Endometriosis is a chronic illness where cells similar to those that line the womb cavity are found in an unnatural site outside the womb in the pelvis and surrounding the reproductive organs. Affecting 5-10% women during their reproductive age, it’s symptoms include dysmenorrhea, dyspareunia, chronic pelvic pain and pain related to ovulation. Dr Suresh Nair explains how the management of endometriosis is multi-disciplinary, and depending on the priority, fertility or relief of pain, there are differing therapeutic options.
The cells that line the womb, form a lining layer called the endometrium. The endometrium reacts to the hormones produced by the ovary every month when eggs are released from the ovary. The endometrium builds up the cells to nourish a potential pregnancy and when this does not happen, it is shed as menstrual blood. Unfortunately, the cells that have gone astray inside the pelvis and over the reproductive organs also build up under the influence of hormones but the blood and tissue shed from these implants have no way of leaving the body. This results in “internal bleeding” and breakdown of the blood and tissue from these sites leading to inflammation. This process can produce pain which is sometimes presents as debilitating menstrual pain (dysmenorrhoea) or painful intercourse (dyspareunia) due to the scarring cause by the disease (endometriosis). It can also cause reduction in fertility potential by production of toxins, inflammation and scarring that blocks the fallopian tubes, affects the release of eggs or produce toxins that “poison” the eggs and sperms and its transport within the fallopian tubes.
The true incidence of endometriosis is unknown. Many women with endometriosis can conceive i.e. not all women with endometriosis are infertile. Endometriosis can be detected in about 30% to 40% of women undergoing laparoscopy as part of an infertility evaluation. Medical statistics have shown that infertility can affect around 40% of women with endometriosis. Although a direct relationship has not been established between endometriosis and infertility, it is accepted that, overall, certain women with endometriosis find it harder to become pregnant than women in general.
The only way to conclusively diagnose the existence and stage of endometriosis is to put in a ‘telescope’ through the umbilicus to look into the pelvis – a surgical procedure called “laparoscopy”. Laparoscopy is not only diagnostic but therapeutic as it allows surgical procedures to remove endometriosis and to restore and repair any distortion of the fertility organs (fallopian tubes and ovaries).
Unfortunately, there is a high recurrence rate of endometriosis as there is no absolute cure for endometriosis. The best that can be done is to suppress it or remove it surgically.
The major limitations of post surgery medical treatment is that if we were to shut down the system, i.e. create menopause like state, this can only go on for a maximum of one year because it can cause loss of bone mass. This can somewhat be mitigated by using a small amount of estrogen hormone called “add-back” therapy to control the menopausal symptoms and minimize bone loss. Other treatments include creating a false pregnancy state e.g. using progesterones like injections of Depo- Provara; continuous contraceptive pills; Vissane and the Mirena intrauterine system. However, in spite of all of these, recurrences still occur.
In spite of surgery to remove endometriosis, sometimes it is impossible to remove all the disease, and often it may involve vital organs such as intestines and ureters, such as the disease has to be left behind even if we do it through the laparoscopic, robotic or open approaches. Thus, as detailed by K Drews, M Barlik, and T Łukaszewski in their recently published study, Conservative treatment of endometriosis, “most of the time clinical treatment is not limited only to one possibility but usually joins a few therapeutic options. One of the possibilities is the surgical treatment, usually laparoscopic. Conservative treatment may be its completion.” “The main medical aim of conservative treatment is to decrease pain by inhibition of inflammation and to reduce or arrest the production of cyclic ovarian hormones, what usually leads to amenorrhea. Drugs used in conservative treatment of endometriosis are often connected with numerous side effects, constituting a serious limitation of a long-term therapy. That is the reason why much research concentrates on http://www.canadianpharmacy365.net/product/danazol/,” the authors have claimed. [Ginekol Pol. 2012 Mar;83(3):209-13]
While in many cases, surgery alone may be sufficient to enable the couple to conceive, in other instances, assistances through fertility treatments that can produce more eggs and concentrate sperms to enter the reproductive system at the right time which is called “super-ovulation and intrauterine insemination” may be necessary. If the tubes are blocked or the disease is so extensive, and when time is running out in older women, doctors advise to promptly resolve to lVF.
Dr Suresh Nair
MBBS (Singapore), M Med
(O&G) (Singapore), FRCOG
(UK), FAMS (O&G)