Endometriosis is a condition in which cells of uterine lining i.e the Endometrium, are present in abnormal locations outside the uterus, for eg. over the ovaries, fallopian tubes, pelvic wall and in the space between rectum and the postrier aspect of the uterus. Just as the uterine lining grows and bleeds under the effect of hormonal cycles every month, similarly these abnormally located cells also grow and cause bleeding every month in the body part where they are situated. Since this abnormal bleeding does not find any outlet from the body, it leads to collection of blood, cyst formation, adhesions and scarring in the surrounding areas. This leads to excessive pain and a variety of other symptoms at the time of periods.
Burden of the disease:
The incidence of Endometriosis is about 10% of all women of childbearing age group. In India about 26 million women between the ages of 18-35 were found to be affected with Endometriosis and about 5% of girls below 18 years, who complain of excessive pain during periods, have got Endometriosis. It is important to understand the disease because it begins at an early age and affects the women in the prime years of their lives, affecting their productivity. Although it is not life threatening, it is still an important cause of morbidity in women.
About one third of the women having Endometriosis may not have any symptoms. However, others may have a variety of symptoms such as:
- Painful periods
- Deep pain during intercourse
- Heavy or irregular bleeding
- Pain during defecation or urination, especially during periods
- Bouts of diarrhea, nausea, vomiting during periods
Clinically, it can be suspected by the Gynaecologist when there is pelvic tenderness on examination or the uterus is found to be having restricted mobility or is deviated posteriorly. Laparoscopy is the gold standard for diagnosis, although sometimes, Ultrasound findings of haemorrhagic cysts in the ovaries or Bulky, deviated uterus may also suggest Endometriosis.
How To Cure Endometriosis
Unfortunately there is no permanent cure for Endometriosis apart from complete surgical removal of Uterus and ovaries. Even then, some of the symptoms caused due to uncorrectable scarring may persist. Hence the approach to treatment depends upon the age of the woman, treating the severity of the symptoms, and whether or not future fertility is desired.
The treatment options are divided into three categories:
- Pain relief
- Fertility enhancement
- Definitive Surgical interventions
This can be accomplished by either non hormonal or hormonal medications.
The non hormonal medications include NSAID’s like Ibuprofen, Naproxen or Opiods & other painkillers which are taken during periods for pain relief.
Hormonal medications include oral and injectible medications. These act on the cyclical production of hormones leading to suppression of Endometriosis. Medications cannot bring about complete elimination of the disease but they may suppress the symptoms and lead to improvement in the quality of life for varying periods lasting as long as medicines are taken and sometimes even for a few months after stopping them.
- Combined Oral Contraceptive Pills – These act on the hormones which lead to the growth of Endometrial tissue every month. They may be given cyclically or continuously and help in decreasing the pain and bleeding substantially in cases of mild or moderate Endometriosis. Combined hormonal regimes are also available in the form of vaginal rings or skin patches which need to be replaced every month as advised by your Gynaecologist.
- Progestogens – Progesterone is one of the main hormones in a woman’s body and the synthetic congeners are called Progestogens. When taken in any form i.e oral/ injectible or intrauterine device, they suppress the growth of Endometrial tissue directly both inside as well as outside the uterus. These are available as oral tablets that can be taken daily or cyclically to suppress the growth of the disease. Intrauterine device (MIRENA) is also available which is inserted into the cavity of the uterus & stays there, releasing a continuous supply of progesterone into the body. Progesterone injections given monthly or once in three months can also suppress Endometriosis. The progesterone agents are a good option to suppress the pain and other symptoms of Endometriosis but they may cause unpleasant side effects such as nausea, giddiness, bloating, headache etc. New preparations are frequently introduced and nowadays the fourth generation progestogens are quite effective in pain relief.
- GnRH agonist – These medicines block the production of ovarian hormones by affecting the production of regulatory hormones by the Pituitary gland in the brain. Thus they bring about an artificial state of menopause which leads to shrinkage of Endometriotic tissue. They are available in the form of nasal sprays taken daily or injections which may be taken monthly or once in three months. Since these agents can cause menopausal symptoms like hot flashes, vaginal dryness, loss of bone density etc., they may need to be combined with artificial Estrogen/Progesterone supplementation and should not be given for more than six months at a time.
- Danazol – This is a synthetic androgen i.e a male hormone, which is given in the form of oral tablets and is effective in controlling Endometriosis but it can cause side effects like abnormal hair growth on the body, Acne, weight gain, deepening of voice etc and hence is not preferred nowadays as the drug of choice for treatment of endometriosis.
Fertility Enhancement Surgery:
In women who are desirous of having pregnancy, treatment is aimed at maximizing the chances of conception by medical or surgical methods as required. Hence, medications such as oral contraceptive pills, Intrauterine devices or GnRH analogoues etc are not usually preferred in these cases. Surgical intervention is targeted at removal of as much disease as possible while at the same time, restoring normal anatomy & tubo-ovarian relationship to improve the chances of conception. Hence, surgery may include one or more of the following depending upon the stage of the disease:
- Removal of any Endometriotic cysts from the ovaries
- Ablation of visible Endometriotic spots in pelvis
- Separation of adhesions /scar tissue in the pelvis to restore normal anatomy
- Presacral neurectomy and Laser Uterine Nerve Ablation are reserved for exceptional cases where the pain is excessive and other treatment approaches have failed.
These surgical interventions are usually accomplished by Laparoscopic surgery but in some cases, a laparotomy may need to be done giving a larger incision on the abdomen. Women with Endometriosis desiring a pregnancy may need Assisted Reproductive Techniques especially if the tubal function is compromised or it is a stage 3 or 4 Endometriosis.
Definitive Surgical Intervention:
In women who have completed childbearing and are not desirous of further pregnancy, if the symptoms are excessively debilitating & not responding to other measures, it is advisable to do a complete Hysterectomy with removal of uterus, cervix, fallopian tubes & both ovaries. Since the progression of the disease is dependent on production of ovarian hormones, the only way to completely stop the progress is by eliminating the hormones from the body. This is achieved either naturally after menopause, or the other option is to remove the ovaries along with the uterus & tubes surgically. This is necessary because even though removal of uterus may lead to cessation of menstrual blood flow, the microscopic cellular deposits which may be persisting in the abdominal and pelvic cavity will continue to respond to ovarian hormones and the pain and other symptoms may persist.
Hysterectomy with removal of fallopian tubes and ovaries can be achieved either by Laparoscopy or by a conventional incision over the abdomen.
The Author, Dr. Smita Vats is practising as a Consultant Gynaecologist and Laparoscopic Surgeon in Gurgaon.She is one of the Best Gynaecologist in Gurgaon and a visiting consultant at various esteemed Hospitals in Gurgaon including Artemis Hospital, Cloud nine Hospital, Paras Hospital & GNH Hospital Gurgaon.