What is endometriosis?

Endometriosis is a condition in which tissue similar to the ones that line your uterus starts growing in other areas of the body, usually in the pelvis, ovaries, and fallopian tubes surrounding the uterus. When the tissue grows in the wrong places, it can cause uncomfortable symptoms which impact daily life.

It is a widely prevalent condition affecting approximately 247 million women globally and 42 million women in India.   (Reference: Gajbhiye RK. Endometriosis and inflammatory immune responses: Indian experience. Am J Reprod Immunol. 2023 Feb;89(2):e13590. )

. Most often, a few places where you can develop endometriosis include:

  • Ovaries (can develop into cysts called endometrioma)
  • Fallopian tube
  • Ligaments that hold the uterus in place (uterosacral ligaments)
  • TOuter surface of the uterus
  • Pouch of Douglas (area between your rectum, cervix, and upper vagina)

Other sites of growth can include the bowel, bladder, or vagina. Rarely, endometriosis appears in the lungs, brain, and skin.

The endometrium is the tissue lining inside of the uterus (womb). This tissue is what you shed during a menstrual period. Endometriosis is when endometrial-like tissue grows on other organs or structures. Since hormones influence the tissue, it may become inflamed during menstruation. Endometriosis growths may swell and bleed like the lining inside your uterus does every month during your menstrual period. This can cause swelling and pain because the tissue grows and bleeds in an area where it cannot easily get out of your body.

Endometriosis is a common condition that can cause pelvic pain and difficulty conceiving. The symptoms of endometriosis are often managed with treatment.

Who is most at risk of developing endometriosis?

Many symptoms are associated with endometriosis, with common being pain in the abdomen, pelvic region, and lower back. Each woman’s experience with endometriosis is different, and symptoms can vary widely. 

  Common symptoms include:

  • Painful menstrual cramps
  • Abdominal pain or back pain during your period or in between periods.
  • Irregular bleeding (including bleeding between periods)
  • It can cause pain during or after sex
  • Heavy bleeding during periods
  • Pregnancy difficulties (infertility)
  • It can cause pain that gets worse before and during menstruation.
  • Painful bowel movements

Some women may experience symptoms of endometriosis soon after they start menstruating, while others may not have symptoms at all. When a woman cannot become pregnant or has surgery for another reason, she frequently discovers she has endometriosis.

It is also important to note that the severity of your symptoms does not necessarily reflect the extent of your endometriosis.

How is endometriosis diagnosed?

Endometriosis is typically diagnosed through medical history review, physical examination (pelvic examination), and imaging tests such as ultrasound or MRI.

The pelvic ultrasound scan may be a transvaginal scan to check the uterus and ovaries.

Laparoscopy: The only definitive way to diagnose endometriosis is through laparoscopy. A small camera is inserted into the abdomen to visualize the pelvic organs and tissues in and around the uterus and check for signs of endometrial tissue growth. This procedure is carried out under general anesthesia. 

Biopsy: If the healthcare provider finds suspicious tissue on laparoscopy, they may use a small device to scrape off a few cells and send them to the laboratory. A pathologist examines the tissues under a microscope. A biopsy is required for a definitive diagnosis of endometriosis.

It is important to note that the diagnosis of endometriosis can be challenging since its symptoms may mimic those of other medical conditions, and the severity of the disease does not always correlate with the degree of pain experienced. As a result, diagnosis can often take years to confirm, and seeking the expertise of a specialist in endometriosis management can be beneficial for a timely and accurate diagnosis.

How endometriosis is treated?

The treatment for endometriosis can vary depending on the age, severity of symptoms, and plans for future pregnancies.

In many circumstances, the treatment plan for endometriosis often prioritizes pain management and addressing fertility issues, particularly for individuals who plan to conceive in the future.

Pain relieving medications:  Various medications are available to alleviate the pain associated with endometriosis. These can include over-the-counter pain relievers or prescription medications, depending on the severity of symptoms.

Hormone Treatments:  Hormonal treatments are often prescribed to manage endometriosis symptoms by reducing or stopping ovulation, which decreases hormonal stimulation, thereby shrinking the endometriosis tissue. Various hormonal treatments are available, including contraceptives, which can prevent pregnancy while managing endometriosis. Some options include:

  • Continuous use of the combined oral contraceptive (COC) pill or patch, which suppresses ovulation and can either temporarily stop or reduce the severity of periods.
  • The intrauterine system (IUS/Mirena) can alleviate pain, reduce bleeding, and even stop periods altogether.
  • Progestogens, in the form of injections, mini-pills, or implants, can provide symptom relief.

Non-contraceptive hormonal treatments:  These may not be effective as contraceptives, and therefore, individuals who do not wish to conceive must use additional contraceptive methods. These non-contraceptive hormonal treatments may include:

  • Progestogens in the form of tablets.
  • Gonadotrophin-releasing hormone agonists (GnRHa) can be administered via injections, implants, or nasal sprays. GnRHa is highly effective but may cause menopausal symptoms such as hot flashes and reduce bone density. To minimize these side effects and prevent bone loss, healthcare providers may prescribe ‘add-back’ therapy as hormone replacement therapy (HRT).

Surgical options to treat endometriosis include:

Laparoscopy: Surgery may be necessary for individuals with advanced endometriosis, persistent pain despite other treatments, or those trying to conceive. Laparoscopy is the most common surgical method used to treat endometriosis.

A surgeon makes a few small incisions in the abdomen during this procedure. They insert a thin tube equipped with a light and camera through one of these incisions. Through the other incisions, they insert small tools to remove endometrial tissue (excision) or apply intense heat to destroy the tissue (ablation).

The surgeon may also remove any scar tissue that has formed in the affected area. Compared to traditional open surgery (laparotomy), laparoscopic surgeries typically involve shorter recovery times and smaller scars.

Hysterectomy: In some cases, removal of the uterus (hysterectomy) may be considered as a treatment option for managing the signs and symptoms of endometriosis, such as heavy menstrual bleeding and painful cramping caused by the uterus, for individuals who do not wish to become pregnant. This procedure is typically only recommended after other treatment options have been exhausted and only if the symptoms are severe and significantly impact the patient’s quality of life.

Does endometriosis go away on its own?

In a few rare instances, endometriosis lesions may resolve on their own over time, with the lesions getting smaller and the individual experiencing fewer symptoms. This can also occur after menopause due to decreased estrogen levels. However, for most individuals, endometriosis requires ongoing treatment to manage symptoms such as pain. Regular appointments with a healthcare provider are crucial for monitoring the condition and developing a long-term treatment plan. This may include a combination of medications, hormone therapy, and surgery, as well as lifestyle changes like exercise and dietary modifications, having a diet filled with fiber and foods with omega-3 fats, and avoiding alcohol, caffeine, processed foods, and sugary drinks.

How does endometriosis affect fertility?

Endometriosis does not necessarily mean that you will be unable to conceive. While some people with endometriosis may have difficulty getting pregnant or experience infertility, many others can conceive without any medical help. There are multiple reasons for infertility in women with endometriosis, including:

  • Pelvic adhesions and scar tissues can cause organs and ligaments to stick together, leading to blockages that prevent sperm and egg contact
  • Decrease in the quality and quantity of eggs in the ovary
  • Inflammation caused by endometriosis can release molecules called cytokines that repel sperm
  • Pain with intercourse can also lead to a decreased ability to have intercourse, further affecting fertility.

Can you get pregnant if you have endometriosis?

If you have endometriosis, you can still become pregnant, although it could be challenging. In fact, endometriosis is a common cause of infertility. If you have endometriosis and are trying to conceive, it is essential to talk to your healthcare provider about the best treatment options for you. Depending on your situation, you may need to change your medication or consider surgical intervention to manage your endometriosis. Treatment options include fertility preservation and in vitro fertilization (IVF), which may help women become pregnant. Your healthcare provider will work with you to develop a personalized treatment plan that can help increase your chances of getting pregnant.

Can endometriosis be prevented?

At this time, there is no known way to prevent endometriosis. However, there are steps you can take to help manage your symptoms and reduce your risk of complications. These include maintaining a healthy weight, staying physically active, and managing stress. It is also essential to have regular check-ups with your healthcare provider to monitor your condition and discuss any changes in symptoms.

There are a few factors that may lower the risk of developing endometriosis:

  • Pregnancy: Women with at least one pregnancy have a lower risk of developing endometriosis.
  • Breastfeeding: Studies suggest that breastfeeding may reduce the risk of endometriosis.
  • Healthy weight: Maintaining a healthy weight through regular exercise and a balanced diet may lower the risk of endometriosis.
  • Starting menstruation period at a later age

Is there a link between endometriosis and PCOS?

Endometriosis and PCOS are very different, but both are common conditions and have similar symptoms. It is also possible for both conditions to occur at the same time. Studies have shown that if you have PCOS, you have a higher risk of developing endometriosis.

To conclude, if you are experiencing symptoms like chronic pain, heavy periods, or difficulties getting pregnant, it is crucial to speak with your healthcare provider about the possibility of endometriosis. This condition can significantly impact your daily life, but there are treatment options available that can help manage symptoms and improve your overall quality of life. With the proper treatment and ongoing care, you can work towards managing your endometriosis over the long term.

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