Endometriosis causes subfertility, painful intercourse and chronic pelvic pain with obvious impact on quality of life, employment and relationships. Up to 10% of all women in their reproductive years are affected by endometriosis from as young as age eight to post menopause. In Australia alone, about 600,000 females suffer from this condition.
Endometriosis is functioning endometrium-like tissue outside the uterine cavity that undergoes hormonal and immune inflammatory interactions. Common locations include the ovaries, Fallopian tubes, utero-sacral ligaments, Pouch of Douglas, and pelvic peritoneum. Sometimes endometriosis lesions are also found in abdominal surgery scars, intestines, rectum, bladder and external genitalia.
Most common symptoms
• Pelvic pain before and during periods. The amount of pain is not necessarily related to the extent of the endometriosis lesions.
• Pain during or after intercourse, perhaps worse around the time of periods.
• About 30-40% of women with infertility have endometriosis.
• Heavy bleeding.
• Preterm birth, pre-eclampsia and antepartum haemorrhage are more likely to happen in women with endometriosis (especially those with ovarian endometriomata). This has implications for prenatal care and assisted reproductive technology procedures offered.
A careful medical history looks for symptoms that come and go in relation to the menstrual cycle. Clinical examination to detect endometrial nodules is more successful if performed during menstruation.
The diagnosis of peritoneal endometriosis is generally considered definitive after laparoscopy and visual inspection but histological confirmation of at least one lesion is ideal. In cases of ovarian endometrioma and deeply infiltrating lesions, histology helps in indentifying endometriosis and excluding malignancy. There is no evidence to support particular timing of laparoscopy, except not to perform within three months of hormonal treatment, to avoid under-diagnosis and under-staging.
With no known cure for endometriosis, treatment varies, depending on the type and intensity of symptoms. The most common specific treatments are:
1. Hormonal treatments aim to stop the ovaries producing cyclical hormones that endometriosis tissue reacts to. Although these drugs can force disease remission during treatment and for months or years afterwards, . However, their side effects and preventing fertility effects are a problem for some women. Hormonal treatments include:
• Oral contraceptives
• Progesterone derivative drugs
• Testosterone derivative drugs (e.g. danazol, gestrinone)
• Gonadotropin-releasing hormone drugs (GnRH).
2. Encourage pregnancy
3. Surgery (from conservative to radical).
4. Symptom relief until menopause.
5. Complementary treatments (e.g. high frequency TENS, acupuncture, magnesium and Vitamin B1 in dysmenorrhoea).
Key points in endometriosis management*
Women with symptoms suggestive of endometriosis can be treated with an empirical trial of a hormonal drug to reduce menstrual flow.
All hormonal drugs studied are equally effective if used to suppress ovarian function for 6-months, although their side effects and costs differ.
Ablation of endometriotic lesions reduces endometriosis-associated pain.
In minimal-mild endometriosis, hormonal treatments are not effective to treat infertility, but ablation of endometriotic lesions plus adhesiolysis is effective compared to diagnostic laparoscopy alone.
Surgical excision of moderate-severe endometriosis does not enhance pregnancy rates but IVF is appropriate, especially if there are coexisting causes of infertility and/or other treatments have failed.
Resources: www.endometriosis.org.au/ and www.endo-online.org
*From European Society of Human Reproduction and Embryology Guidelines.