Endometriosis

By Dr. Ragini Agrawal

Smita was suffering from severe abdominal pain during menstruation from the age of 20. She had painful heavy bleeding for all 5 days. Even tablets did not have much effect. At the age of 24 years she got married. She used to have severe pain during sexual intercourse. 2 years later she was still unable to conceive so she visited a gynaecologist. The doctor advised her to go for an ultrasound. On examination it was found that she is suffering from severe grade endometriosis along with chocolate cyst of both the ovaries.

The question arises – what is this disease and what the implication of these complaints? Endometriosis is a long lasting disease which is not a cancer but it makes life hell. It is she of most common causes of pelvic pain and infertility in women.

In this disease tissues like lining of uterine cavity (endometrium) is found outside uterus. Its implants are found everywhere in the abdominal cavity but usually around uterus like on the fallopian tubes, ovary and the membrane surrounding pelvic area. Sometimes this membrane invades the muscles of uterus and then this disease called adenomyosis. Sometimes it can invade the urinary bladder, surrounding areas of the intestine and the rectum. Sometimes ectopic endometrium is even reported in the eye, mouth or even any of the lungs.

What happens actually is that every month when the woman bleeds, she bleeds outside which is called menstruation. When she bleeds from these implants outside uterus and inside the pelvic cavity, it leads to the formation of adhesions between neighbouring organs and fluid-filled structures around the uterus and ovary, giving rise to big chocolate cysts. This fluid is nothing but a collection of old blood.

There are several theories why it happens but nothing is certain yet.

Repercussions: Implications of the disease is painful and heavy menstruation, a dull ache in the abdomen and pain during intercourse. These patients usually suffer from pain during defecation too. Major impact of this problem in women is the inability to conceive.

Women during their reproductive years (between the onset of menstruation to menopause) are usually affected by endometriosis. The incidence of endometriosis across the world is almost she in ten women during the reproductive years (10%).

Symptoms: Pelvic pain is the most common presentation of endometriosis. This pain is correlated with the menstrual cycle. However with the advancement of the disease, women may experience pain at other times also. This pain can be so severe and debilitating in nature that the woman is not able to do daily activities. The pain is present during the whole menstrual cycle. Sometimes even during ovulation or during defecation, more so during menstruation, the pain persists. While passing urine also, she can experience pain. Sexual intercourse is a painful phenomenon. A persistent dull ache in the back region is also reported.

Other than pain, most women report heavy or irregular bleeding, constipation or diarrhoea during menstruation. Chronic fatigue and feverish feeling is also present sometimes.

Second most common symptom which women present is infertility. About 30% women with endometriosis are sub-fertile.

If pain during menstruation affects your daily schedule of work and social life, your dysmenorrhoea may be because of endometriosis and this is the right time to visit your gynec.

Treatment: According to European Society of Human Reproduction and Embryology (ESHRE) guidelines for identifying and alleviating the disease following is suggested:

For women presenting with symptoms suggestive of endometriosis, an authoritative diagnosis of most forms of endometriosis requires visual inspection of the pelvis by laparoscopy as the Gold Standard investigation. However, pain symptoms suggestive of the disease can be treated without a perfect diagnosis using a therapeutic trial of a hormonal drug to reduce menstrual flow.

Women whose disease has been confirmed with laparoscopy, suppression of ovarian function for 6-months reduces pain associated with endometriosis. All hormonal drugs studied are equally effective but they have different side-effects and costs. Reduction of the lesions associated with the disease reduces endometriosis-connected pain and the minimal effect is seen in patients with minimum disease. There is often no evidence that performing laparoscopic uterine nerve ablation (LUNA) is required.

In mild endometriosis, function of the ovaries is suppressed to improve fertility but this is not effective. However, when endometriotic lesions are ablated and adhesiolysis is also done, the treatment is effective in comparison with only diagnostic laparoscopy. Evidence that surgical removal of moderately severe endometriosis improves chances of pregnancy, is not clear enough. IVF is a suitable treatment particularly if there are other causes of infertility existing simultaneously and/or if other treatments have not worked. But IVF pregnancy rates are lower in cases of women with endometriosis than in those with infertility due to an issue in the fallopian tubes.

Managing severe/deeply infiltrating endometriosis is complicated and requires the necessary expertise to deal with it. Self-help can provide invaluable counselling, support and advice.

Still endometriosis is enigmatic since the causes are not clearly known and the definition is anatomical. There is no proper treatment as it is difficult to diagnose. Laparoscopy is still a gold standard for diagnosis of the disease.

Medical management is not completely effective and surgical treatments can also have some limitations. The disease may relapse. It is locally an invasive disease, many times involving the bowel and bladder too. And complete operation can be very risky. She may require resection of bowel too.

About Dr. Ragini Agrawal: Dr. Ragini Agrawal is a Gynaecologist and Clinical Director at W-Hospital by Pratiksha, Gurgaon.