1.1 About endometriosis
Under normal circumstances, during the menstrual cycle, the innermost layer of the uterus, called the endometrium, gradually thickens and becomes engorged due to the stimulation of female hormones. This prepares the uterus to receive a fertilized egg. If the egg is not fertilized, the endometrium sheds and breaks down, resulting in menstruation.
However, sometimes the endometrium may appear outside the uterus, which is known as endometriosis. The ectopic endometrium undergoes cyclic changes similar to the normal endometrium, becoming engorged and swollen in response to hormonal stimulation. But if this ectopic endometrium bleeds and the blood flows into the body cavity, it can cause pain and lead to complications such as inflammation. Furthermore, the persistent inflammatory response causes the formation of scar tissue in the surrounding tissues and organs, leading to adhesions that connect these tissues and organs together, affecting the normal functioning of the body’s organs.
The most common sites for endometriosis are the ovaries, followed by the fallopian tubes and the connective tissues surrounding the uterus. In rarer cases, endometriosis can occur in the bladder, intestines, or other organs.
When endometriosis appears within the ovaries, it forms cysts called endometriomas or “chocolate cysts” because they contain brown fluid derived from menstrual blood deposits. These cysts generally do not cause pain or significant clinical symptoms. However, if the cyst ruptures and the blood inside the cyst flows into the abdominal cavity, it can cause severe lower abdominal pain and the formation of adhesions.
1.2 Cause of endometriosis
The exact cause of endometriosis is still uncertain in the medical field. Some theories suggest that endometriosis occurs when menstrual blood does not flow out of the body through the vagina during the menstrual cycle but instead flows backward through the fallopian tubes and reaches the ovaries.
Endometriosis can basically occur in women of reproductive age. Additionally, white women have a higher likelihood of developing endometriosis compared to women of other ethnicities. Furthermore, women who give birth for the first time after the age of 30 and women who experience infertility have a higher risk of developing endometriosis. There is also a genetic component to endometriosis, as it can run in families.
1.3 Symptoms of endometriosis
Common symptoms of endometriosis include:
Lower abdominal or pelvic pain:
Lower abdominal or pelvic pain is the most common symptom. Patients often experience pain similar to menstrual cramps before or after their period, and in some cases, the pain can be severe. Some patients may experience chronic pelvic pain that lasts for a long time. The pain can be localized on one side of the body, in the middle, or radiate to both sides. Some patients may also experience pain during sexual intercourse before or during their menstrual period.
Changes in menstrual cycle:
Patients may notice significant changes before or after their menstrual period. For example, they may experience spotting before their period, irregular periods, or heavy menstrual bleeding.
Difficulty getting pregnant:
Endometriosis can reduce a patient’s fertility by causing pelvic adhesions and blocking the fallopian tubes, making it difficult for them to conceive.
Other symptoms:
Endometriosis that affects the intestines or bladder can cause symptoms such as bloating in the lower abdomen, pain during bowel movements, or blood in the stool during the menstrual period.
In general, the symptoms of endometriosis may disappear during pregnancy or after menopause.
1.5 Diagnosis of endometriosis
To diagnose endometriosis, doctors typically begin with a detailed medical history and symptom assessment, including inquiries about the patient’s symptoms, medical history, and family history. They will then perform a thorough gynecological examination, including a pelvic exam, to assess for signs of endometriosis and rule out other similar gynecological conditions.
However, to confirm a diagnosis of endometriosis, the only definitive method is to examine the inside of the patient’s abdomen in detail. This is done using a procedure called laparoscopy. Laparoscopy is a minimally invasive surgical procedure performed in a hospital’s operating room. During the procedure, a slender instrument called a laparoscope is inserted into the abdomen through a small incision below the navel. The laparoscope has a camera at the end that projects the view of the abdominal cavity onto a monitor, allowing the doctor to examine the pelvic organs and identify any abnormal endometrial tissue indicative of endometriosis. If necessary, the doctor may also take a small sample of the ectopic endometrial tissue for a biopsy to confirm the diagnosis. This procedure typically takes around 30 minutes, and patients usually do not require an overnight hospital stay.
1.6 Treatment of endometriosis
The treatment goals for endometriosis include:
- Relieving pain caused by endometriosis.
- Removing or reducing the abnormal endometrial tissue.
- Shrinking or slowing down the growth of endometrial implants.
- Preserving or restoring fertility in patients.
The doctor needs to develop a tailored treatment plan based on the individual patient’s circumstances, taking into account factors such as age, severity of symptoms, presence of complications related to endometriosis, and the patient’s desire for fertility.
Common treatment options for endometriosis include:
- Pain medication: Nonsteroidal anti-inflammatory drugs (NSAIDs) can help alleviate discomfort and pain associated with endometriosis.
- Hormonal therapy: Since the abnormal endometrial cells in endometriosis respond to estrogen similar to normal endometrial cells, hormonal therapy aims to lower the estrogen levels in the body, thereby reducing the size of endometrial implants. Hormonal treatment options may include combined oral contraceptives, androgen hormones (Danazol), progesterone, or medications that mimic the action of gonadotropin-releasing hormone (GnRH).
- Complementary therapies: These may include acupuncture, herbal treatments, aromatherapy, and homeopathy, which can help relieve symptoms in some patients.
- Surgery for endometriosis: Surgery aims to remove as much of the abnormal endometrial tissue as possible while preserving fertility. Surgery may be considered if the patient experiences severe symptoms that cannot be managed with pain medication or hormonal therapy, if the area of endometrial implants is larger than four centimeters, if endometriosis causes tubal blockage leading to infertility, or if there are extensive adhesions in the pelvic region affecting organ function. Surgery is often performed using minimally invasive techniques such as laparoscopy, but more complex cases may require laparotomy. During surgery, the abnormal endometrial tissue is excised or destroyed using instruments or laser, and any associated adhesions are released.
It is important to note that while hormonal therapy and surgery can help manage endometriosis, they may not provide a permanent cure. Symptoms may recur after stopping hormonal treatment, and approximately one in five patients may experience recurrence within five years after surgery. Therefore, to prevent recurrence, doctors may prescribe hormonal medication after surgery.
In cases where the condition is severe or the patient does not desire fertility, complete removal of the ovaries (oophorectomy) may be recommended as a definitive treatment for endometriosis.