5min read
What is endometriosis?
What are some common symptoms of endometriosis?
What are the ‘most current ways’ to manage endometriosis in women?
Endometriosis is a chronic, inflammatory, albeit non-threatening, condition defined by the presence of endometrial-like tissue (lining of the uterus) in unusual places outside the uterus. The ‘unusual or extra’ endometrial tissue is usually located inside the pelvic region but can appear anywhere in the body. While some women experience pelvic pain and/or sub fertility, many women may not experience any symptoms at all. This condition can progress, and re-occur despite best medical and/or surgical treatments and can, therefore, cause significant distress in women across their lifespans.
Endometriosis can be extremely painful and is more common than most people realise. The prevalence of endometriosis in reproductive aged women is between 3% and 10 %, and up to 50% in women with infertility. The mean age at the time of diagnosis ranges between 25 and 35 years. The ‘typical’ delay in diagnosing endometriosis could be up to 4-10 years, which is most likely due to lack of reliable non-invasive tests or biomarkers, thus, impacting women and their families both, emotionally and financially.
Common symptoms of endometriosis
Symptoms of endometriosis can vary from person to person. However, commonly presenting complaints include:
- Pelvic/back/leg pain between and during periods.
- Chronic pelvic pain
- Painful sexual intercourse
- Irregular periods
- Heavy and painful periods
- Bladder frequency &/or pain when urinating.
- Painful bowel movements.
- Digestive problems including irritable bowel syndrome (IBS).
- Sub or poor fertility
- Depression/anxiety
- Chronic fatigue
- Immune related disorders such as allergies
| If you notice any of the following predictors, consider a diagnoses of endometriosis: Severe pain with menstrual cycle or periods Abdominopelvic pain Heavy menstrual bleeding Infertility Painful sexual intercourse Post-sexual intercourse bleeding A previous diagnosis of ovarian cyst, irritable bowel syndrome or pelvic inflammatory disease |
A recent (2021) study in 600 women with endometriosis found that most women report at least one of the 3 classic symptoms: painful periods or dysmenorrhea in 80%; non-menstrual pelvic pain in 78%; and painful sexual intercourse or dyspareunia in 58%. At least 48% of the women with endometriosis reported all three symptoms in the respective study. Approximately 50% of the patients with dysmenorrhea report severe pain, many with general pelvic pain reported moderate (42%) or severe (30%) pain regardless of any current treatments. Most women (77%) experienced moderate or severe pain.
| What causes endometriosis? Endometriosis is of unknown cause or origin, however, many theories have been identified to describe this condition. – Sampson’s backward menstruation and implantation theory describes that the endometrial tissues are transported to the abdominal area via Fallopian tubes. – Other explanations include the coelomic metaplasia theory (embryonic defects) or the vascular and lymphatic dissemination of endometrial cells Women with estrogen-imbalance, poor immune function, and a positive family history have a higher chance to develop endometriosis. A first degree relative with endometriosis can increase the risk to 6-7 times! |
Why endometriosis may cause infertility in women?
Endometriosis is strongly associated with infertility in women. Between 20% and 50% of infertile women have endometriosis. This can be a considerable emotional challenge for a couple planning to have a family. Some reasons for infertility include:
- Poor uterine anatomy or structure to receive sperm
- Poor ovarian, tubal or endometrial function due to the chronic nature of inflammation in the body.
How is endometriosis diagnosed?
The diagnosis of endometriosis is:
- Suspected from the history, signs and symptoms
- Corroborated by physical examination and imaging (ultrasound or MRI)
- PROVEN by tissue (histological) examination of specimens collected during laparoscopy.
NOTE that the diagnosis of endometriosis cannot be confirmed through symptoms or physical examination. Transvaginal ultrasonography is highly dependent on experienced clinicians and cannot be used for diagnosis.Similarly, the use of MRI (magnetic resonance imaging) or biomarkers such as CA-125 are not established and not recommended.
The gold standard test for diagnosis is a combination of laparoscopy (where a camera is put inside the abdomen and explored for endometriotic spots) and tissue extraction for verification (histological exam).
Instead of doing an invasive test such as a surgery, empirical medical treatment for pain is recommended.
What are some treatment options in endometriosis?
There are certain mainstay therapies that have been recommended by the 2014 European society of human reproduction and embryology. However, a significant portion of women may not respond positively to the medical and surgical options leading to a re-occurrence of pain, thus needing other evidence-based complementary approaches.
A. Medical recommendations include:
- Analgesics for pain (NSAIDs)
- Hormonal contraceptives (estrogen- progestin)
- Progestagens and anti-progestagens
- GnRHagonists and antagonists
- Aromatase inhibitors
B. Surgical recommendations include:
- Laparoscopic surgery or laparotomy. Laparoscopic surgery (scarring and removal of tissue) is preferred due to less pain, shorter hospital stay, quicker recovery and better cosmetic outcome
- The objective of surgery is to restore the normal anatomical relationships, to remove or destroy all viable disease to the extent possible and to prevent or delay recurrences.
C. In women with infertility: For minimal and mild endometriosis, controlled ovarian hyperstimulation with timed intercourse or Intrauterine insemination (IUI) is recommended, while for the advanced stages, in-vitro fertilization or IVF is suggested.
D. Complementary approaches:
- Diet: Less information is known on the effects of diet in endometriosis, however, the nurses’ health study on 3800 participants indicated that women with >2 servings of red meat/day have a 56% greater risk to develop endometriosis as compared to less red meat consumption.
- Exercise: A few studies have found a positive and protective effect of regular exercise on suppressing the inflammatory and estrogen pathways in endometriosis, however more research is needed. Pelvic rehabilitation has also been suggested to improve pain and quality of life in women with endometriosis.
- Psychological and mind-body interventions: A variety of interventions including Chinese medicine, hypnotherapy, cognitive behavioral therapy, mindfulness, meditation and yoga have been suggested to decrease the stress and inflammatory responses in women with endometriosis, therefore, causing a reduction of pain. However more research is needed.
- Acupuncture: Several studies have shown a positive effect of acupuncture on pain and is a recommended treatment in endometriosis.
Hope you find this article useful! Also, check out other blogs on pelvic health written by our team! We want to hear from you! Please give us some feedback by writing in the comment section below. Look forward to our many discussions!
Written by:
Sakshi Chopra, MBBS DGO DNB (Gynaecologist)
Hina Garg, PT, MS, PhD, NCS, CEEAA (Physical therapist)
REFERENCES
- Agarwal SK, Antunez-Flores O, Foster WG, et al. Real-world characteristics of women with endometriosis-related pain entering a multidisciplinary endometriosis program. BMC Women’s Health. 2021;21(1):1-14.
- Ball E. & Khan K. Recent advances in understanding and managing chronic pelvic pain in women with special consideration to endometriosis. F1000Research, 2020, 9.
- Hunt JB. Pelvic Physical Therapy for Chronic Pain and Dysfunction Following Laparoscopic Excision of Endometriosis: Case Report. Internet Journal of Allied Health Sciences & Practice. 2019;17(3):1-8.
- Mira TAA, Buen MM, Borges MG, Yela DA, Benetti PCL, Benetti-Pinto CL. Systematic review and meta-analysis of complementary treatments for women with symptomatic endometriosis. International Journal of Gynecology & Obstetrics. 2018;143(1):2-9.
- Becker CM, Gattrell WT, Gude K, Singh SS. Reevaluating response and failure of medical treatment of endometriosis: a systematic review. Fertility & Sterility. 2017;108(1):125-136.
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- Brosens I, Puttemans P, Campo R, Gordts S, Kinkel K: Diagnosis of endometriosis: pelvic endoscopy and imaging techniques. Baillieres Best Pract. Res. Clin.Obstet.Gynaecol.18,285-303 (2004).
- Sampson JA: Peritoneal endometriosis due to the menstrual dissemination of endometrial tissue into the peritoneal cavity. Am. J. Obstet. Gynecol.14,422-426(1927).