Endometriosis

What is Endometriosis?

Endometriosis is a medical condition in which the endometrial tissue that lines the inner surface of the uterus grows outside the uterus. It most commonly forms on the ovaries, fallopian tubes, outer surface of the uterus, and uterine ligaments and rarely sometimes develops in the areas such as the vagina, bowel, bladder, and rectum.

Is Endometriosis a medical emergency?

Endometriosis is not a medical emergency.

Types

Depending upon the location they occur, endometriosis is divided into the following:

• Superficial Peritoneal Endometriosis: The lesions appear on the lining of the pelvis and abdomen and do not invade deeply
• Deeply Infiltrating Endometriosis: The lesions invade deeply into the tissues and can extend into the nearby organs like ovaries, bladder, and bowels.
• Abdominal Endometriosis: The endometrial lesions grow on the abdominal wall and the sites of surgical incisions
• Diaphragmatic Endometriosis: This is a rare kind of disease. Endometrial lesions are formed on the diaphragm.

Causes

There are no exact causes of endometriosis, but some of the possible causes include the following:

• Retrograde (backward) menstruation: Menstrual blood containing endometrial cells flows back into the pelvic cavity instead of flowing through the fallopian tubes. These endometrial cells stick to other organs and grow, leading to complications.
• Peritoneal layer transformation: The pelvic tissue's peritoneal layer transforms into endometrial-like cells. They grow and bleed in the pelvic cavity during every menstrual cycle, causing complications.
• Surgical scars: Endometrial cells can attach to the surgical incisions after a C-section or hysterectomy. They slowly invade the incision line and cause complications.
• Hormonal causes: In some cases, hormones like estrogen can convert embryonic cells into endometrial-like cells during puberty and can cause the disease
• Immune system disorders: It can also cause endometriosis

Risk factors 

Factors that influence the development of endometriosis are as follows:

• Family history of endometriosis
• Prolonged exposure to estrogen
• Late menopause
• Early menarche, below 11 years of age
• Having less than 27 days between menstrual periods
• Heavy menstrual periods lasting for 7 days
• Never giving birth to a child
• Obstruction of menstrual flow due to any underlying medical conditions
• Underweight

Signs & Symptoms

Signs and symptoms of endometriosis include the following:

• Pelvic pain along with abdominal and back pain
• Painful periods. Severe abdominal cramps during and after a menstrual period
• Excessive bleeding during a menstrual period
• Vaginal bleeding between menstrual periods
• Pain during sexual intercourse
• Pain during urination, frequent urination, and urinary urgency
• Pain during physical activity like exercise, standing, or walking
• Infertility

Investigations

The investigations that are performed to diagnose endometriosis include the following:

• Laboratory tests:
  • CBP & ESR
  • Complete urine examination with culture
  • CA-125 test
  • CCR1 test
• Pelvic examination: A complete pelvic examination is done manually to palpate the areas of the pelvis and identify any abnormalities
• Ultrasound: Transvaginal ultrasound is performed to identify deep infiltrating lesions, their size, and location
• Laparoscopy: A laparoscope is used to visualize the abdominal cavity. It is used to determine the severity of the disease and diagnose the extent of the disease.
• MRI Imaging: MRI captures images of organs and tissues. It determines the location and size of the endometrial lesions.

Diagnosis

A diagnosis is confirmed based on medical history, clinical evaluation, and investigation results.

Stages

Endometriosis is classified into four stages:

• Stage I-minimal: Superficial lesions and a few filmy adhesions are present in the pelvic cavity.
• Stage II-mild: Mild endometrial implants and few adhesions are present in the pelvic cavity.
• Stage III-moderate: Deep endometrial implants with more adhesions are present on the ovaries and pelvic cavity.
• Stage IV-severe: Large deep endometrial implants with extensive adhesions are present on the ovaries and pelvic cavity. Endometrial implants can also be on fallopian tubes, bowels, or the bladder.

Treatment options

Treatment of endometriosis depends upon the severity of the condition.

Medical treatment

Medical treatment may include the following:

• Pain medications:
  • Non-steroidal anti-inflammatory drugs like ibuprofen and naproxen
  • Opioids like morphine sulfate
  • An immunomodulating agent such as pentoxifylline
• Hormonal medications:
  • Hormonal birth control pills: These pills control the hormones that are responsible for the formation of endometrial tissues
  • Gonadotropin-releasing hormone (Gn-RH) agonists and antagonists: These drugs stop the production of ovarian-stimulating hormones, and lower the levels of estrogen, and prevent menstruation
  • Progestin therapy: These drugs stop menstrual periods and the growth of endometrial implants
  • Aromatase inhibitors: These drugs reduce the estrogen levels in the body

Interventional treatment including surgery and indications for surgery/ Surgical treatment

Surgical treatment of endometriosis includes:

• Conservative Surgery: Conservative surgery involves the excision of endometrial implants and the removal of adhesions while preserving the ovaries and uterus.
• Semi-conservative Surgery: This is performed in women who do not desire fertility in the future and who are too young for surgical menopause. This surgery consists of removing the uterus and excision endometrial implants.
• Radical hysterectomy: Radical hysterectomy refers to the complete removal of the uterus ovaries and excision of endometrial implants.

Role of Diet/ Exercise/ Lifestyle changes/ Preventive measures

The treatment includes warm baths and heating pads to relax pelvic muscles and alleviate menstrual cramps. Preventive measures for the disease include the following:

• Regular exercise
• Avoiding alcohol and caffeine

Complications

Endometriosis can cause the following complications:

• Infertility
• Scar tissue formation
• Adhesions
• Organ fusion
• Severe pain during periods
• Pelvic cysts and ovarian cysts
• Bowel and ureter obstructions
• Cancer development like ovarian cancer

Prognosis

Although endometriosis is considered a chronic condition based on its high recurrence rate, the overall prognosis is good.

When to contact the doctor or hospital? / How to identify the complications?

Medical consultation is recommended if the signs and symptoms of endometriosis are noticed.

Indications for hospitalization if required

Surgical treatment for endometriosis requires hospitalization.

Suggested clinical specialists/ Department to consult for this condition

Gynaecology