Endometriosis is the second most common gynaecological condition in the UK, and 1 in 10 women in the UK are thought to be affected. It can affect any woman of child bearing age.
What is endometriosis?
Endometriosis is the name given to the condition where cells which normally line the womb(endometrium) are found elsewhere in the body (deposits). The most common places to find these deposits are around the Fallopian tubes and ovaries. Each month the endometrial deposits build up and breakdown in a similar way to the endometrium in the uterus. Unlike the uterine endometrium there is no way for the blood to escape. This can cause blood filled cysts, inflammation and scarring( adhesions). Adhesions can form to surrounding tissues and organs such as the bladder and bowel.
What are the symptoms?
Symptoms can be varied depending on the site and severity of the condition. 15-20 % of women with endometriosis have no symptoms. Often periods are heavy and painful. Bladder and bowel symptoms and fatigue are also common. Pain during intercourse can also be a symptom.
How is endometriosis diagnosed?
Making the diagnosis can take time and the average time from first symptoms to diagnosis is 7.5 years. This is because symptoms are often varied and can present with symptoms from other systems such as bowel, due to adhesions.
A full history should be taken and a full examination should always be performed.
Specific tests for diagnosing endometriosis:
- Ultrasound scan. This is a non-invasive test that shows the structure of the pelvic organs. In endometriosis cysts can be found and other problems excluded. Adhesions are not seen on this type of scan but the sonographer can sometimes tell if organs are not moving normally suggesting they are stuck down by adhesions.
- Blood tests. May show anaemia if periods are heavy and can help to rule out other conditions. There is no specific blood test for endometriosis.
- This is the definitive test for endometriosis. During this procedure, considered key hole surgery, small incisions in the belly button and the lower abdomen are made and the scope can be inserted. The pelvic organs are viewed directly and any deposits , adhesions or cysts can be seen. Treatment can be performed at the same time.
Ok, so now we have a diagnosis – is there any treatment?
Unfortunately, there is no cure for endometriosis. There are however treatments available to reduce symptoms and improve quality of life.
As the endometrium proliferates under the control of oestrogen, most hormonal treatments aim to decrease oestrogen levels.
- Oral contraceptive pill. This works by suppressing ovulation and thins the endometrium
- Progesterone tablets reduce ovulation and supress oestrogen levels
- GnRH ( gonadotrophin releasing hormone) analogues These are modified versions of the stimulating hormones that control the menstrual cycle. They are given by depo injection. Oestrogen production is suppressed and a menopause like state is induced. Sometimes HRT is required in addition to help menopausal symptoms.
- Testosterone Derivatives testosterone is the male hormone and it reduces oestrogen and progesterone production. This is a second line treatment and is usually reserved for patients who do not respond to trial of the treatments above.
- Mirena Coil. This works by supressing the endometrium whilst providing an effective method of contraception.
Surgery can be performed through the laparoscope (key hole) or sometimes by open surgery. Surgery can remove cysts , endometrial deposits and adhesions can be divided.
Analgesics, pain modifier tablets and TENS nerve stimulators can be used to help control pain.
Therapies such as acupuncture, homeopathy, herbalism, dietary modifications may all be tried as patients respond differently to treatments. The evidence for these therapies is variable.
Does endometriosis affect fertility?
Many women who have endometriosis successfully achieve pregnancy. Infertility can be caused by endometriosis if the Fallopian tubes become blocked or kinked due to adhesions. There are test that can be done to assess the patency of the tubes and sometimes surgery can improve this.
Hormonal treatments to suppress endometriosis do not cause infertility and are reversible if stopped to plan pregnancy.
Once pregnant the pregnancy should be no different from normal.
Are there any new advances in treatment?
There has not been a new medication for ten years. There is a new drug which is currently available in the USA since 2018, and if successful it may become available in the UK. There is a trial currently assessing this new drug in the UK.
It is called Elagolix and is a GnRH antagonist. It is a once daily tablet which suppresses oestrogen but it is more easily reversible , and as it does not completely suppress oestrogen, it has less side effects. It is intended for use in moderate to severe endometriosis.
Take Home Points
Early diagnosis is important to catch the condition in the early stages.
If you have symptoms that could be endometriosis seek professional advice early and don’t be afraid to suggest the possibility of endometriosis to your healthcare professional.
While there is no cure currently, this debilitating condition can be controlled and improved.
If you have any concerns about you having endometriosis, you have any fertility or gynaecological concerns do get in touch and one of our doctors will be able to help.