What is Endometriosis ?

May 22, 2015 0

Endometriosis is a common condition that affects women during the reproductive years. Endometriosis is a condition where tissue, similar to the one that normally grows inside the uterus (lining of uterus), also grows outside of the uterus. The tissue inside the uterus is called “endometrium” and the tissue outside of the uterus is called “endometriosis”. The most common places where endometriosis occurs are the ovaries, the fallopian tubes, the bowel, and the areas in front, in back, and to the sides of the uterus.

If you have severe pain during menses and also having some trouble in conceiving then you may be having endometriosis. While some women with endometriosis have severe symptoms some may have few or no symptoms.

There is no cure for endometriosis, but there are several treatment options. The best treatment depends on your individual situation which can be judged by your fertility specialist.

At Ankoor clinic the treatment is custom made for each individual depending upon the symptoms and severity of the condition. Such individualization gives the best results to our patients.

 

What are the causes of endometriosis?

The cause of endometriosis is not known. A common theory is that some menstrual blood and endometrium flows backwards through the fallopian tubes and into the pelvis during a menstrual period. This tissue then grows where ever it lands in the pelvis. This is called the retrograde menstruation theory. It explains external endometriosis.

In some cases internal endometriosis is seen. The Germ line theory explains it. In these cases the endometrium grows internally due to the germ cells that grow in this abnormal location causing endometriosis.

There are several other theories. However it is best to focus on treatment rather than cause in cases of endometriosis.

How does endometriosis cause infertility?

There are many ways in which endometriosis affects fertility.

  1. Anatomical distortion – Moderate to severe endometriosis causes damage to the ovaries or fallopian tubes which leads to fibrosis and scarring. This may lead to anatomical distortion of the fallopian tubes leading to blockage of the fallopian tubes or any obstruction between the fallopian tube and ovaries.
  2. Immunological aspects – It has been seen that even in mild cases of endometriosis the women produce antibodies against the sperm or even the egg and embryo leading to infertility.
  3. Quality of egg / oocyte – In case of even mild degree of endometriosis the quality of egg is also compromised leading to infertility or even abortions.
  4. Interlukin (IL) induced damage of gametes – Endometriosis causes release of toxic Interlukins(ILs) and Cytokines(CKs) in the woman. These adversely affect both the sperm as well as the egg or ova leading to their damage and hence difficulty in conception.

What are the symptoms associated with endometriosis?

The symptoms of endometriosis vary a lot. While some women with endometriosis have no symptoms a few may have very severe symptoms like severe pain in the pelvic area, especially with periods. The common symptoms are:

    1. Pain during menses (Dysmenorrhoea) 
    • Pelvic pain caused by endometriosis can occur:
      • Just before or during the menstrual period. In some women, painful periods get worse over time (Dysmenorrhoea)
      • Between menstrual periods, with worsened pain during the period
      • With bowel movements or while urinating, especially during the period

    Pelvic pain can also be caused by many other conditions, such as pelvic infections and irritable bowel syndrome. A gynaecologist can help to figure out if endometriosis may be the cause of your pain.

    1. During or after sex (Dyspareunia) –

    Some women experience severe pain during or just after intercourse/ sex due to endometriosis induced adhesions and scarring between the pelvic structures.

    1. Difficulty getting pregnant (Infertility)

    Endometriosis can make it more difficult to become pregnant. This might occur because endometriosis causes scar tissue to develop, which can damage the ovaries or fallopian tubes. Even women with endometriosis who do not have scar tissue can have difficulty becoming pregnant due to reasons explained above.

    However, in women who become pregnant, endometriosis does not harm the pregnancy. Symptoms of endometriosis often improve after pregnancy.

     

    1. Premenstrual spotting-

    Some women do not have any major symptoms or complaints other than just a few days of premenstrual spotting.

    1. Asymptomatic-

    Some women do not have any symptom of endometriosis and are diagnosed to have a blood filled cyst incidentally on USG. This cyst is called as an endometrioma. Endometriomas are usually filled with old blood that resembles chocolate syrup; thus, they are sometimes called chocolate cysts. Endometriomas are sometimes seen during a pelvic ultrasound or felt during a pelvic exam.

    1. Rare symptoms-

    Sometimes if there are endometriotic deposits in the bladder or bowel region then the women may have bleeding while passing urine or even blood in stools.

     

How is endometriosis diagnosed?

Endometriosis may be suspected if the woman has any of the above symptoms.

Clinical examination by your fertility specialist can help further confirm endometriosis.

In other cases a pelvic ultrasound may reveal endometriosis in the form of persistent fluid collection in the pouch of douglas (suggestive of endometriosis), endometrioma which are type of ovarian cyst or rarely if there are dense adhesions.


CHOCHOLATE CYST ON USG

 

However, the only way to know for sure if you have endometriosis is to have surgery. Symptoms of the patient do not routinely point towards the severity of the disease as women with mild disease can have severe symptoms, and women with severe disease can have mild symptoms. Endometriosis is considered mild, moderate, or severe depending on what is found during surgery. During surgery the endometriosis can be divided into 4 stages depending upon the severity, with stage 1 being the mildest form of endometriosis and stage 4 the severest form. Treatment is based on the staging of endometriosis.

CHOCOLATE CYST ON USG 2

In some cases for differentiation a CTscan or MRI may be required.

MRI - CHOCOLATE CYST

 

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What are the different stages of endometriosis?

The American Society for Reproductive Medicine (ASRM) classification system for endometriosis is the most accepted.

Endometriosis is classified into one of four stages:

I-minimal, II-mild, III-moderate, and IV-severe.

This classification depends on location, extent, and depth of endometriosis implants; presence and severity of adhesions; and presence and size of ovarian endometrioma.

A majority of women have minimal or mild endometriosis, which is characterized by mild adhesions and superficial implants.

Moderate and severe endometriosis is characterized by chocolate cysts and more severe adhesions.

The stage of endometriosis does not correlate with the presence of or severity of symptoms; with stage IV endometriosis, infertility is very likely.

STAGING OF ENDOMETRIOSIS 1

STAGING OF ENDOMETRIOSIS

 

However , unfortunately no staging system correlates well with the chance of conception following therapy. This poor predictive ability is related to the arbitrary assignment of point scores for pathology and arbitrary cut off.

 

What are the treatment options available?

There are many treatment options for endometriosis. But the treatment depends on many factors such as age of the women, desire for fertility, need of contraception, severity of symptoms, extent of endometriosis (excessive involvement of bowel or bladder) and last of all patient’s desirability. So the treatment has to be tailor made for a particular woman.

However here we will be discussing management of endometriosis related to fertility. Medical management with pain killers or oral contraceptive pills or only progesterone pills is not suitable for these patients. In some cases GnRh injections are given to relieve from symptoms but again these are not advisable in women who desire fertility.

The best protocol of management in infertile patient is usually surgical clearance followed by ovulation induction and IUI or IVF-ICSI in very severe disease. Many a time surgical clearance is followed by spontaneous pregnancies also. However sometimes ovulation induction with planned relations or IUI can precede surgical intervention with good pregnancy rates. In some cases of severe disease wherein there is spread to bladder or rectum an IVF cycle may be planned without clearing the disease completely. The decision of treatment has to be taken by the doctor and couple after understanding the pros and cons.

Research has not firmly proved that removing mild endometriosis improves fertility. For moderate to severe endometriosis, surgery will improve your chances of pregnancy. In some severe cases, a fertility specialist will recommend skipping surgical removal and using IVF.

Generally in Stage 1 and 2 of endometriosis management includes gonadotrophin stimulated 3 to 6 cycles of intra uterine insemination (IUI) depending upon the age of the woman and her AMH levels. In severe cases of endometriosis like Stage 3 and 4, surgery is followed by gonadotrophins. In these cases the success rate in terms of pregnancy following an IUI is generally poor around 5%. Hence, in such women better results are achieved by using GnRh therapy for 4-6 months followed by IVF or ICSI.

Stage 1 3 to 6 cycles of Gonadotrophin stimulated intra uterine insemination (IUI)
Stage 2 3 to 6 cycles of Gonadotrophin stimulated intra uterine insemination (IUI)
Stage 3 Surgery is followed by gonadotrophins may be tried but pregnancy rates are very low

Surgical clearance followed by ovulation induction and IUI or IVF-ICSI gives better results

Stage 4 Surgical clearance followed by ovulation induction and IUI or IVF-ICSI

 

How is endometriosis managed laparoscopically?

Laparoscopy is the most common procedure used to diagnose and remove mild to moderate endometriosis. Instead of using a large abdominal incision, the surgeon inserts a lighted viewing instrument called a laparoscope through a small incision. If the surgeon needs better access, he or she makes one or two more small incisions for inserting other surgical instruments.

The internal organs are examined to look for signs of endometriosis (dark blackish or brownish powdery spots, also called as gun powder appearance) and other possible problems like adhesions or blood filled cysts. Any visible endometriosis implants and scar tissue that may be causing pain or infertility are removed. Removal of endometriosis or scar tissue involves using one of the various techniques, including cutting and removing tissue (excision) or destroying it with a laser beam or electric current (electrocautery).

4-endometriosis

 

 

 

 

If an endometriosis cyst is found growing on an ovary (endometrioma), it is likely to be removed. There are various ways of surgically treating an endometrioma, including draining it, cutting out part of it, or removing it completely (cystectomy). Any of these treatments brings pain relief for most women but not all. Cystectomy is most likely to relieve pain for a longer time, prevent an endometrioma from growing back, and prevent the need for another surgery.

 

Video of Endometrioma

What are the risks and complications involved?

The complications are more or less similar to any laparoscopic surgery. However in case of extensive endometriosis there is a slightly more chance of organ injury.

In some instances minimal to mild endometriosis spots may not be seen during a laparoscopy surgery and these may flare up later during treatment and may need additional surgery.

 

Why and How to prevent recurrence of endometriosis ?

Management of infertility along with endometriosis can be long and tiring for some patients. It is seen that some women do not continue the treatment of endometriosis, but this has severe repercussions and can lead to extensive endometriosis and scarring. Few women after undergoing the surgery and 3 to 4 few IUI cycles, if they do not conceive then become frustrated and stop the treatment . This leads to recurrence of endometriotic lesions and further damage to the tubes and ovaries.

If the couple/ woman is exhausted physically or mentally and wants to a break then it is a good idea to take some simple medications like hormonal pills eg.

1) Oral contraceptive pills continuously for months together so that she does not get her menses and future endometriosis can be avoided.

2) Progesterone supplementation can also be used for shorter duration of period in woman planning for conception as this will prevent further endometriosis and if in case the women becomes pregnant it will benefit the pregnancy too.

However, waiting for too long is not advisable in cases of endometriosis as it further lowers the chances of getting pregnant.

 

Another important aspect is that women with endometriosis have shown to have an adverse pregnancy outcome as compared to women who do not have endometriosis. Hence vigilant monitoring and care during pregnancy is also very important.

 

I am 21 years and have been diagnosed with endometriosis. Will it affect my chances of getting pregnant in future? How long can I postpone my pregnancy

Yes, endometriosis affects the changes of getting pregnant adversely. Studies have shown that the endometriotic lesions and cysts go on increasing in size if not treated and will damage the normal architecture and functioning of the reproductive organs.

Endometriotic/ chocolate cysts damage the normal ovarian tissue and hence reduce the ovarian reserve. Studies have shown that in untreated cases , over a period of time the AMH (Anti mullerian hormone ) values go on decreasing. (AMH is a marker of ovarian reserve).

To summarise , waiting for too long is not advisable in cases of endometriosis as it further diminishes the chances of pregnancy due to ovarian damage and tubal adhesions formation.

 

I am 28 years old, married and have undergone surgical excision of chocolate cyst 2 months back. I am tired of the prolonged treatment for infertility and endometriosis. What should I do?

If the couple/ woman is exhausted physically or mentally and wants to a break then it is a good idea to take some simple medications like hormonal pills eg.

1) Oral contraceptive pills continuosly for months together so that she does not get her menses and future endometriosis can be avoided.

2) Progesterone supplementation can also be used for shorter duration of period in woman planning for conception as this will prevent further endometriosis and if in case the women becomes pregnant it will benefit the pregnancy too.

However , waiting for too long is not advisable in cases of endometriosis as it further diminishes the chances of pregnancy due to ovarian damage and tubal adhesions formation.

 



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