Endometriosis is a disorder of the female reproductive system, where endometrial tissue (the normal lining of the uterus) is found in areas other than the uterus.

The most common sites are in the pelvis—the ovaries or tissues near the uterus and fallopian tubes, including the bladder, ligaments and bowel.

How does Endometriosis occur?

The exact causes of endometriosis are still not fully understood. It is believed that endometriosis occurs as a result of normal tissue from the uterus escaping into the fallopian tube and out into the pelvic area at the time of menstruation (“retrograde menstruation”). These tissue fragments are then thought to implant and grow onto the surrounding pelvic tissue and, sometimes, organs.

Because these fragments are made of the same tissue as the lining of the uterus, they too respond to the hormonal changes that occur during the menstrual cycle and, therefore, “bleed”. Whereas menstrual blood can escape from the body, this has no exit and, as a result, the areas surrounding the implants of tissue become irritated or inflamed.

Some of the blood and tissue may form into cysts (fluid filled lumps)—sometimes known as “chocolate” cysts, due to the colour similarity.

The continual release of blood contributes to the formation of scar tissue. If the endometriosis is severe, bands of this scarred tissue (“adhesions”) may develop.

Effects of Endometriosis on fertility

Endometriosis and infertility are definitely related and although some women with endometriosis remain fertile, endometriosis is regarded as one of the most common causes of infertility in women over 25 years of age. It has been further estimated that between a third and a half of all women with infertility problems have some degree of endometriosis.

Why it causes infertility is unclear. For women with severe endometriosis, their fallopian tubes may be damaged so that it is impossible for the egg to reach the sperm. Other women may have “chocolate cysts” on their ovaries which impair ovulation. But even where it is mild or where the endometriosis is not found on the tubes or ovaries, women can remain infertile.

Symptoms of Endometriosis

Pain is the major symptom, though its intensity may vary. It may be experienced as a sharp stabbing pain, a constant or intermittent dull ache, or as a severe cramping pain.

This pain may be felt:

• with periods (mild, moderate or severe pain);
• during ovulation (mild, moderate or severe pain midway between periods);
• in the bowel during menstruation, or bowel movements or when passing wind;
• during or after sexual intercourse;

Other symptoms may include:

• infertility;
• diarrhoea or constipation;
• heavy or irregular bleeding (sometimes involving the loss of large clots of blood or tissue);
• pre-menstrual tension.

The severity of your symptoms has little to do with the extent of your endometriosis. Some women may have severe pain from just a slight build-up of tissue, whereas other women may have only the mildest symptoms despite an extensive build-up of tissue.

Diagnosis

The presence of endometriosis may be diagnosed at the initial consultation and examination, however, a firm diagnosis can only be made when the endometriosis is actually seen, using a surgical procedure known as a laparoscopy. This enables the doctor to view the ovaries, fallopian tubes, uterus and other pelvic organs.

Treatment

Options for treatment may include no treatment at all (if the symptoms are tolerable), drug therapy or surgery.

1. Drug Therapy

Drug therapy is used to suppress ovulation and, therefore, menstruation. Some of the drugs used are the oral contraceptive pill, progesterone (which cause a pseudo-pregnancy) and Synarel (which causes a pseudo-menopause) and Danazol (which is often the preferred choice). These drugs are not always effective.

These medications are usually taken for 6-12 months, depending on the severity of the condition. These synthetic male hormones suppress the function of the ovaries by acting on the pituitary so that hormones necessary for ovulation are not produced. By keeping a woman free of menstruation (“pseudo-menopause”) the endometrial tissue does not have a chance to bleed, thus enabling the inflamed areas to heal.

Possible side effects include weight gain of 1-4kgs, some decrease in breast size, a tendency towards acne, occasional increase in body hair, oily skin and symptoms of the menopause such as hot flushes and nausea.

Symptoms should be reversible after the drug is discontinued. Normal ovulation and ovarian functions should return to normal following cessation of medication.

This treatment gives some women immediate and substantial relief from symptoms.

Not every woman suffers from these side effects but for others the side effects can be worse than the original symptoms.

2. Surgery

Where more severe forms of endometriosis exist, particularly where “chocolate cyst” formation in the ovary and tubal adhesions prevent normal egg transportation, surgery is indicated to restore normal anatomy as far as possible.

Surgical procedures may range from simple cautery of endometriosis spots to extensive removal of scar tissue and microsurgery.

Surgical use of laser technology is also becoming more frequent.

A combination of surgical treatment and medication has been used with impressive results—up to 79% pregnancy rate in a reported series.

Further Information

For further information on Endometriosis and Endometriosis support groups, go to the Endometriosis Association of Victoria (Australia).

WITH THANKS TO THE INFERTILITY FEDERATION OF AUSTRALASIA INC.