Endometriosis: What are the symptoms?

Endometriosis can cause women to experience a number of symptoms which cause discomfort and disruption to daily life. Although the condition cannot be cured, a number of conservative and surgical treatment options can help women to manage their symptoms and relieve pain. In this informative article for patients, highly respected consultant obstetrician and gynaecologist Dr Sharmistha Guha shares her expert insight on the symptoms of endometriosis, how the severity of the condition is assessed and the available treatment options.

What is endometriosis?

Endometriosis is a gynaecological condition in which the cells from the lining of the womb are deposited outside of the womb, in the pelvic area. This occurs most commonly on other gynaecological organs, such as the ovaries and fallopian tubes, but can also affect other organs, such as the bowel, bladder and pelvic and abdominal wall (peritoneum). It can very rarely be found in distant areas such as the upper abdomen and lungs. These cells grow cyclically on stimulation by the oestrogen hormone.

Endometriosis affects women of all ages and is a significant long term condition that can impact a woman’s life. However, there are different grades of endometriosis and the extent to which it affects a woman’s life is dependent on the severity of the disease. It is a treatable condition and there are a range of treatment options available.

What are the symptoms of endometriosis?

Dysmenorrhoea (period pain)

The most common symptom is dysmenorrhoea, which is period pain. Women with endometriosis often complain of significant dysmenorrhoea for which they may have to regularly take pain killers and in severe cases, the pain may affect their lifestyle and keep them off work. However, dysmenorrhoea is a common symptom in younger women soon after menarche (the start of periods) and this is not always due to endometriosis.

Dyspareunia (pain during intercourse)

This is also quite significant in women with moderate to severe endometriosis. This is mainly deep pain in the lower abdomen during intercourse and is present in eighty to ninety per cent of cases. This pain is due to adhesions of the pelvic organs resulting from endometriosis.

Pelvic pain

Women may present with pelvic pain at other times of their cycle, in addition to dysmenorrhoea. This pain is much like period pain and may vary in intensity during different times of the cycle.

Dyschezia

This is pain experienced while opening the bowels and is especially worse at the time of a woman’s period. There could also be pain on urinating if the bladder is involved.

Additionally, women suffering from endometriosis may experience:

• irregular or heavy bleeding
• bleeding from the back passage or in wee during periods
• difficulty in getting pregnant

What causes endometriosis?

The causes of endometriosis are not fully understood although there are several theories. The most logical theory is regarding retrograde menstruation where a minimal amount of blood and endometrial cells go out through the fallopian tubes into the pelvis.

This happens in every woman, however there is a genetic and immunological predisposition in some women which makes them prone to endometriosis. These factors cause the endometrial cells to deposit in other areas outside of the womb, such as the ovaries, fallopian tubes and bowel as well as the pelvic and abdominal wall (peritoneum), which causes an inflammatory response.

These cells flare up every month during a woman’s period and cause microscopic bleeding. This old blood becomes a sticky, chocolate-coloured and thick fluid which, over time, forms into a chocolate cyst. Due to their sticky nature, these cysts make one organ stick to another and over time, adhesions (scarring) are formed. This is when fallopian tubes may become blocked and normal pelvic anatomy is disrupted, resulting in pain and problems in getting pregnant.

Endometriosis is classified into four grades according to severity of the disease:

• Grade 1: Mild peritoneal implants only
• Grade 2: Implants more than Grade 1 and ovarian chocolate cyst (unilateral or bilateral)
• Grade 3: Deep infiltrating disease where the endometriosis deposits are deep in the pelvis and which involves the bowel along with ovarian cysts
• Grade 4: Deep infiltrating disease involving the bowel and organs outside the pelvis

How is endometriosis diagnosed?

The gold standard test for diagnosing endometriosis is a diagnostic laparoscopy (keyhole surgery), where a camera is inserted in the abdomen and all of the pelvic organs are examined closely with the naked eye. Grade 1 endometriosis is otherwise difficult to diagnose with ultrasound or imaging techniques.

Firstly a detailed history and internal vaginal examination is necessary to raise suspicion and get a differential diagnosis. A transvaginal ultrasound scan performed by experienced personnel could indicate adhesions and any nodules between the bowel and vagina and ovarian cysts are easy to diagnose on an ultrasound scan. Additionally, an MRI scan of the pelvis is also indicated in severe endometriosis to quantify the grade of the disease, especially prior to surgery.

What treatments are available for endometriosis?

There are various treatment options available for endometriosis. Medical treatment may comprise of pain killers, such as Mefenemic Acid or Ibuprofen, to be taken during periods.

Hormonal treatment with progesterone is recommended to keep endometriosis suppressed. This is available in various forms depending on the age and preference of the patient. The available options include:

• combined oral contraceptive pills or patches
• progesterone only pills
• progesterone tablets
• intrauterine system (coil) containing progesterone hormone
• contraceptive implant

Surgical treatment for endometriosis may involve:

Keyhole surgery

• laparoscopic removal of endometriotic patches, cysts from ovaries and division of adhesions, which can also be performed by laser
• laparoscopic treatment of endometriosis on the bowel or in severe cases, bowel resection

Open surgery

• open surgery to remove the womb, ovaries and fallopian tubes, including endometriotic patches involving the bowel

The treatment for endometriosis would be dependent on the patient’s age, choice and fertility aspirations and therefore the treatment plan is individualised.

If you are concerned about the symptoms of endometriosis or are seeking treatment for the condition, you can schedule a consultation with Dr Guha by visiting her Top Doctors profile.