Endometriosis
Endometriosis occurs when cells, similar to those that line the uterus, are found outside the uterus in the pelvic cavity. Each month these cells respond to hormones in the same way they would if they were in the uterus and bleed. This bleeding causes inflammation in the pelvis, causing pain and subsequent scarring. Endometriosis affects approximately 10% of women.
No one is completely sure how endometriosis occurs, however we suspect that during foetal development in your mother’s uterus, the cells that will form the lining of the uterus (the endometrium) lie near the cells that will form the lining of the pelvis (the peritoneum). These two groups of cells can intermingle, with islands of endometrial cells growing within the lining of the pelvis as it develops. At puberty, the hormones that cause a period to occur also activate the endometrial cells in the pelvis. They start to bleed, and this leads to scarring and subsequent pain.
Endometriosis can be diagnosed by listening to your story.
Common symptoms include:
- Distressingly painful periods that are unable to be managed by taking common painkillers
- Pain with bowel motions at the time of a period
- Pain passing urine
- Painful intercourse
- Mid-cycle pain
- Pain throughout the month often similar to period pain but at a lower level and getting worse at the time of a period
- Bleeding between periods. Bleeding may or may not be heavy, but up to 50% of women with endometriosis have heavy periods. This may be due to adenomyosis. This is a cousin of endometriosis where the endometrial cells are buried with the muscle layer of the uterus. When these cells bleed each month the muscle layer of the uterus swells and can cause heavy, painful periods, and on occasion bleeding between periods
40% of women with endometriosis also have an irritated bowel syndrome.
Treatment of endometriosis:
If endometriosis is suspected, a Laparoscopy is required for formal diagnosis and treatment of the disease. One operation (occasionally two) is usually all that is required to diagnose and treat the condition.
A laparoscopy involves:
- General anesthetic (being put to sleep)
- A telescope is inserted through the tummy button (umbilicus)
- A photo is taken of the pelvis
- If endometriosis is found, it is removed through three small incisions below the umbilicus
- The surgery takes on average 1 to 2 hours. When you awake after surgery, you have small dressings over each of your incisions. All stitches are under the skin and will dissolve. Most women require 1-2 nights in hospital. At home you are encouraged to walk, lift and can drive within 4-5 days.
In 95% of cases, all of the endometriosis found can be removed however, 5% will have “severe endometriosis”. This is an extensive disease which involves either the bowel wall (the rectum) and the ovaries, or both, and often infiltrates into the deeper tissue of the pelvic floor. Although endometriosis can be removed safely from the bowel, it may require a second operation. For women with severe endometriosis, the findings are discussed after surgery and subsequent surgery arranged. Appropriate bowel preparation is necessary, and a General Surgeon is available if required.
The endometriosis pain you have experienced can take up to three months after surgery to start to improve. This happens because the nerves in your pelvis that were irritated by the endometriosis are also irritated by the removal of the disease. After surgery, the majority of women require no further operative treatment.
In my own audit, 12.8% of patients with stage I and II disease need repeat surgery within 2-3 years. This does not always indicate that endometriosis has returned. If a second look laparoscopy is performed, then 25% of cases have post-operative scarring rather than endometriosis as the reason for their discomfort. Scarring occurs following all surgery to a greater or lesser extent. By dividing the scar tissue, the symptoms will often improve considerably.
Approximately 60% of women with endometriosis can conceive, although it may take a little longer than usual. In those couples having difficulty conceiving, where no other cause for their infertility has been identified, removal of endometriosis, if present, will markedly improve their chances of becoming pregnant.
Surgical risks and complications are low. Surgery will improve the pain syndrome related to endometriosis, however, it has little effect on heavy periods. The heavy periods can be managed medically using one of the following:
- Cyklokapron
- Oral progesterone therapy
- Mirena IUCD
- Combined oral contraceptive pill (the pill)
- Anti-inflammatories (will also help any residual discomfort)
Generally, Michael does not use danazol, gestrinone or LH analogues as they suppress rather than cure symptoms, and have significant side effects.
Michael finds managing women with endometriosis rewarding as outcomes following surgery are generally very good.
Frequently asked questions about Endometriosis
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- Will pregnancy help my endometriosis?
Pregnancy will temporarily relieve the symptoms of endometriosis. However, Laparoscopic removal of endometriosis is the treatment of choice in managing those women with symptoms of endometriosis.
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- Is endometriosis a chronic condition and can it be cured?
Endometriosis can be a chronic condition if it is not identified and treated appropriately. There is on average a 7-11 year delay in diagnosis following the onset of symptoms. Following laparoscopic excision of endometriosis the great majority of women do not experience a recurrence of their disease.
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- Will Hysterectomy cure endometriosis?
Hysterectomy will not cure endometriosis but it does cure adenomyosis.
Hysterectomy (removal of the uterus with conservation of the ovaries) is a treatment option for those women who have finished their families and have ongoing heavy periods.
If endometriosis is present it needs to be removed at the time of the Hysterectomy or else the symptoms related to endometriosis will continue.
Endometriosis can occur following Hysterectomy and there are few indications for removing the ovaries at the time of Hysterectomy in those women with endometriosis.
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- Is endometriosis a disease of the 21st century?
Endometriosis has been recognised for much of the 20th century. Previously, symptoms had to be serious before surgery was contemplated. This involved a midline incision in the abdominal wall called a laparotomy.
However, following the development of laparoscopy endometriosis was diagnosed more readily. Medications were developed to treat the symptoms of endometriosis; these mimic either pregnancy or menopause as these are two areas in a woman’s life when symptoms of endometriosis settle down.
However, these medications suppress rather than cure the symptoms whilst they are being taken and they have significant side effects. If the symptoms of endometriosis continued then a Hysterectomy (removal of the uterus) was recommended often with removal of the ovaries. The endometriosis was usually not removed.
Over the past 15 years Laparoscopic excision or removal of endometriosis has become the mainstay of treatment.
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- I am having problems trying to get pregnant what should I do?
Women who have normal periods and no pain syndrome will need to have a number of basic investigations performed.
These are usually performed if pregnancy does not occur within 6-12 months of attempting to become pregnant.
Many of these investigations can be performed by your General Practitioner and include:
- Hormone profile check which involves a blood test on the 2nd day of your period.
- Ultrasound scan just before ovulation on Day 12 of your cycle (Day 1 is the first day of your period i.e. 12 days after your period starts) to see whether you are producing an egg.
- Further blood test 7 days before your period is due (i.e. on Day 21 for those women who have a 28 day menstrual cycle) to confirm that ovulation has occurred.
Assessment of your partner’s sperm
If any abnormality is detected or if you are still not able to conceive, then referral to a Fertility Unit would be sensible.Women with fertility problems associated with heavy, painful periods would benefit from referral to a Gynaecological surgeon to exclude endometriosis.
Endometriosis is associated with difficulty conceiving.
If endometriosis is identified as the only reason why you are unable to conceive, and excised your pregnancy rate will improve. -
- If I have an ovarian cyst on ultrasound scan which is suggestive of endometriosis, how is this managed?
A cyst which contains endometriosis is called an endometrioma. This can be associated with more severe endometriosis. CA125 detected by a blood test can be a marker of endometriosis and is often increased if an ovarian cyst contains endometriosis.
We manage an endometrioma by removing the cyst from the ovary Laparoscopically. Ovaries are rarely removed. Any endometriosis in the pelvis is usually removed at the same time.
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- I understand that endometriosis can be severe involving the bowel wall. How do you manage this form of endometriosis?
Severe endometriosis is usually diagnosed at the time of Laparoscopy. Treatment sometimes requires a second Laparoscopy and bowel prep is sometimes required pre-operatively.
Surgery takes 2-4 hours and normally Hospital stay is 2-4 days and you can return to work after 2 weeks.
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- After a Hysterectomy will the quality of my orgasm and my desire to have sex be diminished in any way?
The great majority of women who have a Hysterectomy will find that their libido (sex drive) will improve. The symptoms that resulted in a Hysterectomy being performed often cause decreased libido. After a Hysterectomy these symptoms improve as does libido. In general terms the quality of orgasm is no different following Hysterectomy.
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- What happens if I have any worries or concerns after surgery?
Written post-operative information will be given to you before going home, and these hand-outs can also be found on our website (view recovery guide). My telephone number is included in this information and I would encourage you to phone me if you have any concerns.
