Endometriosis is a condition where tissue that looks like the lining of the uterus is found outside the uterus.
It causes painful, heavy periods, which tend to get worse over time.
The most common symptom of endometriosis is painful periods. This is often progressive, so over an interval of a year or two the periods become noticeably more painful. The pain is usually like period pain but significantly stronger. The pain may start just before the period and usually eases as the period finishes.
Along with painful periods endometriosis often causes periods to be very heavy.
Severity of symptoms
Interestingly, the severity of symptoms don’t correlate with the severity of disease. Some women with very mild endometriosis have severe symptoms. Other women with very advanced disease have minimal symptoms.
Endometriosis is associated with infertility. The relationship is two way, as fertility from any cause can increase the likelihood of endometriosis and endometriosis sometimes reduces fertility. Treating endometriosis may improve fertility and most fertility experts recommend treatment of endometriosis if infertility is a problem.
Pain with sex
Endometriosis in the pelvis can cause pain with sex. The pain occurs with deep penetration and is like there is a point deep in the pelvis that is tender to touch. Pain that occurs with first penetration is called superficial dyspareunia. This type of pain is not usually associated with sex but may be a by-product of deep dyspareunia.
Endometriosis can cause a deep pelvic ache throughout the period. This occurs in association with deep invasive endometriosis.
Painful bowel motions
Endometriosis on the bowel can cause pain when opening the bowels.
Bleeding in the bowel motion
Occasionally, if endometriosis has grown through the wall of the bowel, it may cause bleeding from the bowel.
Types of Endometriosis
The most common location for endometriosis is on the pelvic sidewall, next to where the ovary lies. This area is called the ovarian fossa. The fallopian tubes drape over the ovary and so this ovarian fossa is a natural place for cells from retrograde menstruation to land. The “bleeding” and inflammation behind the ovary can cause adhesions between the ovary and the pelvic sidewall. This may be noticed on an ultrasound scan where the ovaries become less mobile, and rather fixed in position.
Endometriosis is often seen on the surface of the peritoneum, the thin film that covers all of the pelvic structures. Initially it may appear as reddened areas or pockets in the peritoneum. As the endometrium ages, tiny blood filled sacs may develop. These are called “powder burn” lesions because they are seen as a number of black round lesions 2 to 3 mm in diameter. When burst, these lesions are seen to be filled with the same chocolate material as endometriomas.
When endometriosis develops on the ovary it often forms into and endometrioma. This is a cyst like structure, filled with old blood. This blood changes into a brown fluid and so these structures are often called chocolate cysts. The active endometriosis lies around the outside of the structure and bleeds into the fluid each month. Endometriomas tend to slowly increase in size over time.
Deep invasive endometriosis
Endometriosis may grow down from the lining of the pelvic organs, into the underlying structures. The uterosacral ligaments behind the uterus are a common site for this type of endometriosis. It can also occur on the bowel and on the side of the pelvis around the ureter.
The simplest treatment for mild symptoms is pain relief. Usually we would choose on of the NSAIDs such as Ibuprofen or Naproxen.
The ordinary combined pill may be helpful in controlling period pain, particularly when used with packets “back to back” with no gap for several cycles. The Mirena coil reduces the pain of periods and can be very helpful in controlling period pain associated with endometriosis. Finally, some women find that a progesterone only pill such as Cerazette gives them very light periods or no bleeding at all and minimal period pain.
Pregnancy is a very good natural treatment for endometriosis. If the time is right for starting a family, the symptoms of endometriosis will usually improve dramatically with a pregnancy.
Continuous progesterone, given in moderate doses, suppresses the ovarian hormone cycle, and so supresses endometriosis. This can be helpful treatment for endometriosis.
These completely suppress the ovarian cycle and supresses endometriosis as well. Superficial endometriosis tends to respond to medical treatment but endometriomas and invasive endometriosis tend not to respond.
Excision of endometriosis is usually a laparoscopic or keyhole procedure. This can be done with a laparoscope directly or with robotic assistance. The aim is to remove all of the endometriosis and this usually results in a dramatic improvement in symptoms.
If a women has completed her family, the best treatment for endometriosis is a hysterectomy and removal of the ovaries and visible endometriosis. HRT can then be given as estrogen only which dramatically improves the quality of life in women who have suffered from symptoms of endometriosis for years.