The Endometriosis Story
Endometriosis is considered to be one of the most difficult conditions to diagnose and manage and is largely a conundrum for many a doctor as well as the patients. Considered part of the spectrum of chronic pain conditions due to pelvic pain of more than 6 months, it can be a debilitating condition affecting a woman’s quality of life, ability to work and earn, sexual relationships and normal daily activities.
It is relatively common affecting 5-10% of women of childbearing age with the peak incidence between the ages of 25 and 35 years. In women on management for infertility with pelvic pain, up to 50% are found to have coexisting endometriosis. There is usually a 4 to 10-year delay between reporting symptoms and making a diagnosis thus years of suffering before proper treatment begins.
Risk factors for its development include early age at first menstruation, short menstrual cycle (less than 21 days), heavy menses, delayed age of first delivery and positive family history. Risk is high in women whose first-degree relatives have endometriosis. The highest prevalence is seen in women of Asian origin.
The exact cause is unknown, with many theories in the medical literature. The most common theory is called Sampson’s Retrograde Transplantation Theory whereby tissues of the inner lining of the uterus (endometrium) are pushed through the fallopian tubes to the pelvis and abdomen during the menses and they implant in those sites.
During subsequent periods, those tissues also bleed as they are sensitive to hormonal influence causing the severe pain and inflammation that is typical of endometriosis. This theory does not explain why it can occur in girls before puberty, in men and in distant sites like the chest cavity and the brain.
Patients commonly present with severe period pain, deep pain during and/or after sexual intercourse, difficulty conceiving, back pain, pain on passing stool and urine and if severe, blood in urine and stool. Other rarer symptoms include blood in the chest cavity (haemothorax) and bleeding into the brain.
Diagnosis begins with a good history and a complete physical examination including vaginal examination to rule out other possible causes of similar symptoms. The only definitive way to diagnose endometriosis, however, is via laparoscopy whereby a tiny camera and instruments are inserted through tiny incisions on the abdomen (ports), visually inspecting the pelvis and taking samples (biopsy) to clinch the diagnosis.
However, a negative biopsy result does not always rule out endometriosis. The benefit of laparoscopy is that treatment can be done at the same time in select cases. Other investigations include a pelvic ultrasound to rule out endometriosis cysts of the ovaries (endometriomas/chocolate cysts) and a pelvic MRI for the more severe stages of endometriosis (Deep Infiltrating Endometriosis, DIE).
Treatment, once a diagnosis is made, must be individualised and various options are available. Initially, a 3-month trial of simple pain medication (paracetamol with or without an NSAID e.g. Diclofenac) is advised. There is also a role for neuromodulator drugs like gabapentin and amitryptiline.
Some women would want a trial of treatment before surgery so various hormonal treatment options exist ranging from the daily combined contraceptive pill taken continuously, hormonal IUD and 3 monthly injections which may have some undesirable side effects like weight gain, mood swings, acne, bloating.
Surgical management is by laparoscopic ablation/excision and removal of any endometriomas (cystectomy). As a last resort, surgery to remove the uterus and ovaries can be done (Total hysterectomy and bilateral salpingo-oophorectomy).
Dr Christopher Obwaka – Chief Medical Officer And Resident Obstetrician And Gynocologist Medlux International