Ask an expert: What are the early signs of endometriosis?

Endometriosis can cause a myriad of symptoms in many parts of the body, with women typically suffering from chronic pelvic pain and severely painful periods for years before receiving an accurate diagnosis. To shed light on this complex condition, revered consultant gynaecologist and fertility specialist Dr Ahmed Elgheriany discusses the early symptoms to look out for and possible causes in this informative article, his first in a detailed series on endometriosis.

What is endometriosis?

Endometriosis is a very strange disease which occurs when cells from the lining of the womb (endometrium) appear outside the womb itself. Endometrium cells may be found in a variety of places outside of the womb, most commonly the tummy, the pelvis and the uterus. When a woman’s period comes every month, these cells will start to bleed, as those within the womb do, in whichever area of the body they are found.

In response, the body deals with this bleeding as it would a flesh wound and inflammatory markers are secreted. As part of the healing process, fibrous tissues develop in the area which lead to scars building up in the affected part of the body. This can cause pain, affect the anatomy of the pelvis and may also have a toxic effect on the ovaries and uterus which can affect implantation and fertility.

Endometriosis can cause many chronic symptoms, including pelvic pain, constipation or bloating, but this varies according to the location of the endometrium within the body.

One of the most commonly affected parts of the body are the uterosacral ligaments (the ligaments behind the uterus, the neck of the womb and the sacrum). Endometrium can also be found on the fallopian tubes or between the rectum and the vagina. Endometrium within the muscle of the womb can cause severe problems and this is known as adenomyosis.

Additionally, endometrium can also can be found on the bladder or very rarely, can travel up to the diaphragm which causes a reflected pain to the shoulders or problems with upper tummy pain. In other rare cases, endometrium are found on the lung which can lead to bleeding, breathing difficulties and chest pain. The huge spectrum of symptoms it can cause make endometriosis a complex condition.

What are the early symptoms of endometriosis?

The early symptoms of endometriosis are dysmenorrhea, dyspareunia and deep pelvic pain.

Dysmenorrhea means painful periods, experienced throughout most of the patient’s life. The severity of this pain could increase or decrease over time and typically begins before the first days of bleeding each month. The pain may persist throughout the period and for a few days after the bleeding has stopped. This pain can interfere with daily life leading to repeated absences from school or work and many months and years of discomfort.

The second common symptom is dyspareunia, which to be more precise is pain which occurs with deep penetration during intercourse. Mostly it’s in the same spot and is often caused by endometrium implanted on to the uterosacral ligament which contains some nerves that can easily be hurt during intercourse.

The third sign is chronic or deep pelvic pain, most often caused by chronic spasm in the pelvic muscle related to persistent constipation or pain that occurs. This is the most problematic pain symptom related to the condition because there is no test to diagnose it and unfortunately, will likely continue to affect the woman even after treatment including surgery. As this pain can be due to chronic constipation, diarrhoea, bloating or severe spasm related to pain with intercourse, the pelvic muscle itself will need to be relaxed in order to provide relief. At a later stage, we can employ a range of therapies to manage this pain after undergoing treatment. This may include acupuncture, cognitive behavioural therapy or the advice of a pain therapist.

What are the causes of endometriosis?

The exact cause of endometriosis is unknown. One theory relates to the idea of retrograde menstruation, where rather than leaving the body with the period, some cells are retained and travel back into your tummy and go on to cause the symptoms every month. However, this theory is quite weak as ninety per cent of women will experience retrograde menstruation but only ten per cent experience symptoms.

Another theory is that some stem cells are implanted into the peritoneum (the lining of the tummy) at birth. These cells then start to perforate into endometrial cells which are stimulated by the oestrogen hormone with the monthly period, leading to inflammation, scarring and so forth. This explains what we understand about how endometriosis can be affected by environmental factors, such the condition’s response to diet modification and the fact that it can be affected by microbiomes in the gut.

The third theory about the cause of endometriosis is that endometrium cells travel from the womb via the lymphatic system or blood supply to be implanted in other places. This could explain why endometrium cells can be found in the lung or brain, although this is very rare and affects fewer than ten percent of cases.

Finally, some people suggest that endometriosis is heterogenic and develops as a result of surgical procedures in the womb, such as caesarean section or removal of a fibroid myomectomy. In some cases, endometrium cells are found in the scars from these operations and may lead to severe pain throughout and following recovery.

If you are concerned by chronic pain associated with periods or sex and would like to discuss your individual case with Dr Elgheriany, you can schedule a consultation with him by visiting his Top Doctors profile.