Current concepts in Endometriosis
- By Dr Emma Boulton
- ● 11 Nov 2015
Endometriosis is a common condition estimated to affect about 10% of all women during their reproductive years. It is being diagnosed more frequently, though whether this represents a true increase in incidence or better diagnosis is not clear. Endometriosis is a condition where the cells which would normally line the uterus are located outside of the uterus but still behave as if they are inside the uterus. These specialised cells respond to hormones and cause blood loss, as they would do during a normal menstrual cycle.
If these cells are located outside of the uterus then the blood cannot escape and the bleeding into the tissues leads to scarring and sometimes the tissues can become and get stuck to each other, or solidify into solid lumps of endometriosis tissue (called endometriomas or chocolate cysts).
The main feature of endometriosis is that it causes pain and problems with fertility. The mean time from the onset of symptoms and diagnosis is approximately 8 years. So even in very technologically advanced countries such as Australia, we are still not very good at diagnosing it. Endometriosis mostly occurs within the pelvis i.e. there are endometrial cells which appear outside of the uterus but still within the pelvis. These patches of endometriosis can be stuck to ligaments and ovaries. However, there is increasing evidence that you can get endometriosis in locations completely remote from the pelvis, such as in the chest or in the nose. A recent forum which was the ASRM Conference, where researchers at Yale University have suggested that endometriosis arises as a form of stem cell migration. Therefore, endometriosis could affect practically any part of the body and studies performed in mice have suggested that it’s possible for endometriosis to be inside the brain. So it is possible that women with endometriosis may have microscopic implants of endometrial cells in many parts of the body and this maybe a reason why women have endometriosis like syndrome, where symptoms are not specific to the genitalia or urinary tract but can be systemic. It is likely that research in coming years will help us identify causes for the increasing incidence of endometriosis and likely therefore to yield best treatments.
Commonly symptoms of endometriosis include dysmenorrhea (very painful periods), dysuria (painful urination), dyschezia (pain in the rectum), which may cause painful defecation and dyspareunia (painful sexual intercourse). This is likely to be due to pockets and deposits of endometrial tissue that are located outside of the uterus which can cause inflammation, scarring and pain whenever organs in the pelvis are stretched or have pressure put on them. Essentially, endometriosis commonly presents with subfertility or infertility, abnormal menstrual bleeding or menstrual pain but we also know that endometriosis can be without symptoms at all.
Treatments include changes to lifestyle, the first of these being taking regular exercise and managing weight. Interestingly, exercise is helpful for many conditions because of the endorphins that are released during exercise, which counteract pain. By managing weight and not being obese the levels of natural estrogen in the body are reduced, which is an internal hormonal control for endometriosis. Other than lifestyle, there are surgical interventions such as excision (removal) of the endometriosis during a laparoscopy. When surgery is performed for endometriosis, the emphasis is on normalising the anatomy and removing endometriosis deposits (minimising diathermy and therefore further scarring). There are also many hormonal treatments for endometriosis including the combined oral contraceptive pill, hormone releasing intrauterine device and a treatment which has just become available in Australia, called Dienogest and this has been proven to be effective for treatment of endometriosis and may be used in conjunction with for instance the hormone releasing IUD.
If a woman is diagnosed with endometriosis and she is wanting to become pregnant, she may be a candidate for assisted reproductive technology (IVF/embryo/egg freezing). If a women with endometriosis is considering some assisted reproductive technology such as IVF, it may well be that a measure of her AMH (Anti-Mullerian Hormone) which is an indicator of ovarian reserve, will help her and her clinician decide how quickly she should be referred or should be considering intervention to help her get pregnant.
Endometriosis is increasing in terms of incidence and prevalence. The reasons for this are not clear but having better awareness of the symptoms and issues relating to this condition will help both patients and doctors improve the quality of life for their patients, either in terms of pain management or by successful reproduction.
Here at Clinic 66 our doctors will be able to assist you with diagnosis, referral and treatment if you suspect you have or are diagnosed with endometriosis.
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