Causes

It is thought that some cells from the womb lining (the endometrium) reach the pelvis. During periods (menstruation), when the lining of the womb is shed, they may pass backwards along the Fallopian tubes. As a result, these endometrial cells survive between the organs of the pelvic region, such as the fallopian tube, uterus, ovary, bladder, and bowel. In the same way that the womb lining responds to female hormones, the endometrial cells do so. During the period, the cells multiply, swell, and break down as they prepare to be shed. Since they are trapped inside the pelvic region, they cannot escape. As a result, they form ‘endometriosis’ patches.

Endometriosis patches are generally ‘sticky’, causing organs to adhere together, such as the bladder joining the womb (adhesions). In large cases of endometriosis, cysts may form and bleed each month when menstruation occurs. 

Symptoms

It is possible to find patches of endometriosis of varying sizes, ranging from small pinheads to large clumps. The amount of endometriosis does not necessarily determine the symptoms. There are women who have large patches of endometriosis without any symptoms. Other women may only have a few spots of endometriosis but have a lot of symptoms. Here are some symptoms to look out for.

Painful periods – the pain usually starts a few days before the period and lasts throughout the period. It differs from normal period pain, which usually lasts for a shorter period and is not as severe. 

Sexual pain – may last for several hours after sex and is often felt deep inside.

Lower abdomen and pelvis pain – usually around menstruation. Pain may become constant but is usually more severe before and during periods.

Other menstrual symptoms such as heavy or prolonged periods may also occur.

Endometriosis clumps block the passage of the egg from the ovary to the fallopian tube, making it difficult to become pregnant.

Some uncommon symptoms include pain while passing faeces (motions), and blood in urine or faeces. Rarely, patches of endometriosis can appear elsewhere on the body. As a result, you may experience unusual monthly pains during your period.

It is necessary to perform further tests to rule out other conditions that may cause these symptoms. Laparoscopy is usually used to confirm the diagnosis. In this procedure, a small cut is made in the abdominal wall below the umbilicus (tummy button) under anaesthesia. During the procedure, a ‘telescope’ is pushed through the skin to give a glimpse inside. Endometriosis patches can be seen.

It is estimated that about one in three women with endometriosis will become more severe if left untreated. As for the rest, it does not appear to worsen or disappear over time. Life expectancy is not reduced due to endometriosis, nor is it cancerous.

Treatments

Painkillers

For mild symptoms, painkillers such as paracetamol may suffice. In some cases, painkillers that are anti-inflammatory (such as ibuprofen, diclofenac, naproxen, etc.) may be better than paracetamol. It is possible to take painkillers along with any other treatment.

The use of hormones

Women’s main hormone, oestrogen, is crucial for endometrial cells. Treatments with hormones suppress (reduce) oestrogen production or block its effects on endometrial cells. A lack of hormones starves the endometrial cells, making them die. After that, they may gradually shrink and disappear. Hormone medications come in various forms and are usually prescribed by a specialist. They all have a similar success rate. A variety of factors are considered, including the severity of symptoms, age, plans for pregnancy, and possible side effects. The response to treatment varies from woman to woman. The side effects of treatments are also different. Trying one treatment may be fine. The switch to another treatment is not uncommon if the first does not work.

Surgical procedures

Large patches of endometriosis may need surgery to remove. Taking this step may be helpful in easing symptoms and increasing the chances of getting pregnant if you have infertility issues. Those who have completed their families and tried other treatments without success may be able to undergo a hysterectomy (removal of the womb) and ovaries removal. In most cases, this cures the symptoms.

To discuss diagnosis and treatment options, please book an appointment with our specialist.

To learn more about endometriosis, please click on https://www.nhs.uk/conditions/endometriosis/

Dr Ibrahim Yahli MD MRCPsych