What is endometriosis?

The inner lining of the uterus is called as the “endometrium”. Every month, in response to the hormones estradiol and progesterone produced by the ovary, this lining forms into a “bed” of cells. If the egg has been fertilized by the sperms then the resultant embryo attaches or implants on the endometrium. In case, the egg is not fertilized in that month then this lining of the uterus is shed resulting in menstrual bleeding.

In some women, the endometrium grows at places other than in the uterus. The endometrium can be present near or on the ovaries, the fallopian tubes or any other part of the abdomen. There is no outlet for the endometrium formed at locations others than within the uterus and this tissue accumulates within the body. Such a condition is called as endometriosis.

What is the cause of endometriosis ?

The exact cause of endometriosis is not yet known. There are a number of theories which have been postulated to explain this condition.

It is postulated that in women who have anomalies of the reproductive tract, retrograde menstruation occurs i.e., there is a backward flow of menstrual discharge. These endometrial cells implant on the ovaries or any part of the pelvic cavity where is grows and regresses every month in response to the menstrual changes.

It has also been thought that endometriosis may have a genetic origin as women whose mothers or sisters who suffer from endometriosis are more prone to it.

What are the symptoms ?

Many women with endometriosis may not have any symptoms. The type of symptoms and their intensity depends upon the location of the endometriotic tissue and the extent to which the disease has spread. However, the most common symptoms associated with endometriosis are:

severe cramps during or prior to menstruation.

pain during intercourse

some women with endometriosis may complain of vaginal bleeding at irregular intervals.

Infertility could be a result of endomtroisis.

How is it diagnosed?

The diagnosis of endometriosis cannot be made on the basis of the patients symptoms alone and needs to be confirmed by a diagnostic laparoscopy.

Laparoscopy is a minor surgical procedure by which a laparoscope (a thin telescope) is inserted into the abdomen through the navel. This enables the surgeon to directly visualize the reproductive organs. The presence of endometriosis and the extent to which it has spread can be gauged by the surgeon. Whether the endometriosis is deep or superficial and the extent of adhesions it has caused is determined and the endometriosis is scored as minimal, mild, moderate or severe.

Can it cause infertility?

Endometriosis on its own does not necessarily cause infertility. However, the endometriotic tissues can hinder conception. Endometriosis may cause adhesions around the ovary and the fallopian tube. These adhesions may interfere with the release of the eggs from the ovary; they may interfere with the capturing of the eggs by the fallopian tube. In such instances, endometriosis may be a cause of infertility.

Can it be treated with medications ?

Three different types of medications are available for the treatment of endometriosis. Endometrial tissue, be it at its natural site in the uterus, or the extra-uterine location of endometrial tissue in patients with endometriosis, is under the control of the hormones produced by the ovary. The aim of medical treatment is to prevent the secretion of hormones by the ovaries or negate their effect. In all these three types of medical treatment of endometriosis, menstruation ceases as long as the woman is on medication and the symptoms of endometriosis can be overcome. The three types of medications currently available are:

Oral contraceptive pills can be taken continuously without waiting for a withdrawal bleed.

Danazol. This drug leads to a drop in the levels of the hormone estradiol in the blood and prevents the proliferation of the endometrial implants. Small patches of endometriosis can be treated successfully with Danazol.

Gonadotropin releasing Hormone analogs (GnRHa). These are the newest class of hormones that have been used to treat endometriosis. This drug creates a pseudo-state of menopause and as long as the woman is on GnRHa treatment, she produce negligible amounts of reproductive hormones. In the absence of reproductive hormones in the body, the endometrial lining becomes very thin.

All these medications have several side effects and need to be taken only under the supervision of a doctor.

Can endometriosis be treated surgically?

Endometriosis can also be surgically treated. If the endometrial implants are very large then it is advisable to surgically remove these implants. This is generally done under laparoscopic visualisation. The endometrial implants are “cauterised” or “ablated” with a mild degree of electrical current. This procedure should be performed only by a well trained endoscopic surgeon so that no part of the reproductive tract is damaged.

What are the other options of treating infertility in spite of endometriosis.

In women who have endometriosis and are infertile but do not suffer from any other symptoms of endometriosis then their problem can be treated by any of the assisted reproductive technologies. If her fallopian tubes are not blocked then she can be treated by intra-uterine insemination or gamete intra-fallopian transfer. If the tubes are blocked or are unhealthy then she can be treated by in vitro fertilization and embryo transfer.