What is Endometriosis ?

In order to understand Endometriosis it helps to know a little of the anatomy and workings of the uterus :

This diagram is a graphical representation of a side view cross section of the female pelvic area it shows the typical locations of pockets of endometriosis. The abdominal cavity is lined by a silky tissue called the peritoneum and endometriosis is found attached to this sometimes.

The endometrium ( pronounced endo-me-tree-um) is a temporary   layer of tissue that lines the inside of a woman’s uterus which is replaced each month. Under the influence of interacting female hormones the endometrium builds up during each menstrual cycle in readiness to be a spongy bed into which  a fertilised egg can implant . However if pregnancy does not occur in that month the endometrium breaks free and is shed at the end of the cycle as a period.

Endometriosis (pronounced endo– me–tree–o-sis) is a condition where small islands of this endometrium tissue are found in places outside the uterus. Common sites are in the small cul-de-sac called the Pouch of Douglas which lies like a sort of gutter behind the uterus between it and the bowel (see picture above ). These pockets of endometriosis may also be attached to the outside wall of the bowel, uterus, bladder, on or inside the ovaries or stuck on to the lining ( r peritoneum) of the abdominal cavity. The mechanism for how this tissue comes to be found outside the uterus is still the subject of research.

However there are several schools of thought on the causes of Endometriosis :

The most widely held view is that Endometriosis results from the back flow leakage of tiny amounts of menstrual tissue up and out through the fallopian tubes where the particles attach themselves to the organs or tissue within the abdominal cavity and flourish. This theory cannot explain how endometriosis pockets have been found, albeit rarely, in organs such as the lungs which are not in direct contact with the uterus .

This diagram shows the normal direction of menstrual flow down through the vagina and illustrates the theory that Endometriosis may be due to  back flow of menstrual blood - NB. the flow is only graphically represented here and  in reality it is probably only tiny amounts of blood that escape up the tubes

Some experts believe that this remote phenomenon can be explained through the minute fragments of endometrial being spread by either the blood stream or lymphatic drainage system like seeds pollinating far away from their flower.

It is very important to point out that Endometriosis is NOT a form cancer.

Another theory is that it is there are certain people who, given the right triggers, have an abnormal reaction within primitive cells in  the lining tissue ( peritoneum)  of the abdominal cavity and under certain hormonal, genetic or environmental influence these cells are transformed in to endometrial cells and proliferate into pockets of endometriosis.

What are the Symptoms of Endometriosis?

Because the pockets of endometriosis are the same tissue as that which lines the uterus they too respond to the cyclical changes in hormones. The pockets swell and bleed just like the normal endometrium in the uterus . This is thought to be responsible for the characteristic severe pain of Endometriosis associated with periods. Some people worry about this blood accumulating however the body has an efficient ability to reabsorb it. But meanwhile this blood is an irritant to the internal abdominal cavity and causes pain . The period pain that women with endometriosis suffer is frequently so severe that it interferes with their work and enjoyment of life.This is not acceptable, but even today some women still accept  severe period pain as their "lot" and often  don't seek help.

Women with endometriosis frequently experience discomfort or even more severe pain with sexual intercourse and also complain of pain at other times in the cycle as well as premenstrual spotting.  They can also get symptoms from pockets of endometriosis tissue in organs quite remote from the uterus. There have been reports of pockets causing bleeding in the bowel or even the lungs.

This condition has very often gone undiagnosed because women are apt to not talk about period pain or simply assume that everyone experiences  period pain like theirs . Doctors are also sometimes not au fait with the condition. It may also be misdiagnosed as a bowel complaint or pain of some other origin.

The truth is that no woman should have her life disrupted by period or pelvic pain and should always seek help for it. Of course not all period pain is due to Endometriosis but it is important to consider it. If you think you may have Endometriosis talk about it with your doctor or ask for a referral to a specialist centre that deals with the problem.

Some groups estimate that maybe 90 million women worldwide suffer form Endometriosis.

It is estimated that in 20% of all women who undergo gynaecological surgery for other reasons Endometriosis will be found at operation. However not all of these will have symptoms and may never have any problems related to their endometriosis.

Endometriosis occurs in women in their reproductive years – it is rare below 15 and not usually seen after menopause.  

Until fairly recently the pick up rate and diagnosis of Endometriosis has been poor. Education is the key – both of the public and medical practitioners.

Women need to be encouraged to talk about period pain and not just accept it as their "lot". Doctors need to be educated about the condition and the  debilitating effects of pelvic pain on a woman’s lifestyle and relationships. Men need to understand the ramifications of the condition on a woman's view of herself especially with regard to the fertility issues.

Delays in diagnosis have been common in some studies have shown in some women it has taken up to 8 years before a diagnosis has been made.

Ultrasounds and scans may rule out other causes of pain but Endometriosis can only be accurately diagnosed by laparoscopy. This is where a specialist gynaecologist performs a procedure under anaesthetic in which a fibre optic tube (laparoscope) is inserted through a small incision under the umbilicus (belly button) and he (or she) literally makes the diagnosis based on visualising the tissue and possibly biopsying it. It is now common for gynaecologists to video tape these procedures which means the patient may be able later to see first hand the cause of their pain.

What is the Treatment for Endometriosis ?

Endometriosis is considered to be a chronic relapsing condition. There is currently no cure but treatment is aimed at pain control fertility preservation and relapse reduction.

There are five main areas of treatment and most women will use a combination of these. Any woman with Endometriosis should inform her self as much as possible of treatment options and current status of these options. She should certainly be part of the treatment decision making process. There are excellent facilities on the Internet provided by the Endometriosis support groups I will list some if my favourite sites at the end of this article.

1. Medication for pain relief – There are various medications available and the over the counter non steroidal anti-inflammatory medications marketed for period pain are useful for controlling  cramps and worth a try,  but maybe insufficient for endometriosis.
2. Surgery – surgery has been a mainstay in the treatment of Endometriosis. The aim of conservative surgery is to remove the pockets of Endometriosis in an attempt reduce pain and hopefully restore or maintain fertility. The problem with surgery is that each time the abdominal cavity is opened there is a likely hood of developing filmy internal scar tissue called adhesions. It can become a "catch 22" situation in that the adhesions may also produce pain and there is often a dilemma about doing further procedures to divide these when the treatment may end up inducing more problems! Advances in endoscopic techniques, especially the use of robotics, has allowed some highly skilled surgeons to be able to use scissors and scalpel over lasers in an attempt to reduce scar reaction. Some severe long term  cases of endometriosis end up requiring  more radical surgery such as hysterectomy  but this only after all conservative methods have been exhausted. There are many emotional issues surrounding the notion of this latter type of surgery in young women with regard to final loss of fertility and it should not be entered into without appropriate counselling.
3. Hormonal treatment – The aim of hormonal treatment is to shrink the endometriosis tissue and switch off ovulation. This is often instituted before surgery to reduce the size of the pockets. The problem with long term hormones is that side effects of the treatments may be not well tolerated by some women. It is very important for women to be fully informed of the potential side-effects of any treatment before she commences it.
4. Alternative methods – more and more Complimentary Medicine is being used in the treatment of conditions like Endometriosis where Western Medicine has no cure. Methods like Traditional Chinese herbal treatments are now accepted as part of the regime options in many Centres.
5. Psychological and emotional support - Because Endometriosis is a chronic relapsing condition that causes pain which possibly requires surgery on several occasions  and  because it can be associated with fertility problems it is a mine field that often places a major stress on a woman's emotional reserve and can have a not a ripple, but a tidal wave effect on her relationships and career. There are endometriosis support groups in most capital cities.

Tubal blockage is the most common cause of infertility. The most common causes of tubal blockage are infection and endometriosis. Endometriosis may also disrupt the function of the ovaries.The association with fertility problems is extremely distressing to young women and their partners when they first learn of their diagnosis. It is important to put the condition in context. That is not all endometriosis will result in infertility ( may be 30% of cases diagnosed) and not all infertility is due to endometriosis. It should also be remembered that many cases are diagnosed because the person has sought investigations for infertility.

http://www.endometriosisassn.org/ The American Endometriosis support group has excellent information

http://www.ivf.com/endohtml.html This is another American Health information site with very upto date and comprehensive info – a bit more scientific.

http://www.ecca.com.au/ A new Australian Endometriosis group headed by Professor Carl Wood one of the pioneers of IVF in Australia. Click on their "information button" for good info and pics of Endo

http://www.endometriosis.org.au/ Endometriosis association of Australia . This group has been working hard for years to raise awareness of the condition and give support to sufferers.