What is endometriosis?
Endometriosis is a quite common medical condition during which cells from the lining of the uterus (endometrium) grow in other parts of the body, usually around the uterus, the ovaries, the fallopian tubes or the peritoneum. Endometriosis affects 1 in 10 women, mainly during their reproductive years. Endometriosis is neither some kind of infection nor a malignancy.
Areas of endometriosis are usually found at the following sites:
• Ovaries, where cysts are created (also called ‘chocolate cysts’)
• On top or inside the fallopian tubes
• Anywhere around or on top of the uterus
• On the peritoneum (the tissue that covers all the internal organs inside the abdomen)
In rare cases, endometriosis is found on the intestine or the bladder or even on other organs (lungs, kidneys).
At early stages, endometriosis appears in the form of ‘spots’ on the pelvis or the organs (tubes, ovaries). These spots can be transparent, white, brown, red, black or blue. The severity and the course of endometriosis are quite unpredictable. In some women, these spots grow bigger. If they grow inside the ovary, then a cyst full of blood is formed. This kind of cyst is called a ‘chocolate cyst’ because of its colour (brown-red). One such cyst could be as small as a pea or as big as an orange. These cysts might cause trauma to the tissue where they grow upon (adhesions). Adhesions make the organs ‘stick together’ or cover them entirely. Adhesions might be the reason why the fallopian tubes cannot hold the egg at ovulation, thus hindering egg fertilisation by the sperm.
What are the symptoms of endometriosis?
The most common symptoms of endometriosis are:
• Pain in the abdomen or the pelvis
• Pain during or after sexual intercourse
• Pain during a woman’s period
• Heavy bleeding
Some women with endometriosis may have no symptoms at all while others feel a lot of pain during their period, have chronic pelvic pain or pain during intercourse. In other women, the main problem is infertility. Endometriosis is often diagnosed during an operation e.g. cyst removal from an ovary.
What causes endometriosis?
During a woman’s menstrual cycle, the endometrium (the lining of the uterus) is subject to the effect of hormones (estrogens, progesterone) and thickens in order to be ready for the implantation of a fertilised egg. If there is no pregnancy, the endometrium is shed during a woman’s period.
Endometriosis occurs when endometrial cells grow in other parts of the body. Every month these cells follow the menstrual cycle, just like the lining of the uterus (they grow thicker and then are shed). However, these cells cannot follow the normal course (bleeding during a woman’s period); this causes infection pain and trauma of the reproductive organs (ovaries, fallopian tubes).
Why do some women have endometriosis?
It is not yet clear why some women have endometriosis while others do not. Several theories have been proposed, but the one that seems more likely is that during a woman’s period some blood ‘flows backwards’ and transfers tissue from the uterus to the tubes, the ovaries etc.
A woman may be diagnosed with endometriosis at any time of her life, but many doctors believe that it is more frequent in women who did not have a pregnancy. In any case, 25-50% of women with fertility problems have endometriosis.
Severity of endometriosis
Cases of endometriosis can be split in 4 categories depending on the location, the size of the spots, the existence and severity of adhesions and the existence of chocolate cysts: I – minimum, II – mild, III- medium, IV – severe. Most women have endometriosis stage I or II. These women have superficial spots and mild adhesions. However, these women usually experience infertility, chronic pain and period cramps. Stage III and IV means that there are chocolate cysts, as well as more severe adhesions.
Which tests confirm the diagnosis of endometriosis?
Some women have one or more symptoms of endometriosis. Some women have no symptoms, while others have difficulty getting pregnant (infertility).
Apart from the medical history, the symptoms and the clinical examination, there are certain tests to confirm the diagnosis of endometriosis:
• Ultrasound (vaginal)
This test can help determine whether there are cysts in the ovaries. Even if the ultrasound is normal, there is a possibility that endometriosis is found elsewhere.
Laparoscopy is considered the only way to absolutely confirm the diagnosis of endometriosis. Laparoscopy is a minor operation, performed in hospital, under general anesthesia. A small incision is performed under the belly button and through that, the laparoscope is inserted into the abdomen. The laparoscope has a camera attached to it. In this way, the doctor can inspect the internal organs and detect endometriosis. During laparoscopy the doctor can remove the affected tissues, if necessary. After the operation, the woman must stay at the hospital for a few hours and can go home afterwards.
With laparoscopy, the doctor can identify the extent and severity of endometriosis. Doctors use a scoring system depending on the extent of the lesions and the existence of adhesions and cysts in the ovaries. A score of 1-15 means that the patient has minimal or mild endometriosis, while a score of 16 or more means medium to severe endometriosis. This scoring system unfortunately has nothing to do with the ability of a patient to conceive (infertility) or the pain she feels.
Endometriosis and infertility
One in two women with infertility is diagnosed with endometriosis. A woman with mild endometriosis has every month 2-4.5% chance to conceive naturally (normally reaching 15-20%). However, a woman with endometriosis will not necessarily have fertility problems, too.
It is quite clear how endometriosis affects fertility, especially in women with no adhesions. The existing theory suggests that endometriosis causes small, but significant changes in the pelvis: infection, changes of the immune system, hormonal changes, changes in the way the fallopian tubes function or even problems in fertilisation or embryo implantation. In more severe cases, adhesions are critical and cause infertility by blocking the release of the egg or the entry of the sperm inside the tube. Adhesions also affect the motility of the tubes and their ability to hold the egg during ovulation.
Depending on the symptoms, the clinical examination and test results, there are different therapeutic approaches, such as hormonal therapy, pain management or surgical intervention to remove chocolate cysts.
Contraceptive pills reduce the intensity of pain during the woman’s period or chronic pain. The pill is very safe in general – severe adverse reactions such as vascular and heart problems are extremely rare. The pill does not stop the progression of endometriosis, but possibly reduces relapses.
Surgical removal of endometriosis lesions, adhesions and ovarian cysts is necessary when endometriosis is advanced, in order to preserve the patient’s fertility. Following such a procedure, pain is reduced in 60-80% of women. Endometriosis returns in 40-80% of women within 2 years; this is why the surgery should be supplemented by medication. Following 6 months of treatment, endometriosis will return in 50% of women within 5-10 years. Such a treatment is suitable for women who are not interested in achieving a pregnancy at that time. For women who are interested in getting pregnant as soon as possible, a 6-month treatment will delay a pregnancy. So, when trying to decide on the best way to treat a patient with endometriosis, it is important to be aware of the patient’s aims (pain management, pregnancy). In any case, long-term pain management is sometimes a challenge for patients and doctors alike.
When pregnant, many patients do not feel the symptoms of endometriosis, possibly due to hormonal changes during pregnancy. After the baby is born, endometriosis returns.
Women with endometriosis and fertility problems should take a thorough fertility checkup before deciding on treatment e.g. laparoscopy. Factors such as age, duration of infertility, pain, severity of endometriosis should be considered.
Laparoscopy in women with minimal or mild endometriosis offers a small but significant boost to their chances of achieving a pregnancy. In a large clinical study, 29% of women who had undergone laparoscopy to treat endometriosis have conceived within 9 months. In women who did not undergo laparoscopy, the percentage was 17%. This study indicates that after laparoscopy a woman has enhanced fertility for a longer period. Treating medium or severe endometriosis with laparoscopy increases the pregnancy rate in women with no other infertility problems.
Medication for endometriosis, such as contraceptive pills, is effective for pain management (during a woman’s period or sexual intercourse), but does not improve fertility. However, treating endometriosis with medication might delay the treatment of infertility. A critical factor is the patient’s age. Women over 35 have diminished fertility anyway, so for endometriosis patients who are older than 35, a more aggressive approach is recommended. Fertility treatments constitute the most effective approach in women with medium or severe endometriosis, especially if surgery failed to restore their fertility.
In case there is a relapse of endometriosis after surgery and the patient is trying for a pregnancy, we often proceed directly with fertility treatments without repeating the surgery, since every surgery reduces the volume of the ovaries. In case there are large cysts in both ovaries, their surgical removal is necessary.
In any case, 1 in 3 women suffers from mild endometriosis that cannot be detected by ultrasonography. In these cases, laparoscopy is not necessary.