Endometriosis
Endometriosis is a common cause of infertility and chronic pelvic pain. By definition, Endometriosis is presence of endometrial tissue (the lining of the inside of uterus) outside the uterus. The common sites include ovaries, the broad ligament ( this is the sheet of tissue that covers the uterus like a file), the pelvic cavity, abdomen and in some cases distant sites like lung.
The primary problem is endometriosis seems to be the presence of endometrial tissue at other body sites. The endometrial tissue outside the uterus behaves the same was as inside i.e estrogen and progesterone cause the same effect on these ectopic endometrial tissue as they wound inside the uterus. This leads to cyclical bleeding and shedding of endometrium in these ectopic sites.
The blood and other tissue breakdown products are very potent inflammatory mediators and cause extensive inflammation of the ectopic sites. This leads to scarring and adhesion.
The commonest symptom of endometriosis is pelvic pain. Initially it is present as dysmenorrhea. This pain is typically located over lower abdomen and inside of legs. The pain worsens during the later days of periods. Over a period of time because of the vicious cycle of inflammation and scarring the organs in pelvis namely, uterus, ovaries, bladder and rectum stick together because of adhesions and this leads to chronic deep seated pelvic pain. This pain is often refractory to therapy. Women may also have pain while having sexual intercourse and painful urination.
Apart from pain the most prominent presentation of endometriosis is during evaluation for infertility. Endometriosis frequently causes endometriosis and this diagnosis must always be kept in mind while investigating endometriosis. Endometriosis causes infertility by destruction of the regular anatomy of fallopian tubes and ovaries. Apart from this there are other unknown mechanisms at work here.
The other symptoms of endometriosis include nausea, vomiting, dizziness, heavy menstrual bleeding, urinary problems, constipation, and painful defecation.
A discussion on the causes of endometriosis is beyond the scope of this article. It would suffice to know that endometriosis is most probably caused by retrograde menstruation associated with several other hormonal and immunological factors.
The surest way to diagnose endometriosis is to visualise the lesions either by laparoscopy or laprotomy. Laparoscopy offers the advantages of keyhole approach and lesser trauma to the patient. It is possible to visualise the entire pelvis thru a small incision made just below the naval. The incision heals so well that you will actually have to look for the scar to find it.
Other than these methods, ultrasound examination and MRI of the pelvis can provide diagnostic clues. But a normal ultrasound or MRI does not rule out endometriosis as these lesions are very small to be picked up by these investigations.
While there is no cure for endometriosis, in many patients menopause (natural or surgical) will abate the process. In patients in the reproductive years, endometriosis is merely managed: the goal is to provide pain relief, to restrict progression of the process, and to restore or preserve fertility where needed. In younger women with unfulfilled reproductive potential, surgical treatment attempts to remove endometrial tissue and preserving the ovaries without damaging normal tissue. In women who do not have need to maintain their reproductive potential, hysterectomy and/or removal of the ovaries may be an option; however, this will not guarantee that the endometriosis and/or the symptoms of endometriosis will not come back, and surgery may induce adhesions which can lead to complications.
Hormonal agents: Progesterone counteracts estrogen and inhibits the growth of the endometrium. Such therapy can reduce or eliminate menstruation in a controlled and reversible fashion.
Other than progesterone long term oral contraceptives can reduce the pain associated with endometriosis. They probably work by reducing the menstrual outflow every month.
Danazol and GnRH analogues have also been used for management of endometriosis but are only used for less than six months due to their side effects.At present modern medicine does not have much to offer to patients of endometriosis in the form of a credible cure. However as medical science progresses there will always be the hope that some new novel therapy may come about for this disabling disease.