• Estrogen: It is believed that endometriosis is estrogen-dependent, increasing growth, inflammation, and pain. However, the absence of estrogen does not always indicate the absence of endometriosis.

Risk factors of Endometriosis

As per studies, it is suggested that some factors can increase the risk of developing endometriosis, such as:

• Early menstruation (before age 11)

• Heavy menstrual periods lasting more than seven days
• An abnormal uterus
• Family history of endometriosis
• Shorter menstrual periods (less than 27 days on average)

Some things that can lower the risk of endometriosis include:

• Pregnancy and breastfeeding
• Eating fruits, especially citrus fruits
• First menstruation after age 14

Common symptoms and complications of Endometriosis

Symptoms

The most common symptom of endometriosis is severe pain in the pelvic region, especially during the menstrual periods. The other symptoms include

• Heavy bleeding during periods or spotting between periods
• Back pain during the period
• Pain during sex
• Infertility
• Pain when peeing or pooping
• Stomach issues like bloating, constipation, or diarrhoea

Some women also experience:

• Fatigue
• Depression or anxiety
• Chronic pelvic pain

Some women may have endometriosis without experiencing any symptoms and only discover it when they face difficulty getting pregnant.

Complications 

The endometrium tissue is hormonally responsive and may undergo bleeding, fibrosis, inflammation, and adhesion formation leading to pelvic pain. Over time, the symptoms may worsen and make it difficult to naturally conceive, causing complications that include:

• Cancer risk (rare risk of the non-cancerous cyst becoming cancerous)
• Endometrioma rupture
• Endometrioma infection
• Decidualization of Endometrioma During Pregnancy (due to pregnancy, the cyst may change in appearance)
• Risk of pregnancy complications
• Bladder or bowel issues
• Shortness of breath (very rare)

Diagnosis of Endometriosis

In many cases, diagnosis of endometriosis often starts with the symptoms, because a careful history of menstrual symptoms such as painful and heavy periods provides the basis for suspecting endometriosis.

• Physical examination: During a pelvic exam, a speculum and light can be used to see the inside of the vagina and cervix. Doctors use their hands to manually feel the cysts or scars in the abdomen.
  • Vaginal examination: A doctor inserts one or two gloved fingers inside the vagina, pressing down on the abdomen at the same time. The following are the signs that can be commonly observed in endometriosis.
    • Tenderness or pain when pressing inside the vagina
    • Small nodules or lumps behind the uterus
    • Swollen areas near the ovaries
    • A uterus that doesn’t move freely due to sticking to scar tissue

After the examination, the doctor may order certain tests to look at the signs and confirm the diagnosis of endometriosis. Common diagnostic imaging investigations include:

• MRI: It is a non-invasive scan that uses magnetic waves to examine the organs and tissues inside the body, especially to diagnose endometriomas.
• Ultrasound: Ultrasound, specifically transvaginal sonography (TVS), is a valuable tool for examining the uterus to identify endometriosis by spotting signs like cysts and masses.

Other tests include:

• Laparoscopy: A small cut can be made in the abdomen, and a thin tube with a camera and a light will be inserted, allowing for the examination of the tissues in and around the uterus to look for signs of endometrial tissue growth.
• Biopsy: If the doctor finds suspicious abnormal tissue, a small device can be used to scrape off a few cells and send them to the laboratory to examine the tissues under a microscope to diagnose endometriosis.

Treatment options (medical and surgical) for Endometriosis

Your doctor creates a treatment plan for endometriosis based on factors such as age, severity of symptoms, endometriosis, and plans for future pregnancies. Most of the cases can be resolved without surgery, especially with pain management.

Medical management of endometriosis

• Pain medicines
  • Analgesics
• Hormone therapy
  • Combined Oral Contraceptives (COCs)
  • Progestins
  • GnRH agonists and antagonists
  • Aromatase inhibitors

Surgical management of endometriosis

• Laparoscopic surgery
• Hysterectomy

Medical management of endometriosis

Medications can manage the symptoms by reducing the pain and suppressing the menstrual cycle.

Pain medicines

• Analgesics: Especially NSAIDs can help alleviate pain associated with endometriosis by blocking the production of prostaglandins.

Hormonal therapy:

Hormonal birth control can come as combination therapy (progestin and estrogen) or progestin-only options. Hormonal therapies can regulate cycles and improve the chances of conception, especially for those with endometriosis-related fertility.

• Combined Oral Contraceptives (COCs): These pills contain both progestin and estrogen, regulating periods and reducing pain.
• Progestins: These drugs, available in various forms like injections or pills, can suppress the growth of endometrial tissue and decrease pain.
• GnRH agonists and antagonists: These medications help to stop the hormones that cause the menstrual cycle and lower the estrogen levels, causing endometriosis tissue to shrink.
• Aromatase inhibitors: These are a class of medicines that decrease the estrogen levels in the body. They may recommend it along with progestin or combination birth control pills.

Surgical management of endometriosis

Doctors recommend surgery to treat some cases of endometriosis when conservative treatments (hormone therapy and pain medication) are not effectively managing symptoms or when there are complications for women, such as experiencing infertility due to endometriosis.

• Laparoscopic surgery: This is also called keyhole surgery, where a surgeon makes tiny cuts in the abdomen and inserts a thin, tube-like tool into the body to see inside the body and inserts additional surgical instruments to remove the endometrial tissue.

Rarely, open surgery (larger incision) can be performed to remove thick bands of scar tissue.

• Hysterectomy: In severe cases, the surgeon may suggest removing the uterus with or without the removal of ovaries based on the patient’s age, severity, future pregnancies, and overall reproductive health.

Prevention of endometriosis

Currently, there is no proven way to prevent endometriosis. However, increased awareness, early diagnosis, and proper management can help slow or stop its progression and reduce the long-term impact of its symptoms.

Living and coping with endometriosis

Living with any medical condition can be physically and emotionally challenging, especially with chronic conditions that have no cure, which are hard to accept and cope with.

Endometriosis is one of the chronic gynaecological conditions that causes painful symptoms and even fertility issues. Living with this condition involves a combination of medical treatments and lifestyle adjustments like dietary changes, exercise, and surgery in severe cases.

Sometimes emotional support from friends, family, and therapy can be needed and make a big difference emotionally. Though endometriosis has no cure, many women can manage it effectively and lead fulfilling lives.

Conclusion:

Endometriosis is a chronic yet manageable condition that affects many women worldwide. While it can cause significant pain, complications, and fertility issues, early diagnosis and a personalized treatment plan — including medication, surgery, and lifestyle changes — can greatly improve quality of life. With the right support and care, many women with endometriosis can lead healthy, fulfilling lives.