Endometriosis is a condition where tissue similar to the lining inside the uterus (endometrium) is found elsewhere, typically near the uterus, ovaries, and fallopian tubes. It is a very common condition, affecting about 1 in every 10 women. If your mother or sister has the disease, your chances of developing endometriosis are higher. Endometriosis usually develops during a woman’s reproductive years and affects the process of becoming pregnant. It can be a long-term condition that can have a significant impact on a person’s physical, mental, and daily well-being.
What are the Symptoms of Endometriosis?
Common symptoms include pelvic pain and painful menstrual periods, sometimes irregular cycles or heavy periods (excessive bleeding). It may cause pain during sexual intercourse and can lead to fertility issues. You might even experience pain related to your bowels, bladder, lower back, or upper legs, and prolonged fatigue. Despite all these explanations, sometimes some women with endometriosis may have no symptoms and find out about it accidentally during an ultrasound.
Endometriosis can cause pain in a regular pattern, and this pain often worsens before and during the menstrual period. Some women experience pain in the lower abdomen and pelvis most of the time, but for others, these pains may only occur occasionally. The pain might improve during pregnancy, and sometimes it may disappear without any treatment.
What are the Causes of Endometriosis or Chocolate Cyst?
It is still not precisely clear what causes endometriosis, but there are a number of theories:
- Transportation through the Blood or Lymphatic System: Endometrial tissues are transported through the blood or lymphatic systems to other areas of the body, similar to how cancerous cells can spread throughout the body.
- Direct Implantation (Direct Transfer): Endometrial cells may attach to the abdominal wall or other areas of the body following surgery such as a C-section or hysterectomy.
- Genetics: Endometriosis appears to run in some families more than others, suggesting a possible genetic link to the disease.
- Retrograde Menstruation: Instead of exiting the body during a woman’s menstrual period, the endometrial tissue enters the fallopian tubes and the abdomen; essentially, the blood flows backward.
- Transformation (Coelomic Metaplasia): Other cells in the body may transform into endometrial cells and begin to grow outside the uterus.
Endometriosis is dependent on a female hormone called estrogen. This means that just like the endometrial lining of the uterus, which bleeds monthly in response to hormonal changes, this similar tissue outside the uterus also bleeds with hormonal changes during the menstrual cycle. This bleeding can cause pain, inflammation, and scarring. This scar tissue is known as adhesions and may damage pelvic organs or cause pelvic viscera such as the bladder, intestines, uterus, ovaries, ureters, etc., to stick together.
What are the Risk Factors for Endometriosis?
The latest research indicates that certain factors increase the risk of developing endometriosis. These factors include:
- Having a mother, sister, or daughter with endometriosis.
- Having an unusual uterus that causes blood to flow back into the abdomen (diagnosed by a doctor).
- Starting menstruation before the age of 11.
- A shorter menstrual cycle (less than 27 days on average).
- Menstrual periods with heavy bleeding for more than seven days.
Some factors that may reduce the risk of developing endometriosis include:
- Pregnancy and breastfeeding
- Starting menstruation after the age of 14
- Consumption of fruits, especially citrus fruits
Common Locations for Endometriosis Tissue:
- On the ovaries: This can form a mass usually called an Endometrioma or Chocolate Cyst.
- On the peritoneum: The peritoneum is a continuous membrane that lines and supports the abdominal and pelvic organs.
- On the fallopian tubes.
- In front of, behind, or around the uterus.
- In the area between the vagina and the rectum.
Endometriosis may also occur in the muscular wall of the uterus (adenomyosis) and sometimes on the intestines or bladder. Occasionally, it may be found in other parts of the body, though these cases are rare.
What are the Signs of Endometriosis?
The most common sign of endometriosis is chronic (long-term) pelvic pain, especially before and during the menstrual period. Pain during sexual intercourse may also occur. If endometriosis affects the bowels, pain during bowel movements may occur. The individual may experience diarrhea or constipation during menstruation. If it affects the bladder, pain during urination may occur. Heavy menstrual bleeding is another symptom of endometriosis. Fatigue or lack of energy are also among its symptoms.
Many women with endometriosis have no symptoms. Asymptomatic women often discover they have endometriosis when they are unable to conceive or when undergoing surgery for other reasons.
Is there a Connection Between Endometriosis and Infertility?
Endometriosis is one of the common reasons associated with female infertility. Approximately 24 to 50 percent of infertile women have this condition. Mild to moderate cases of endometriosis may only be a temporary factor in infertility. Surgery to remove the endometrial tissue can help treat infertility.
It is not exactly clear how endometriosis causes infertility. It is likely that the scar tissue caused by endometriosis can impact the release of eggs from the ovaries or block the egg’s path through the fallopian tube so that it cannot reach the uterus. Endometriosis may also damage sperm or eggs before implantation in the uterus.
Many women with endometriosis and related infertility can still conceive and experience a successful pregnancy. Treatment methods including In Vitro Fertilization (IVF) can help women become pregnant.
How is Endometriosis Diagnosed?
Diagnosing endometriosis can be a challenge due to the following reasons:
- The symptoms of endometriosis vary greatly. Common symptoms may be similar to pain caused by other conditions such as Irritable Bowel Syndrome (IBS) or Pelvic Inflammatory Disease (PID). Different women have different symptoms, and some women have no symptoms at all.
Occasionally, vaginal and rectal examinations can help feel nodules or detect adhesions of the uterus and ovaries, or visualize bleeding points in the vagina. However, the physical exam does not have a high diagnostic value, and a normal exam does not rule out the disease.
The most common diagnostic tool is transvaginal and sometimes transrectal ultrasound, which is helpful in diagnosing endometriosis cysts or chocolate cysts. It can also show involvement of the space between the vagina and the rectum. It also helps in assessing the severity of the disease and the involvement and adhesion of pelvic organs. MRI can also be used in advanced cases of the disease.
There is no specific blood test for the diagnosis of this disease.
Finally, in cases where a definitive diagnosis is not reached despite all examinations and ultrasound, laparoscopic surgery can be used.
How is Endometriosis Staged?
Doctors classify endometriosis into Stage 1 to Stage 4. These stages are determined based on where the endometrial tissue has formed in the body, how widespread it is, and how much tissue is present in these areas.
Having a more advanced stage of endometriosis does not always mean having more severe symptoms or more pain. Some women with Stage 4 endometriosis have few or no symptoms, while those with Stage 1 may have severe symptoms.
Drug Treatment for Endometriosis and Endometrioma or Chocolate Cyst:
Medications used to treat endometriosis include pain relievers such as Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and hormonal medications including combined hormonal contraceptives, progesterone derivatives, and Gonadotropin-Releasing Hormone (GnRH) agonists and antagonists. Hormonal medications help reduce the growth of endometrial tissue and may prevent the formation of new tissue. These drugs generally do not eliminate existing endometriosis tissue. These treatments are provided by reducing or stopping ovulation enough to decrease hormonal stimulation and shrink the endometriosis. Treatments involving hormonal therapy can change hormone levels or stop the production of certain hormones in the body.
Drug treatment requires the patient’s understanding of the nature of their disease and their cooperation in continuing the treatment under the supervision of a specialist gynecologist. This is because the drug treatment for this disease lasts several years, sometimes even until menopause.
Surgical Treatment for Endometriosis and Chocolate Cyst:
Surgery, using laparoscopy or laparotomy, helps to remove the endometriosis tissue. Removing this tissue may reduce pain and improve fertility, especially when an endometrioma or chocolate cyst is removed.
During surgery, care must be taken not to damage ovarian tissue as much as possible, and the ovaries should be preserved, especially in young patients and those who wish to conceive and are pre-menopausal.
After surgery, most women experience relief from pain. However, there is a possibility of the pain returning. Up to 8 out of every 10 women experience pain again within two years of surgery. This may be due to endometriosis that was not visible or removable at the time of surgery. The more severe the disease, the higher the likelihood of its recurrence. Taking birth control pills or other medications after surgery may help extend the pain-free period.
Finally, if the pain is severe and does not respond to drug treatments, a hysterectomy is a surgical procedure used to remove the uterus. Doctors may recommend this procedure as an option for treating endometriosis. Your doctor may also recommend removing the ovaries with or without a hysterectomy. This stops hormone secretion and definitively treats endometriosis, but it may cause you to enter menopause.
Removing the ovaries significantly reduces estrogen levels and decreases the growth of endometrial tissue. However, this is associated with the risks and side effects of menopause, including hot flashes, decreased bone density, heart disease, decreased libido, memory problems, depression, or anxiety. Therefore, the decision to remove the ovaries is made based on factors related to the patient’s symptoms and personal goals, by the patient and the specialist gynecologist.
After a hysterectomy, the individual no longer has a uterus and will be unable to get pregnant or carry a pregnancy. Therefore, this important point must be clearly explained to the patient before surgery.
Women who have had their ovaries removed but still have their uterus may be able to become pregnant using In Vitro Fertilization (IVF). The correct procedure is to remove the eggs from the ovaries before removal and freeze and store them for future fertilization and pregnancy. Alternatively, if no eggs are available, an egg donor can be used. Hysterectomy (removal of the uterus) is considered a “last resort”. The likelihood of future pain is lower if the ovaries are removed at the time of hysterectomy. In any case, the goal of surgical treatment is to remove the endometriosis foci outside the uterus as much as possible.
It is necessary to be under the periodic supervision of your specialist gynecologist and surgeon after treatment, so that any recurrence can be quickly diagnosed and its progression prevented.
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