Introduction: Endometriosis is a name that often comes up whenever we talk of painful disorders. Endometriosis is found to be affecting nearly 10 out of every 100 women/girls of reproductive age over the globe. Because of the varying range of the symptoms associated with it, it becomes very difficult for doctors to diagnose it, and hence, often individuals remain unaware of the fact that they are suffering from it. What is Endometriosis? The term endometriosis can be broken down into two components- endometrium (the tissue lining the uterus) + osis (a medical term used for ‘increase’) which simply means an increase in the endometrium tissue and hence, endometriosis refers to the disorder in which the tissue forming the line of the uterus is found to be growing outside the uterus/uterine cavity, other than being in the usual uterine region. The places where such tissue can be found are the ovaries, bowel, and other areas of the pelvis. Such tissue is known as the endometrial implant. It is, however, very rare that this tissue is found to be spreading beyond the pelvic region. The changes in the hormones seen during the menstrual cycle impact this misplaced tissue. The area can be inflamed and painful as a result, which in turn makes the tissue grow, become thicker, and ultimately break down. Ultimately, this broken tissue gets trapped in the pelvis as it has no other place to go.
This trapped tissue can cause the following conditions:
- Feeling of irritation
- Scar formation
- Adhesions that can bind your pelvic organs together
- Serious/ harsh pain during the periods
- Problems related to fertility
There is not any bit of doubt/uncertainty that endometriosis can have a significant impact on one’s quality of life. One can have problems related to the following things:
- Chronic pain
- Difficulty in maintaining a healthy social life
- Medical expenses
- Problems in relationships
- Stress, anxiety, and even depression
There is no exact answer to “what causes endometriosis?” as the exact causes of endometriosis have not been found yet and hence, it remains an idiopathic condition. Yet, there have been few theories (scientifically not proven) that talk about the causes of endometriosis. These theories are:
- Retrograde Menstruation: This is the oldest theory which suggests that the menstrual blood containing the endometrial cells, instead of leaving through the vagina, flows back into the pelvic cavity through the fallopian tubes.
- Peritoneal cells Transformation: This is also known as the ‘induction theory’ as it proposes that hormones promote the transformation of the peritoneal cells into endometrial-like cells.
- Transformation of Embryonic cells: This theory suggests that hormones like estrogen may be the ones responsible for transforming the embryonic cells (cells in the earliest stages of embryo development) into these endometrial-like implants.
- Surgical scar implantation: This theory suggests that the endometrial cells may get attached to the surgical incision after a surgery like C- section.
- Endometrial cell transport: This theory suggests that the lymphatic system may transport the endometrial cells to other parts of the body.
- Immune system disorder: This states that the problems related to immunity may make the body incapable to recognize and destroy this endometrial-like tissue which normally happens in a healthy individual’s system.
Stages of Endometriosis:
Endometriosis can be classified into 4 stages on the basis of location, amount, depth, size, and the extent of the spread of the endometrial tissue. The 4 stages are:
- Stage 1 /Minimal: In this stage, only small lesions or wounds along with shallow endometrial implants are present. There can also be inflammation in/around the pelvic cavity.
- Stage 2 /Mild: This stage includes light lesions and shallow implants on the ovary and the pelvic lining.
- Stage 3 /Moderate: This stage includes deeper implants on the ovary and pelvic lining. More lesions can be found in this stage. Along with these, small cysts on one or more ovaries can also be found in this stage.
- Stage 4 /Severe: Endometriosis stage 4 is the most advanced stage of endometriosis. There are very deep implants on the ovaries and the pelvic lining in this stage. Lesions can also be found in the fallopian tube and bowel region. Many dense adhesions along with large cysts can be found in this stage.
Risk factors for Endometriosis:
An awareness of the risk factors can help you determine if you are susceptible to the condition or not. In general, there are three significant factors that can help us to get to a logical explanation for the occurrence of endometriosis
- Age: Although women of all ages are at risk of suffering the effects of endometriosis but still, women between the ages of 25-40 are at the greatest risk.
- History: This includes the past histories of various aspects like the family history (if any family member had suffered from endometriosis), pregnancy history (Women who haven’t had any children yet are at greater risk to endometriosis), and menstrual history (if one had problems like shorter, longer, or heavier menstrual cycles).
- Immunity problems: If someone has issues related to the immune system like if the immune system is not able to remove the unwanted tissues like it usually does.
Depending on the above factors, your body may develop a few conditions that make you more prone to endometriosis. These conditions include:
- Disorders of the reproductive tract
- Higher levels of Estrogen
- Auto-immune diseases
- Ovarian or breast cancer
There is no general rule when it comes to the symptoms of endometriosis. Some women may experience mild symptoms as others may be having moderate to severe symptoms. One should, however, be aware that the severity/intensity of your pain doesn’t imply the degree or stage of the condition. There are instances where even mild stages of this disease have been found to cause a great deal of pain. It can also be a case that there is very little discomfort even if there is a severe stage of endometriosis. These symptoms can be either constant or cyclic (getting worsened before and during the menstrual periods).
The most common symptom of endometriosis is pelvic pain. There can also be one/more of the following symptoms:
- Painful periods: Pain/ cramping in the pelvic region can start before the menstrual period and may extend up to several days. Lower back and/or abdominal pain can be experienced.
- Pain during intercourse: Pain during intercourse can be a real problem as this pain is different from the one experienced at the entrance into the vagina. This pain, hence, is also called “deep pain”.
- Experiencing pain with bowel movements and urination: Painful urination and bowel movements are very common symptoms of endometriosis. Blood can also be spotted in some rare cases.
- Heavy bleeding: One may experience heavy bleeding during and/or their menstrual periods.
- Infertility: Endometriosis is a common cause of infertility. This is also the reason that endometriosis is diagnosed in people seeking treatments for infertility.
- Other Symptoms: If you are experiencing fatigue, constipation, bloating, nausea, and diarrhea (especially, during your menstrual periods), there are chances of you having endometriosis. These symptoms can, however, also be due to other conditions like ovarian cysts, PID (Pelvic inflammatory disease), etc.
Diagnosis for endometriosis is found to be difficult most of the time as there are no specific tests that can confirm endometriosis in an individual. There are, however, strategies that are really helpful in the diagnosis of endometriosis which include the following:
- Pelvic examination: A doctor may be able to feel your abdomen for cysts/ scars behind your uterus during a regular pelvic examination.
- History: This includes your personal and family history as if you or any family member of yours have a history of endometriosis, there are higher chances of you having it.
- Imaging Tests: Imaging tests like the ultrasound and the MRI (Magnetic Resonance Imaging) can be suggested by the doctor if she/ he suspects endometriosis.
- Laparoscopy: Laparoscopy is a kind of surgery(slightly invasive) in which a camera is inserted through one’s lower abdomen to look into one’s pelvic area in order to get a visualized image of the interiors. If one is having endometriosis, the presence of endometrium-like tissues can prove the diagnosis. It is a sure-shot method to test for endometriosis.
- Biopsy: In a biopsy test, a sample (small piece of tissue) is removed from the uterine lining in order to examine (done by a pathologist) under a microscope to confirm the diagnosis.
There is no cure for endometriosis as such and hence, healthcare professionals work on managing the symptoms using different treatment methods. These treatment methods include the following:
1. Pain relief: It includes the most conservative treatment option for endometriosis. In this method, various medications for pain relief are administered to manage the symptoms being caused by endometriosis. Non-steroidal medicines like ibuprofen are given to the suffering woman to help with the pain.
2. Hormonal Therapy: Hormonal therapy for endometriosis includes the use of hormonal regulation to manage the symptoms of endometriosis. This is suggested for people who are not planning pregnancy anytime soon. Such therapies only work till the hormones are being taken. These include:
- Birth Control: These include birth control methods like contraceptive pills, patches, and vaginal rings which are generally used to avoid pregnancy.
- IUDs: Intrauterine devices can also be used to lessen the bleeding and pain caused due to endometriosis. However, hormonal IUDs can not be effective for a very long time.
3. GnRH agonists and antagonists: GnRH(Gonadotropin-Releasing Hormone) agonists and antagonists are used in this method to block the production of estrogen. As estrogen is the hormone majorly responsible for female sexual characteristics, blocking its production can cause prevention of menstruation and hence, make artificial menopause-like stages thereby, helping with the symptoms. This method is effective. However, this method has certain side effects like vaginal dryness associated with it. Taking a little dosage of estrogen or progesterone hormone can help in limiting the symptoms further.
4. Steroid Therapy: This includes using a very mild anabolic steroid like Danazol for stopping menstruation and therefore, proves to be effective in reducing the symptoms. Danazol works on the same “pseudo-menopause” concept as the GnRH therapy. Even if someone is taking Danazol, the disease still keeps on progressing. There are also some masculinizing side effects attached to Danazol like acne, growth of hair on the face and body, etc. Studies are being done on other possible drugs also, that can be used to improve the symptoms and slow the disease’s progress.
5. Surgery: If the above treatments do not work, your doctor may recommend you to undergo surgery that involves the removal of the unwanted tissue. This is usually recommended for severe cases when hormones are unable to provide relief or if there are any fertility problems. This endometriosis surgery is usually followed by hormone treatment. This method has proven itself of great help for women with endometriosis who wish to get pregnant. In the case of women who are not interested to get pregnant, the doctor may remove the ovaries perhaps the uterus also. Hence, surgeries for endometriosis can be of two types:
6. Conservative Surgery: Conservative surgery is used for women who wish to get pregnant in the future. This surgery includes the removal/destruction of the endometrial implants/growths without causing any damage to the reproductive organs of the women. This is carried out by burning or vaporizing the growths using the laparoscopy technique. These days, lasers are being used to burn such abnormal growths.
7. Hysterectomy: This is also known as the last resort surgery as it is truly the last resort for people whose symptoms don’t improve. It includes the removal of the uterus and the cervix along with the endometrial implants. The ovaries are also removed as they are responsible for the production of estrogen which, in turn, is responsible for the growth of the endometrial tissue. One should always give a considerate time to think and get a second opinion before saying yes to this surgery as there will be no chances left for getting pregnant after this surgery.
Endometriosis might just be a name for many people, but only those suffering from it know the pain and misery hidden behind it. Even with today’s medical advancements, this remains a chronic disease with no cure and unknown causes. Hence, one should always consult a doctor with a fair share of expertise in dealing with endometriosis. There are various medications, therapies, and surgeries to opt for. You just need a great doctor on your side and no condition can be able to behold the power to impact your daily life.