What is endometriosis?
Pronounced “en-doe-me-tree-O-sis”, this can be a painful condition as it involves the endometrial tissue usually found in the endometrial lining, which is inside your uterus, developing outside of it instead, which can result in a number of complications.
The inside of your uterus is known as the endometrium. Each month you shed endometrial tissue from your endometrium during your menstrual cycle, this is known as menstruation or your period. The areas most commonly affected by endometriosis are the fallopian tubes, ovaries and the tissue that lines the pelvis. In some rare cases, endometrial tissue can sometimes spread to areas beyond the pelvic organs.
When you have endometriosis, the endometrial tissue that is displaced will continue to perform the way it should, thickening in preparation for a fertilised egg and then breaking down resulting in bleeding if the egg is not fertilised and you then have your menstrual cycle. However, because the endometrial tissue is displaced, it has no way to leave the body and therefore becomes trapped. When the ovaries are involved in the condition, then endometriomas, which are cysts, may form. The surrounding tissue can become irritated and inflamed, eventually resulting in the development of adhesions and scar tissue. Adhesions are abnormal groupings of fibrous tissue that may result in pelvic organs and tissues sticking to one another.
Endometriosis often results in pain, which can sometimes be severe, particularly during the sufferer’s menstrual cycle. Issues often arise where fertility is concerned, fortunately, there are a number of treatment options available.
How does endometriosis cause issues with my menstrual cycle?
The tissue that lines your uterus is known as endometrium, as mentioned above. Your body will release certain hormones every month that result in your endometrium thickening as it gets ready for the implantation of a fertilised egg and pregnancy (i.e. a sperm cell has fertilised an egg released from your ovary and this attaches to the uterine wall in order to develop). If you do not fall pregnant, the endometrium will shed, this is when you get your period.
If you suffer from endometriosis, the tissue that implants itself on the outside of your uterus will act as though it is still located within the lining of the uterus. This means that when you have your menstrual cycle, the tissue will thicken and shed which will result in bleeding. However, this shedding has nowhere to go to escape the body as is the case in a normal menstrual cycle. Thus, the tissue implants and becomes irritated and often painful. As stated earlier, this can then form scar tissue or cysts (fluid-filled sacs) in some cases. The scar tissue is what makes it difficult for some endometriosis sufferers to fall pregnant.
What are the stages of endometriosis?
Endometriosis is classified into four stages. These stages are based on the depth, location, severity, presence, size and the extent of the implants of endometrial tissue. The stages range from minimal, mild and moderate to severe.
These stages are not, however, related to the severity of the symptoms the sufferer is experiencing, although infertility, is common with stage four endometrioses.
The stages of endometriosis
Stage 1 endometriosis – Minimal
In stage one endometriosis, there are normally small wounds or lesions with shallow endometrial implants on one of the ovaries. There may also be some inflammation with this in the region of the pelvic cavity.
Stage 2 endometriosis – Mild
Stage two of endometriosis often involves shallow implants of the endometrial tissue with light lesions on one of the ovaries or the pelvic lining.
Stage 3 endometriosis – Moderate
Stage three endometriosis will involve deep implants and more lesions on one of the ovaries, as well as the pelvic lining.
Stage 4 endometriosis – Severe
Stage four of endometriosis is the most severe stage as it involves deep endometrial implants on the ovaries and pelvic lining. It is also possible for lesions to have formed on your bowels and fallopian tubes.
What are the symptoms of endometriosis?
The most prominent symptom associated with endometriosis is mild to severe pelvic pain. This is often associated with the occurrence of one’s menstrual period. It is not uncommon for many women to suffer from cramping during their period, however, those with endometriosis will describe this pain to be far more severe than is usual for most. These same women have also stated that this pain will often progress over time.
The common symptoms and signs associated with endometriosis are:
- Dysmenorrhea (painful periods) – Cramping and pelvic pain may begin in the few days leading up to your menstrual period and will often extend into the days whilst having a period. It is also common to suffer from abdominal pain and lower back pain.
- Pain during intercourse – It is common to experience pain during or even after sexual intercourse if you suffer from endometriosis.
- Pain during urination or bowel movements – If you have endometriosis you are likely to suffer from pain when you urinate or have a bowel movement whilst you have your menstrual period.
- Excessive bleeding – It is normal for most women to have some periods that are heavier than others, however, when this bleeding becomes excessive, which is known as menorrhagia, or when you experience bleeding when you are between menstrual periods, known as menometrorrhagia, you may have endometriosis.
- Infertility – This is commonly associated with stage four endometriosis. Endometriosis is commonly diagnosed when some women are seeking infertility treatment.
- Other symptoms – There are a number of additional symptoms that are associated with endometriosis, which are often experienced or worsened during menstrual periods, these include:
The extent of the condition, however, cannot simply be based on the severity of the pain experienced during menstruation. In some cases, women who suffer from mild endometriosis may have intense pain, in other cases, women with severe or advanced endometriosis may have very little to no pain at all.
Endometriosis is a condition that can be mistaken for a number of other conditions that also result in pelvic pain such as ovarian cysts or PID (pelvic inflammatory disease). Endometriosis may also be confused with other conditions, a common one being IBS (irritable bowel syndrome). IBS is a condition that results in bouts of constipation, abdominal cramping and diarrhoea. IBS has also been known to accompany endometriosis, which often further complicates the diagnosis.
When to see a doctor
If you currently suffer from any of the above symptoms and signs associated with endometriosis, then we suggest that you make an appointment with your doctor.
Endometriosis is known to be a complicated and often challenging condition to live with and manage. Through early diagnosis, you may be able to aid in the treatment and management of the condition and reduce or greatly relieve any symptoms you may suffer from.
What are the causes of endometriosis?
It is important to note that the exact cause of endometriosis is not yet fully known, however, there are some possible explanation for the condition, these include:
- Retrograde menstruation – The theory behind this condition is that the endometrial cells are transported back through the fallopian tubes and into the peritoneal cavity, which is the abdominal lining, during menstruation. This leads to ectopic (tissue that is in the wrong place) endometrial tissue and eventually endometriosis. To put this in simpler terms, the menstrual blood that contains the endometrial cells will flow back up through the fallopian tubes from which it will flow into the pelvic cavity, when it should be flowing out of the body. The endometrial cells that are displaced in this process will then stick to the walls of the pelvic cavity as well as the surfaces of the pelvic organs, and from here they will grow and thicken and eventually bleed with every menstrual cycle you have.
- Embryonic cell transformation – Oestrogen is a hormone that is believed to have the ability to transform the embryonic cells, these are the cells that are in their earliest development stages, into endometrial cells that implant during puberty and develop with time.
- Transformation of the peritoneal cells – Experts explain this in what is referred to as an induction theory, they propose that certain immune factors or hormones that are responsible for promoting the transformation of the peritoneal cells, these are the cells that are found in the inner abdominal lining, transform these cells into endometrial cells.
- Transportation of endometrial cells – This cause of endometriosis suggests that tissue fluid or blood vessels, being part of the lymphatic system in your body, may transport the endometrial cells and spread them to other parts of the body.
- Surgical scar implantation – When you have surgery, such as a caesarean section or a hysterectomy, endometrial cells may implant themselves at the site of incision.
- Disorders of the immune system –Issues with the immune system may result in the body being unable to recognise and in turn destroy the endometrial tissue that is found growing on the outside of your uterus, this allows the tissue to develop and spread over time.
What are the risk factors of endometriosis?
There are a number of factors that can place you at a higher risk for developing endometriosis. The statistics of childbearing women who suffer from endometriosis is about two to 10%. The condition will normally develop a number of years after a woman first started her menstrual period.
The condition can be a difficult and painful one, but understanding the factors that put one at risk can help you to determine where you stand and if you should see a doctor based on the below:
- Age – The condition can affect you at any age in your life, however, women who are between 25 and 40 years old are mostly affected, bear in mind that the symptoms may also start during puberty and become more pronounced over time.
- Family history (genetics) – If you have a family member who has suffered from the condition, then speak to your doctor as your risk of developing the condition may be increased.
- Pregnancy history – In the past it was thought that giving birth eradicated endometriosis. However, while women who have given birth may experience the temporary suppression of endometriosis symptoms, and these symptoms may be further delayed while a woman breastfeeds and does not have a menstrual cycle, pregnancy and giving birth do not cure the condition and symptoms often recur thereafter. This backs the belief that hormones are able to influence the progression and development of the disorder. That said, women who have never been pregnant may have a higher risk of the condition developing.
- Menstrual history – If you are currently having any issues with your menstrual cycle such as severe pain and/or bleeding or if your period started at a younger age, then these factors can increase your risk of developing the condition.
What are the complications of endometriosis?
The most prevalent complication associated with endometriosis is the patient suffering from impaired fertility. Many women who suffer from endometriosis will struggle to get pregnant.
The reasons for these struggles are not yet completely understood. Doctors suggest that when endometriosis is present this often incites adhesions to form in the pelvic regions which can result in the normal anatomical structures distorting, making pregnancy difficult. Another idea is that the condition can affect one’s fertility as it produces inflammatory substances that have an adverse effect on the ovulation and fertilisation process of an egg, as well as the implantation of an embryo.
In order for pregnancy to take place, the egg is released from an ovary, from here it will travel through the corresponding fallopian tube where a sperm cell will fertilise it. Once it has been fertilised, it will attach itself to the uterine wall and start developing into foetus. When endometriosis is present, this may result in an obstruction in the fallopian tube and thus prohibit the sperm cell from fertilising the egg. The condition is also able to damage the egg or the sperm cell.
This is not to say that if you are diagnosed with endometriosis you can never fall pregnant. There are a number of cases where women with mild and even moderate endometriosis have still been able to conceive and carry their pregnancy to full term. Doctors tend to advise women who are diagnosed with the condition to not delay in falling pregnant to prevent complications and difficulties in the event of endometriosis progressing.
There have been some studies conducted that have noted that women who have endometriosis may have an increased risk of developing ovarian cancer. This type of cancer is known as EOC (epithelial ovarian cancer). This cancer risk is at its greatest in women who have both endometriosis as well as primary infertility – i.e. women who haven’t ever been pregnant. This risk has been significantly reduced through using a combination of OCPs (oral contraceptive pills), these are used in the treatment of endometriosis in some cases.
The association between endometriosis and ovarian cancer is not yet clearly defined or understood. There is a theory that suggests that the endometrial cells implant themselves after which they will undergo transformations that turn them into cancer cells, these are known as malignant transformations. Another theory states that there is a possibility that endometriosis may be related to another environmental or genetic factor that may increase your risk of developing cancer.
How is endometriosis diagnosed?
In order for endometriosis to be accurately diagnosed, your doctor will ask you a series of questions in order for him or her to get an understanding of the level of pain experienced, where it occurs and your symptoms.
The tests that are conducted to check for any physical signs of endometriosis may include:
- Pelvic examination – During this exam, the doctor will manually feel, known as palpating, areas in your pelvic region for any abnormalities, these include scars found behind the uterus or any cysts that are found on the reproductive organs. It is not always possible for your doctor to feel the smaller regions of endometriosis, unless a cyst has resulted from them.
- Ultrasound – This is a test that utilises high-frequency sound waves that will produce images that give the doctor a look at your internal organs. Your doctor may make use of an abdominal ultrasound or a transvaginal ultrasound. The images are captured using a device known as a transducer. An abdominal ultrasound will press the transducer against the abdomen and when a transvaginal ultrasound is done, the transducer will be inserted into the vagina. The results of an ultrasound cannot give your doctor a definite diagnosis, but cysts associated with endometriosis, known as endometriomas can be identified.
- Laparoscopy – For the diagnosis of endometriosis to be certain, you will have a laparoscopy. This is done by a surgeon or qualified gynaecologist while you are under general anaesthesia. The surgeon will make a small incision around the area of your navel and will insert an instrument known as a laparoscope. This is a viewing instrument that will allow the surgeon to find any endometrial tissue located outside of your uterus. Samples of the tissue may also be taken, this is known as a biopsy. A laparoscopy can give your doctor information regarding the extent, location, as well as the size of any endometrial implants which will help in finding the right form of treatment.
How is endometriosis treated?
Endometriosis treatment is normally administered through surgery or medications. The approach that is chosen is typically decided on according to your and your doctor’s suggestions. Your doctor will also assess the severity of your condition and whether you want to one day fall pregnant. Conservative approaches are generally the first option.
The following are the options of treatment for endometriosis:
It is likely that your doctor will first recommend some OTC (over-the-counter) pain medication, some of these may include:
- Ibuprofen (Advil, Motrin IB)
- Nonsteroidal anti-inflammatory drugs (NSAIDs)
- Naproxen (Aleve)
These medications usually help in easing the pain of menstrual cramps. If taking and these do not relieve your symptoms, then speak to your doctor about another approach to pain management.
Hormone supplements can help in eliminating or reducing the pain associated with endometriosis. The fluctuating levels of hormones when you have your menstrual period can result in the thickening of endometrial implants which cause endometriosis, these then shed and bleed. Through the use of supplemental hormones, this tissue growth may be slowed and new growth can be prevented.
Hormone therapy is not, however, a permanent solution as symptoms usually return when one stops treatment.
Hormone therapies that are used for the treatment of endometriosis include:
- Hormonal contraceptives – Medications for birth control including birth control pills, vaginal rings and patches can aid in controlling the hormones that are responsible for endometrial tissue building up every month. A lot of women will have a shorter and lighter menstrual flow when they are taking hormonal contraceptives. The use of these types of contraceptives, particularly ones that require a continuous regimen (such as birth control pills), can also help in reducing the pain associated with mild and moderate endometriosis.
- There is also an option for an injection known as medroxyprogesterone (Depo-Provera), which has proven to be effective in stopping menstruation. This will also stop endometrial implants from growing, as well as relieve pain. This is often not your doctor’s first choice as there is risk associated with these hormones affecting your body’s bone production, weight gain and some symptoms of depression.
- Gonadotropin-releasing hormone (Gn-RH) agonists and antagonists – If women take these hormones, they are able to block or stop the production of the hormones that stimulate your ovaries, this will lower your oestrogen levels and in turn, prevent menstruation. This will also result in your endometrial tissue shrinking as these drugs will create what is known as an ‘artificial menopause’ without the severe side effects of menopause, being vaginal dryness, bone loss and hot flushes. This is done through taking low doses of the hormones progesterone and oestrogen, as well as the Gonadotropin-releasing hormone (Gn-RH) agonists. When you stop this treatment, your fertility and periods will return.
- Progestin therapy – This is a form of contraception and can help relieve the symptoms of endometriosis, some examples include:
- The Mirena – This is an intrauterine device (IUD) which is inserted into your uterus to stop you from menstruating and falling pregnant for a number of years, this is often as many as five years. A Mirena contains the progestin hormone which will thicken the cervical mucus so that the sperm cannot reach the egg released from an ovary, this is what will also prevent ovulation and in turn menstruation in some women.
- A contraceptive implant (Nexplanon) – This is a small match stick-size rod that is inserted into your arm. From here it will release hormones that will stop you from being able to fall pregnant.
- A contraceptive injection (Depo-Provera) – This injection is typically given every 12 weeks and contains the same hormone progestin which thickens the cervical mucus, preventing sperm from meeting an egg to fertilise it.
- **My Med Memo – The difference between progesterone and progestin is that progesterone is a natural hormone that our adrenal glands and ovaries produce. It forms an integral part in the balance of hormones in the body as it is necessary for an embryo to survive, as well affords a number of other biological benefits such as regulating the menstrual cycle and playing a role in sexual desire. Progestin is a synthetic hormone that is manufactured, in the above cases, it is used to prevent endometrial hyperplasia (the enlargement and growth of endometriosis) through hormone replacement therapy.
- Danazol – This is a drug that will suppress endometrial growth through blocking the production of hormones that stimulate the ovaries and lead to ovulation, thus preventing menstruation, as well as endometriosis symptoms. However, although rare, if you do ovulate and fall pregnant while taking this drug, there is a risk of it impacting the health of your baby.
If you are diagnosed with endometriosis and want to fall pregnant, then surgery (known as conservative surgery) that will attempt to remove the bulk of your endometriosis whilst also trying to preserve your uterus and ovaries, may be able to increase the chances of you falling pregnant.
If you are suffering from severe pain as a result of endometriosis, then surgery will also often be able to aid in easing the pain, however, this is not to say that the pain will not return in future if endometriosis recurs.
Conservative surgery in the more extensive and severe cases of endometriosis is traditionally done through abdominal surgery although it can also be done laparoscopically. When the surgery is done laparoscopically, the surgeon will make a small incision in your navel area where he or she will then insert a small viewing device known as a laparoscope, from this, the surgeon will make another small incision where he or she can insert instruments that will remove the endometrial tissue.
Abdominal surgery makes a larger incision in your abdomen to remove the endometrial tissue.
Assisted reproductive technologies
These include reproductive techniques that will help you to fall pregnant, these are sometimes preferred over conservative surgery or in cases where conservative surgery was unsuccessful. A popular technique includes In Vitro Fertilization (IVF), this is a fertilisation process that works through extracting your eggs and retrieving a sample of sperm from your partner or a donor, the eggs and sperm are then combined manually in a petri dish in a lab in order for an embryo to form. This will then be inserted into your uterus during an implantation procedure. A few samples are often taken and then inserted into the uterus which can result in twins or triplets. This can, however, often be a costly procedure.
When endometriosis is more severe, a hysterectomy will be conducted that will remove the cervix, ovaries and uterus, this is known as a total hysterectomy. There are different types of hysterectomies. Some of these include:
- A radical hysterectomy – The uterus as well as the tissues on the side of the uterus, the top part of the vagina and the cervix is removed (this is only conducted in chronic cases if there are cancer cells present).
- Hysterectomy with bilateral salpingo-oophorectomy (total hysterectomy) – This will remove the cervix, fallopian tubes, ovaries and fallopian tubes.
This surgery is often considered to be the last resort in the fight against endometriosis, particularly if you are still in your reproductive years as you will not be able to fall pregnant once this is done.
This is a very intrusive and intensive surgery and requires a surgeon you will feel comfortable with and a solid, caring support structure thereafter. This will be your last resort if your endometriosis has gotten to a point where conservative surgery cannot remove it and you cannot manage to live with the symptoms.
Can endometriosis be treated at home?
Lifestyle changes and home remedies for endometriosis
If you find that your pain is persistent or that your medical treatment takes some time to take effect, then you may find the below home and lifestyle remedies to be effective in helping to relieve your discomfort:
- A heating pad, hot water bottle or warm baths will help in relaxing your pelvic muscles and in reducing pain and cramps.
- OTC (over-the-counter) nonsteroidal anti-inflammatory (NSAIDs) drugs can help in relieving the pain of cramping, such as:
- Naproxen (Aleve)
- Ibuprofen (Advil, Motrin IB)
- Regular exercise will also help to improve your symptoms.
Support and coping
If you are suffering from the complications associated with endometriosis, then it may help if you join a women’s support group for fertility and endometriosis issues. It can help to share your feelings and what you are going through with women who are going through something similar. There are also great internet support groups available, just make sure that these are legitimate and that you continually double check the suggestions and advice given with a medical professional.
What is the outlook for endometriosis?
As endometriosis is a chronic condition, it does not have a cure. This does not mean that it has to take a toll on your daily activities and life. There are a variety of treatments available to help in the management of any pain and aid in treating fertility issues. If you suffer from endometriosis, the symptoms will often improve once you have gone through menopause as you will no longer be menstruating.
While endometriosis is something that may initially cause you a great deal of stress when you are first diagnosed, it is important to remember that it affects a number of women who still manage to lead healthy lives and have children, albeit with medical intervention in many cases.
Remember to always have regular check-ups with your gynaecologist in order for the condition to be detected and assessed as early treatment can often increase its effectiveness and aid in preserving fertility.
FAQ about endometriosis
Does diet affect endometriosis?
Making changes to your diet has not been proven to aid in reducing the symptoms of endometrioses. However, sticking to a healthy and balanced diet consisting of green vegetables, fruit, fibre, protein and whole grains can help in improving your ability to combat pain or deal with it and may improve your daily life in being able to function with more energy.
What kind of doctor will treat endometriosis?
An obstetrician-gynaecologist (OB-GYN) will treat endometriosis.
What is endometriosis cyst?
One of the complications associated with endometriosis is the development of endometriosis cysts. These are fluid-filled sacs or growths that are known as endometrial cysts or ovarian endometriomas (when these form on an ovary). The symptoms of these cysts can often be the same as those of endometriosis.
Can endometriosis make you gain weight?
Gaining weight is not considered to be a symptom of endometriosis. Bloating is a symptom of the disease and this can often make your clothes fit tighter, which can make you feel as though you have gained weight.