Endometriosis

Overview

Endometriosis is a disease in which tissue similar to the lining of the uterus grows outside the uterus. It can cause severe pain in the pelvis and make it harder to get pregnant.

Endometriosis can start at a person’s first menstrual period and last until menopause.

With endometriosis, tissue similar to the lining of the uterus grows outside the uterus. This leads to inflammation and scar tissue forming in the pelvic region and (rarely) elsewhere in the body.

The cause of endometriosis is unknown. There is no known way to prevent endometriosis. There is no cure, but its symptoms can be treated with medicines or, in some cases, surgery.

It causes a chronic inflammatory reaction that may result in the formation of scar tissue (adhesions, fibrosis) within the pelvis and other parts of the body. Several lesion types have been described:

• superficial endometriosis found mainly on the pelvic peritoneum
• cystic ovarian endometriosis (endometrioma) found in the ovaries
• deep endometriosis found in the recto-vaginal septum, bladder, and bowel
• in rare cases, endometriosis has also been found outside the pelvis.

Symptoms

Endometriosis often causes severe pain in the pelvis, especially during menstrual periods. Some people also have pain during sex or when using the bathroom. Some people have trouble getting pregnant.

Some people with endometriosis don’t have any symptoms. For those who do, a common symptom is pain in the lower part of the belly (pelvis). Pain may be most noticeable:  

• during a period
• during or after sex
• when urinating or defecating.

Some people also experience:

• chronic pelvic pain
• heavy bleeding during periods or between periods
• trouble getting pregnant
• bloating or nausea
• fatigue
• depression or anxiety.

Symptoms often improve after menopause, but not always.

Endometriosis symptoms are variable and broad, making it difficult for healthcare workers to diagnose. Individuals with symptoms may be unaware of their condition.

Causes

Endometriosis is a complex disease that affects many women worldwide, from the start of their first period (menarche) to menopause, regardless of ethnicity or social status. Many different factors are thought to contribute to its development. Endometriosis is now thought to be caused by:

• Retrograde menstruation happens when menstrual blood with endometrial cells flows back through the fallopian tubes and into the pelvic cavity. At the same time, blood is flowing out of the body through the cervix and vagina during periods. Endometrial-like cells may be transferred outside the uterus during retrograde menstruation, where they might implant and grow.

• Cellular metaplasia is the process by which cells change from one form to another. Cells outside the uterus change into endometrial-like cells and begin to grow.

• The disease can be caused by stem cells and spread throughout the body via blood and lymphatic arteries.

Other factors may potentially play a role in the growth or persistence of ectopic endometrial tissue. Endometriosis, for example, is known to be estrogen-dependent, which increases inflammation, growth, and pain associated with the disease. However, the relationship between estrogen and endometriosis is complicated since the absence of estrogen does not always mean the absence of endometriosis.

Impact

Endometriosis has significant social, public, and economic implications. Due to severe pain, exhaustion, sadness, anxiety, and infertility, it may decrease quality of life. Endometriosis patients may have debilitating pain that prevents them from working or attending school. Endometriosis-related pain in sex can cause interruption or avoidance of intercourse, affecting the sexual health of affected persons and their partners. Addressing endometriosis will empower those affected by it by supporting their human right to the highest standard of sexual and reproductive health, quality of life, and overall well-being.

Prevention

At the moment, there is no known technique to avoid endometriosis. Increased awareness, followed by early diagnosis and management, can halt the disease’s natural progression and minimise the long-term burden of its symptoms, including the risk of central nervous system pain sensitivity. Currently, there is no cure.

Diagnosis

Endometriosis is suspected based on a careful history of menstrual symptoms and chronic pelvic pain. Although various screening tools and tests have been proposed and tested, none are currently validated to reliably identify or predict individuals or communities that are most likely to have the disease. Endometriosis symptoms may mimic those of other illnesses, contributing to diagnosis delays. Ultrasonography or magnetic resonance imaging (MRI) are frequently used to detect ovarian endometrioma, adhesions, and deep nodular forms of disease. Histologic verification, usually following surgical or laparoscopic visualization, might be helpful in confirming the diagnosis, especially for the most frequent superficial lesions. The need for histologic or laparoscopic confirmation should not prevent the beginning of empirical medicinal treatment.

Treatment

Endometriosis treatments differ depending on the severity of symptoms and whether or not pregnancy is intended. There are no cures for the disease.

Endometriosis and its symptoms can be managed with a variety of medications.

Nonsteroidal anti-inflammatory medications (NSAIDs) and analgesics (painkillers) such as ibuprofen and naproxen are frequently used to alleviate pain.

Hormonal medications such as GnRH analogues and contraceptive (birth control) methods can also help in pain management. These methods are as follows:

• pills
• hormonal intrauterine devices (IUDs)
• vaginal rings
• implants
• injections
• patches.

These methods may not be appropriate for those wishing to become pregnant.

Fertility medications and procedures are sometimes used to help women who are having problems getting pregnant due to endometriosis.

Surgery is sometimes done to remove endometriosis lesions, adhesions, and scar tissues. Laparoscopic surgery (the use of a small camera to see inside the body) allows doctors to make small incisions.

Discuss your treatment options with your doctor.

Individual preferences and effectiveness, side effects, long-term safety, prices, and availability all influence treatment options.

Raising awareness can help with early diagnosis. Early treatment can slow or stop the disease’s natural progression and lessen its long-term effects.

In addition to speaking with their doctor, patients may obtain further guidance and emotional support from local patient support groups.

Some treatments have negative effects, and endometriosis-related symptoms may reappear after therapy ends. The choice of treatment depends on  the individual’s effectiveness, adverse side effects, long-term safety, cost, and availability. Most current hormone treatments is not suitable for endometriosis patients who want to get pregnant because they interfere with ovulation.

The extent of the disease often determines success in lowering pain symptoms and increasing pregnancy rates with surgery. Furthermore, even after complete eradication, lesions can recur, and pelvic floor muscle abnormalities might contribute to chronic pelvic pain. In some patients, physiotherapy and complementary treatments may help with secondary pelvic changes, including the pelvic floor and central sensitization. Treatment options for endometriosis-related infertility include laparoscopic surgical removal of endometriosis, ovarian stimulation with intrauterine insemination (IUI), and in vitro fertilization (IVF), but success rates vary.

Challenges and priorities

In many countries, the general public and the majority of front-line healthcare providers are unaware that distressing and life-altering pelvic pain is not normal, resulting in symptom normalization, stigma, and significant diagnostic delay. Patients who could benefit from medical symptomatic therapy are not always treated because primary healthcare providers are unaware of endometriosis. Due to diagnostic delays, quick access to effective treatment techniques such as nonsteroidal analgesics (painkillers), oral contraceptives, and progestin-based contraceptives is frequently not attained. Due to the limited capacity of many countries’ health-care systems, access to specialized surgery for people in need is suboptimal. Furthermore, especially in low and middle-income countries, there is a lack of multidisciplinary teams with the wide range of skills and equipment required for early diagnosis and effective endometriosis treatment. Although primary health care professionals should be involved in screening and basic management of endometriosis, tools to screen and accurately predict patients and populations that are most likely to have the disease are lacking. Furthermore, there are many knowledge gaps, and there is a need for non-invasive diagnostic methods as well as medical treatments that are not preventing pregnancy.

The current focus of the endometriosis response is on addressing these issues.