Endometriosis is a chronic condition where tissue similar to the lining of the uterus (endometrium) grows outside the uterus, often causing pain and infertility.
Causes
- Retrograde Menstruation: The most widely accepted theory. Menstrual blood containing endometrial cells flows back through the fallopian tubes and into the pelvic cavity instead of leaving the body.
- Embryonic Cell Transformation: Hormones such as estrogen might transform embryonic cells into endometrial cell implants during puberty.
- Surgical Scar Implantation: After surgeries like hysterectomy or C-section, the endometrial cells may attach to the surgical incision.
- Endometrial Cell Transport: The blood vessels or tissue fluid (lymphatic) system may transport endometrial cells to other parts of the body.
- Immune System Disorder: A problem with the immune system may make the body unable to recognize and destroy endometrial-like tissue growing outside the uterus.
Diagnosis
- History
- Pain: Especially dysmenorrhea (painful periods), pelvic pain, pain during intercourse, or pain with bowel movements/urination during menstrual periods.
- Menstrual irregularities: Heavy periods or bleeding between periods.
- Infertility: Often first diagnosed in those seeking treatment for infertility.
- Physical Examination
- Pelvic exam: To feel for abnormalities, such as cysts on reproductive organs or scars behind the uterus.
- Palpation: May reveal tender nodules, enlargement of the ovaries, or a retroverted uterus.
- Investigations
- Ultrasound: Transvaginal or abdominal ultrasound to identify cysts associated with endometriosis.
- Magnetic Resonance Imaging (MRI): More detailed imaging.
- Laparoscopy: Gold standard for diagnosis. Provides a definitive diagnosis and staging of endometriosis through direct visualization.
Differential Diagnosis (DDx)
- Pelvic Inflammatory Disease
- Ovarian Cysts
- Irritable Bowel Syndrome (IBS)
- Fibroids
- Interstitial cystitis
Management
- Pain Management: NSAIDs or analgesics to relieve pain.
- Hormonal Therapy:
- COCP – Ethinyloestradiol/Levonorgestrel
- LARCs – Implanon, Mirena, Depo-Provera
- Progestin therapy ie norethisterone
- Conservative Surgery: To remove as much endometriosis as possible while preserving the uterus and ovaries (preferred in women seeking pregnancy).
- Hysterectomy with Removal of Ovaries: Considered in severe cases, particularly when pain is debilitating and fertility is not a concern.
- Assisted Reproductive Technologies: In cases of infertility.
- Lifestyle and Home Remedies Regular exercise and a healthy diet may help reduce estrogen levels, which can aid in the management of endometriosis.
- Monitoring and Follow-up
- Regular follow-ups to monitor symptoms, especially if new symptoms develop or current symptoms worsen.
- Monitoring response to treatment and adjusting as necessary.
- Referral: Consider referral to a gynecologist or endometriosis specialist, particularly for severe cases or when fertility is affected.
- Patient Education:
- Educate about the chronic nature of the disease, treatment options, and impact on fertility.
- Discuss lifestyle modifications that might help with symptom management, like regular exercise and a healthy diet.
- Preventive Measures: There are no proven preventive measures for endometriosis. However, hormonal treatments that reduce or eliminate periods can slow the progression.
Endometriosis can significantly impact the quality of life and requires a tailored approach to management considering the patient’s symptoms, age, and fertility desires.