Endometriosis

Endometriosis is the presence of endometrial tissue in places other than the uterus. 10 – 25% of the general female population has suffered from Endometriosis.

The peak incidence of the disease is seen in 30 – 45 years of age. It is a disease of the females, and to understand the condition better; you need to understand a little bit about the female uterus.

The womb or the uterus consists of three layers. They are perimetrium, myometrium, and endometrium from the outermost layer to the innermost layer. The endometrium is the inner lining of the uterus, which sheds off in 28-day cycles, the process we call periods.

What happens in Endometriosis?

The endometrial tissues start to appear not only inside the uterine cavity but also outside the uterine cavity. The pelvis, ovaries, bladder, and peritoneum are the most common sites.

As you know, your endometrium responds to the 28-day cyclic hormonal changes in your body. Therefore, the same thing happens to the endometrial tissue outside the uterus as the wall. It undergoes cyclical bleeding and local inflammation. Simply saying a desired action is happening in an undesired site in your body. Repeated bleeding and inflammation lead to fibrosis and create fibrotic bands binding your reproductive organs together. This causes damage to your fallopian tubes and ovaries, leading to Subfertility.

It is an estrogen-dependent disease; therefore mostly affects women in the reproductive age group (16 years – 55 years). Because in reproductive ages, estrogen levels in the body are higher than in any other age group.

If the ectopic endometrial tissue is within the myometrium itself, it is called Adenomyosis. The uterus becomes enlarged significantly and feels boggy. This causes severe painful menstruation than Endometriosis.

Ovarian Endometriosis

Here the endometriotic tissues are present in the ovaries. They could either be superficial lesions or form an endometriotic cyst in the ovary, also known as a ‘chocolate cyst.’ There is characteristic deep brown content inside the cyst due to the accumulation of menstrual blood in every monthly menstrual cycle.

Endometriosis symptoms

What does Endometriosis feel like?
What are the first signs of Endometriosis?

• Chronic pelvic pain

This can manifest in several ways. Endometriosis pain could be cyclic or constant and radiate from the lower abdomen to the groin. Mostly the pain is restricted to the time of menstruation and is sometimes associated with heavy menstrual bleeding. Usually, the pain starts before menstruation, increases severity, and peaks on the 2nd -3rd day. The pain settles with few days after menstruation.

• Painful menstrual bleeding (Dysmenorrhea)
• Subfertility
• Pain when engaging in deep sexual intercourse (Dyspareunia)
• Pain when passing urine (Dysuria)
• Pain on defecation (Dyschezia)
• Long term fatigue
• Low back pain

But remember that 2-50% of cases may still have no symptoms!

When to see a doctor?

Many women think that associated pain with menstruation is normal. They tend to cover the pain with simple analgesics and not seek medical advice from an expert. But if you suffer from severe pain with menstruation, remember that it is not always normal. If you have any endometriosis symptoms mentioned above, do not hesitate to have a medical opinion.

Causes for Endometriosis

The actual cause of Endometriosis is not known. Mechanisms are,

• Retrograde menstruation

Normally in the menstruation phase, the inner lining of the endometrium is shed off with blood and is evacuated through the vagina. That is known as antegrade menstruation. According to this mechanism, instead of flowing off through the vagina, menstrual blood flows back through the fallopian tubes and into the pelvic cavity. The endometrial cells in menstrual blood stick to the other organs in the pelvic cavity and start to grow.

• Embryonic cell transformation

All the organs of your body first started to develop when you were inside your mom’s uterus. But with every passing day inside the uterus, the body organs begin to differentiate into a more mature form. Embryologically there is a common origin for some reproductive organs in the females. That means some organs initiate their growth from the same cell type, but later, it differentiates into other cell types. This theory says that cells that embryologically originated from the same cell type undergo re-differentiation into their primitive origin and then transform into endometrial cells.

• Genetic and immunological factors

This may alter the susceptibility of women to develop Endometriosis. What causes Endometriosis in women? As mentioned above, Endometriosis is an Estrogen dependent disease. Hence the longer the exposure to Estrogen higher the risk for Endometriosis.

• Nulliparity: Never giving birth
• Starting periods at an early age
• Older age of menopause (End of menstruation)
• Family history of Endometriosis

Endometriosis Stages

1. Stage 1 (minimal): Small and minimally invasive lesions. There is no or little scar tissue.
2. Stage 2 (mild): More implants have invaded than stage 1. There is a little amount of scar tissue.
3. Stage 3 (moderate): There are many deep implants, and there may be cysts in both ovaries. Thick scar tissue bands are formed named adhesions.
4. Stage 4 (Severe): This is the most widespread stage. There may be large cysts in both ovaries. There are many deep implants and thick adhesions throughout the pelvic cavity.

Complications of Endometriosis

Endometriosis and Fertility

One-third of women with Endometriosis have difficulty getting pregnant. As you know, to get pregnant, sperm should be combined with an ovum in the fallopian tubes and implanted in the uterus. But in Endometriosis, ectopic tissue blocks the tubes and does not allow the sperm to fertilize with the ovum.

Even still, many can successfully progress to pregnancy and end up
with a term birth with mild to moderate Endometriosis. If you are below 35 years of age, where the fertility chance is maximum, and still do not have children, your doctor may advise you not to delay the pregnancy
because the condition can worsen with time.

Endometriosis and cancer

There is only a slight risk of developing ovarian cancer with Endometriosis. The first thing you should understand is that Endometriosis is not cancer. It is a benign condition, but sometimes it can give rise to malignant growths known as cancers. But cancer is a multifactorial disease. Having Endometriosis per se does not cause you harm, but it can develop ovarian carcinoma when combined with other cancer risks.

Endometriosis Diagnosis

Your health care provider will take a detailed and thorough medical history, including your menstrual history. The doctor will conduct a pelvic examination to assess the health of your reproductive organs. The definitive diagnosis of Endometriosis will be based on several checkups.

1. Ultrasound scan
2. Laparoscopy
3. Endometriosis biopsy
4. MRI scan

Endometriosis Treatment

The treatment options depend on your age, desire for pregnancy and
the severity of the symptoms.

If you have minimal Endometriosis with no other abnormal findings in the
scans, if you are unmarried or young married and ready to start a family, or if you are reaching the end of your monthly menses(menopause), you may not need medical or surgical intervention.

Discuss your requirements with your health care provider. Your doctor will consider treating your pain first if you suffer from menstrual pain monthly.

But if your main concern is Subfertility, you will be treated for that first. Like that, your treatment will be according to your symptoms.

Treatments for pain

It can be the medical treatment that means taking pills, or the next option is to go for surgery.

1. NSAID: Paracetamol will be one of your initiating medications for pain relief. Ibuprofen or Codeine could also be prescribed.
2. COCP or birth control pills: These can be prescribed for three months continuously, and your health care provider will follow you up after that.
3. Progesterone only pills
4. GnRH analogs
5. Progesterone releasing Intra-Uterine Device

These treatments have a small chance of developing side effects like any
other drug, such as headache, vomiting, weight gain, and acne. But all the
side effects do not affect everyone. You may have one or two of them, or you may not have any of them.

Endometriosis surgery includes removing the ectopic endometrial tissue by preserving reproductive organs. This is highly effective in managing pain, but it is commonly associated with recurrence.

What is Endometriosis ablation?

The inner lining of the uterus is removed in this procedure. It can reduce the symptoms of Endometriosis, such as heavy menstrual bleeding or painful menstrual bleeding. As treatments for Subfertility, ectopic endometrial tissues will be removed surgically. And this will increase the spontaneous pregnancy rate in minor to moderate diseases.

Fertility sparing surgery is the goal of your health care provider to increase the chance of spontaneous conception, but if you have severe disease In Vitro Fertilization(IVF) will be the option for you.

In the bottom line, there is no simple treatment for Endometriosis that gives you a permanent solution. You will have to be patient and comply with your doctor’s advice and follow the treatment properly for at least three months.

Diet in Endometriosis

What foods are good or bad for Endometriosis is not exactly confirmed. Further studies are needed to prove it, but certain behavioral patterns in our lifestyle, including the diet, can positively or negatively affect the progression of the disease. And what you eat every day sometimes affects the degree of the pain you have in Endometriosis.

The following diet choices may negatively affect Endometriosis,

• A high trans-fat diet
• Red meat
• Gluten

And as mentioned above, it is particularly important to reduce the inflammation in endometrial tissue deposits associated with cyclical monthly bleeding. So, avoid foods or substances that may aggravate the body’s inflammation by releasing inflammatory chemical mediators such as alcohol, caffeine, and saturated fat.

Try to have a well-balanced diet rich in nutrients rather than consuming empty calories. The food items enriched with vitamins and minerals would help you fight the disease by reducing the inflammation and pain caused by Endometriosis. Add more vegetables, fruits, beans, whole grains, and nuts to your diet. That will make your meal fiber-rich. Try to increase your intake of iron-rich foods such as fish, broccoli, and nuts. Antioxidant-rich foods such as oranges, limes, berries, and dark chocolate will help you to boost your body to reduce its inflammation.

Always look at what you eat and monitor how your body responds to your foods. It would be beneficial if you met a professional dietician to modify your diet accordingly.

Exercise and alternative therapy

As with any disease, your mental health is essential to look after your physical health. Try to engage in an active lifestyle. Go out, breathe some fresh air and do some exercises. Yoga is also a suitable method if you like to try it. Acupuncture and a good body massage will also help you to have temporary relief.

The takeaway message

What matters is; that first, you identify your symptoms. If you have any and to diagnose it. Do not take the symptoms easily and meet a gynecologist early as possible. You do not need to unnecessarily be afraid since Endometriosis is a non-cancerous lesion and can have a good result after treatments. But the reality is that there is no effortless way out. Most of the things regarding the disease still remain unfound and non-proven. So, you must take care of yourself by following frequent monitoring and the treatment plan.

Endometriosis and endometrial hyperplasia

Endometrial hyperplasia is the abnormal thickening of the endometrium. So as the definition suggests, it is apparent that Endometriosis and endometrial hyperplasia are two different things. But if you are worried that ‘will having endometriosis increase the chance of getting endometrial hyperplasia? The answer is it is not found out or well-proven yet. It is worth frequent visits to a gynecologist. He will do an ultrasound scan to measure the thickness of your endometrium. And thereby, the doctor will be able to detect hyperplasia if it occurs.