Endometriosis

• Symptoms: Pelvic pain, cramping, dysmenorrhoea, painful sensation during intercourse, aching bowel movement, agonising urination, excessive bleeding, infertility, fatigue, diarrhoea, constipation, bloating, nausea during menstrual periods
• Causes: Lining of the uterus growing outside the intestine, ovaries, uterus, pelvic cavity, and fallopian tubes 
• Risk factors: Family history, defects in fallopian tubes and the uterus, shorter menstrual cycle, duration of bleeding during menstrual periods, age when menstruating began
• Severity: I-minimal, II-mild, III-moderate, and IV-severe
• Which doctor to consult: Gynaecologist

Overview

Endometriosis is a gynaecological disorder that causes the uterus's normal lining to grow abnormally. The painful chronic disease is common and occurs in 1/10th of the global female population. The disorder does not go away without treatment and can cause excruciating pelvic pain and infertility in women.

Women become susceptible to developing endometriosis after they reach reproductive age. It can even occur in women not having children or those having menopause at a later age. Shorter menstrual cycles (less than 27 days) can also be associated with the development of the disorder.

The disorder can remain undetected for years since it is often mistaken for menstrual pain. Other times, patients may suffer no visible symptoms. As the displaced uterine lining or endometrium attaches to other organs and grows, it can cause discomfort leading to severe pain. The condition usually involves the fallopian tubes, pelvic tissue linings, and ovaries. Eventually, it can affect the bladder and bowel, causing painful sensations during urination and defecation.

Endometriosis is most likely caused by retrograde menstrual flow when the blood flows backwards instead of going out of the vagina. The blood moves through the fallopian tubes into the peritoneum in such cases. As the menstrual flow enters the pelvis, it deposits the endometrial cells outside the uterus. These cells can then grow in unusual locations and cause problems.

When to Consult a Doctor?

It is recommended to consult a gynaecologist under the following conditions:

On Symptoms: If patients are experiencing severe pelvic pain, consistent dull period pain, nausea, or excessive menstrual bleeding, they must consult a gynaecologist. These could be signs of endometriosis. Since the condition is complex and challenging, having an early diagnosis can help provide the necessary medical assistance required for the treatment.

Difficulties Regarding Pregnancy: Failing to conceive after several attempts can indicate endometriosis. Although it is not the only cause of infertility, a professional gynaecologist can find the root cause. Since endometriosis blocks the fallopian tubes, the eggs cannot reach the uterus. Also, scar tissues can form due to abnormal growth, making it more difficult to achieve pregnancy.

Delayed Periods: Although a delayed period is not a clear sign of endometriosis, it can help in early diagnosis. Usually, women experiencing endometriosis suffer from painful sensations similar to menstrual cramps. The pain due to endometriosis also increases with time.

Regular Pelvic Exams: Women reaching puberty should consult their gynaecologist at least once a year. Regular health check-ups like a pelvic examination can curb the chances of forming endometriosis. This early diagnosis also helps the doctor inspect the vulva, vagina, cervix, and other areas for lumps.

Diagnosis

Physical Examination: A gynaecologist may perform a pelvic and rectal inspection of the areas for checking any unusual growth. Although the chances of detecting endometriosis through a physical examination are low, it can help in preliminary diagnosis. Reduced uterine mobility, tender uterosacral nodularity, cervical motion tenderness, or a retroverted uterus can all be signs of the disease.

Diagnostic Tests

Imaging Tests: Imaging tests are crucial for detecting endometriosis. These can confirm various information regarding the growth, such as the size, shape, location, etc. There are a few ways the imaging tests can be done.

• Ultrasound: An ultrasound test is done using high-frequency waves that produce images of the inside of the body. A transducer device is pressed against the abdomen or inserted into the vagina. The former is a standard ultrasound, and the latter is transvaginal ultrasound. However, none of these tests can confirm endometriosis. Instead, these tests can identify the cystic lesions associated with the disorder, called endometriomas.
• Magnetic Resonance Imaging (MRI): An MRI examination is another method that helps create a detailed image of the internal organs and tissues. The procedure involves using a magnetic field and radio waves to produce the picture. It is a helpful device to help your doctor in surgical planning.

Blood Tests: A CA125 test is a type of blood test that allows checking the levels of CA125 protein in the blood. This is a tumour marker for various gynaecological examinations as the protein level is high in endometriosis patients. The only drawback of this method is that the CA125 level is also high in pregnant women.

Advanced Test

• Laparoscopy: It is a minimally invasive procedure in which the surgeon makes small incisions and uses a laparoscope for diagnosis. Performing a laparoscopy lets the surgeon gather accurate information about the endometrial growth. It also allows the collection of tissue samples for testing (biopsy). It is also possible to treat endometriosis completely while performing laparoscopic surgery.

Treatment

Home Care: If the pain due to endometriosis becomes too unbearable, few home remedies can help. Applying heat to the pelvic muscles is an excellent remedy, as it allows the muscles to relax. This can ease up the pain and cramping. Taking over-the-counter inflammatory medication like ibuprofen can also provide quick relief from the painful sensations. However, it is recommended not to use them for more than a week. Consuming turmeric capsules or turmeric tea with ginger powder and honey thrice a day may also provide relief.

Medication: Besides over-the-counter pain-relieving drugs, doctors may prescribe other medicines like hormone therapy. These medications are recommended only if the patient is not trying to conceive.

• Aromatase Inhibitors: These are a group of medications that reduce the oestrogen levels in the body. However, the gynaecologist may prescribe these medications along with some progestin or combination hormonal contraceptives.
• Gonadotropin-releasing Hormone (Gn-RH) Agonists and Antagonists: Gonadotropin-releasing hormone controls the release of follicle-stimulating and luteinising hormone. So, the Gn-RH agonists and antagonists drugs help prevent ovarian-stimulating hormone production. As a result, the oestrogen level drops, pausing menstruation artificially. This helps shrink the endometrial tissue. The doctor may even prescribe a small dose of progestin with the Gn-RH drugs to avoid any side effects.
• Hormonal Contraceptives: Various contraceptives such as patches, vaginal rings, and birth control pills can moderate the hormones responsible for endometriosis build-up. Many patients are reported to have shorter and less painful menstrual flow while using these.
• Progestin Therapy: Oral progestins can be an effective medication against endometriosis. Drugs like levonorgestrel or progestin pills can stop menstrual cycles and the growth of endometrial implants.

Surgical Treatment

• Conservative Surgery: Conservative surgery allows the surgical removal of the endometriosis implants without damaging the ovaries and uterus. So, this is beneficial for those trying to conceive. The procedure is usually performed laparoscopically. However, in more severe cases, abdominal surgery is unavoidable.
• Fertility Treatment: Since endometriosis directly impacts the ability to conceive, gynaecologists may recommend a fertility treatment. This is usually done in the presence of a fertility specialist. The process involves various steps like ovary stimulation and in vitro fertilisation.
• Hysterectomy: Hysterectomy is another surgical method that helps remove the uterine lining that grows outside the uterus. Previously, removing the uterus (hysterectomy) and ovaries (oophorectomy) was the most popular treatment method. But now, alternate ways to preserve the uterus and ovaries are preferred.

Risk and Complications if Left Untreated

• Chronic Pain: Rapid undetected or untreated development of endometrial implants can make the areas extremely painful. The painful sensation is much more severe than the usual menstrual cramps. As a result, the quality of life is affected, as the patient may feel fatigued all the time and experience pain during intercourse. Also, consistent diarrhoea and other gastrointestinal complications can make matters worse.
• Infertility: Untreated endometriosis is a known cause of infertility. The misplaced uterine growths can block the fallopian tubes, restricting the movement of eggs to the uterus. Moreover, scar tissue can make it challenging to become pregnant.
• Urination Problems: Untreated endometriosis can impact various surrounding organs, depending on the severity. One of the common side effects of long-term endometriosis is the feeling of pain while urinating. Patients may also find it difficult to clear their bowels while suffering from uterine pain.
• Ovarian Cysts: The unusual endometrial tissue growth on other organs like the pelvis and abdomen can cause ovarian cyst formation. This, in turn, can lead to rapidly growing and enlarged cysts that pressure the ovary. The ovarian cysts can even burst, causing sepsis.
• Cancer: Leaving endometriosis untreated for a long time can develop epithelial ovarian cancer. This common type of ovarian cancer includes primary peritoneal and high-grade serous ovarian cancer (HGSOC). The condition can even lead to low-grade endometrial endometrioid carcinomas. These tend to spread quickly; the only solution is debulking surgery on the tumours.

Additional Information

• Classification of endometriosis:

a. Stage I: Minimal disease with some superficial endometrial implants 
b. Stage II: Milder version of the disease with deeper implants noticeable 
c. Stage III: Moderate disorder with deep endometrial implants and development of ovarian cysts 
d. Stage IV: Severe endometriosis with numerous deep implants, large cysts, and dense adhesions

• Effect of endometriosis on mental health: Apart from physical pain, patients with endometriosis can often succumb to mental distress. Dealing with chronic pain for too long can cause them to suffer from anxiety and depression. So, a patient may need to consult a mental health counsellor and a gynaecologist simultaneously.
• Pregnancy with endometriosis: Despite the complications that endometriosis causes, it is possible for patients with endometriosis to get pregnant. The disorder may damage the egg and cause inflammation, but women with the disease can still give birth. It is best to consult a gynaecologist regarding the treatment options, including medication and surgical procedures.