The endometrium is the tissue that lines the womb (uterus). This thickens during a menstrual cycle and breaks down on a monthly basis and is shed during the menstrual period. Endometriosis is a condition characterised by the growth of endometrial tissue in abnormal sites. Most commonly patches of endometriosis grow outside the uterus in the pelvic area but they can occur in almost any site in the body e.g. on the bowel, in the bladder and in the lungs. At the time of a menstrual period when the endometrium breaks down the spots of endometriosis can bleed causing pain and inflammation and result in adhesions and sub-fertility. One in ten women will suffer with endometriosis during their reproductive life span. Frequently endometriosis is a condition that worsens with time and may re-occur after treatment.
Endometriosis can occur on the surface of the ovaries and also within the ovaries themselves. In this situation they can form blood filled cysts called endometriomas (chocolate cysts). Endometriosis can be classified into four stages based on it severity with Stage 1 being the least severe and Stage 4 being the most severe. With Stage 4 disease the organs adjacent to the uterus such as the bowel and bladder are usually involved.
The most common symptom is pain in the pelvic area at the time of the menstrual period. The degree of pain can vary from mild to very severe. The severity of the pain does not necessarily relate to the stage of the disease. Other symptoms that may be present are:
- Pain during ovulation.
- Pain during sexual intercourse.
- Painful periods.
- Heavy prolonged or irregular bleeding.
- Spotting before or after periods.
- Difficulty in conceiving (sub-fertility).
If patches of endometriosis are present in other parts of the body other problems can arise:
Urinary tract endometriosis can cause blood to be present in the urine and also pain on passing urine if situated in the bladder.
Bowel endometriosis can cause bleeding from the rectum and pain on defecation. Pulmonary (lung) endometriosis can cause coughing up blood typically at the time of a period.
Painful lumps in the skin can indicate endometriosis in the skin typically in scar tissue after surgery.
Patients suffering with pelvic pain, irregular bleeding or period problems will need to have an ultrasound scan performed. This is best done by the transvaginal route as it will give a clear picture of the uterus, endometrium and ovaries. Ovarian cysts and endometriomas can normally be diagnosed this way.
The only way to confirm a diagnosis of endometriosis is to perform a laparoscopy (keyhole surgery). This involves placing a tube (laparoscope) through a small incision in the abdominal wall under general anaesthesia attached to a camera. It is normally possibly to treat endometriosis by this method as well. Laparoscopy is normally performed as a day case procedure so that patients can go home the same day as surgery.
Endometriosis can be treated in a variety of ways but the majority of cases will be treated at the time of diagnosis by keyhole surgery. Other treatments may also be used in conjunction with surgery.
- Anti-inflammatory drugs.
- Combined oral contraceptive pill – taken continuously for six to nine months to prevent menstrual bleeding.
- Progesterone therapy taken for six to nine months continuously to stop menstrual periods.
- GNRH analogues – these drugs can be taken as a nasal spray or a monthly or three monthly injection to create a temporary menopause.
This is the most effective form of treatment. In the majority of cases, surgical treatment of endometriosis can be performed by laparoscopy (keyhole surgery). Superficial patches of endometriosis on the peritoneum may be treated with diathermy or be excised. Where there are deep nodules of endometriosis, surgery is more extensive and may involve excision of small parts of the bowel. Where fertility is now longer required and severe debilitating cases hysterectomy and oophorectomy (removal of the womb and ovaries) may be necessary. In the majority of cases surgery can be performed as a keyhole procedure but in some cases open surgery is required. The incidence of complications from surgery is very low. However injuries to adjacent organs such as the bowel, bladder and ureters can occur.