Facts About Endometriosis, 'The Wandering Endometrium'

Friday, 03 July 2009 10:19

Endometriosis is the occurrence of endometrial tissue in sites outside the endometrial lining of the uterus. The most commonly affected sites are the pelvic organs and the peritoneum. They may also be found at distant sites such as the lungs.

Endometriosis affects approximately 10-20% of women of reproductive age (Moen et al 1991); while amongst infertile women, its prevalence is estimated to range between 30 - 50% (American Society for Reproductive Medicine, 2004). It occurs primarily in women in their 20’s and 30’s, though it can occur in teenagers. It sometimes runs in families.

Various theories have been propounded as possible aetiological factors and include the following; Sampson’s Retrograde-Menstruation Theory, Metaplasia Theory, Vascular Theory, and Faulty Immune System Theory.

Signs and symptoms related to endometriosis include; chronic pelvic pain, dysmenorrhoer (painful periods), painful intercourse, cyst formation (endometrioma) and cyclical bleeding from sites such as the nasal cavity, bladder and lungs. Infertility is also a known complication of endometriosis due to varied factors such as increased internal scar formation (adhesions), distorted pelvic anatomy and hostile environment for fertilization and conception.

The diagnosis is often made clinically, based on the patient’s complaints often related to cyclical discomforts- dysmenorrhoer, bleeding from unusual sites etc. Laparoscopy, a minor surgical procedure used to view the peritoneal cavity, is the gold standard for diagnosis. This involves taking the patient to the theatre and while under anaesthesia, the peritoneal (abdominal) cavity is carefully inspected with the aid of an endoscope connected to a monitor. Endometriotic deposits identified may have the following appearances - red, powder burn (black) or brown. Endometriotic cysts which contain chocolaty fluid require drainage and excision of the cyst cavity.

Management of endometriosis depends on the goal of treatment which includes; pain relief, preservation or restoration of fertility amongst others. Treatment can be conservative (using medications) or surgical.

Analgesics such as the NSAIDs (Non steroidal anti-inflammatory drugs) provide good pain relief in patients with severe dysmenorrhea. Oral contraceptive pills are also useful in providing relief of pain by ensuring a pseudo- pregnancy state thereby minimizing retrograde menstruation. Progestins may also be given to cause atrophy (shrinking) of the endometriotic tissue. Danazol which is a weak androgen can also be use to provide relief of symptoms attributable to endometriosis. It suppresses ovulation and causes endometrial regression.Gonadotropin releasing hormone analogues such as buserelin, nafarelin are also available in various formulations for the treatment of endometriosis.

Surgical management involves laparoscopic excision /cauterization of endometriotic deposits, drainage of endometriotic cyst, and division of internal scars (adhesions). Laparotomy (open surgery) may also be performed in centres where laparoscopic facilities are not available. Extreme cases may benefit from removal of the womb and its appendages (hysterectomy). The choice of treatment therefore largely depends on the patient’s symptoms and whether reproduction is desired.

Infertility associated with endometriosis can be managed using Assisted Conception. For mild cases of endometriosis without tubal problems, Intra-uterine insemination may be offered. However for extensive or severe endometriosis with pelvic anatomy distortion, In-vitro fertilization and embryo transfer is most appropriate.

Early presentation and management provides symptomatic relief and halts the progression of the endometriotic activity which if prolonged would ultimately distort the pelvic anatomy leading to chronic pelvic pain and infertility. It is therefore important to increase the level of awareness of the public by providing information relevant to the subject matter while providing updates on approaches to care. Physicians must also demonstrate a high sense of suspicion following complaints of cyclical discomforts amongst women of reproductive age.

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