Endometriosis is a reasonably common condition where the tissue that lines the uterus is found to be growing where it shouldn't, outside the uterus. Common symptoms include pelvic pain, unusual menstrual bleeding and difficulty getting pregnant.
In New Zealand it is estimated the condition affects one in 10 women. Endometriosis will usually be treated through lifestyle modifications, medication or surgery.
Signs and symptoms
Endometriosis is a condition that develops slowly and tends to worsen as it progresses. The most common symptoms of endometriosis include:
- Pelvic pain - often, but not always, associated with menstrual periods. the pain can be severe and debilitating
- Pain during sexual intercourse
- Abnormal menstrual bleeding (heavy periods or bleeding between periods)
- Difficulty or inability to get pregnant.
Other symptoms experienced may include:
- Lower back pain
- Bowel pain, bloating, pain with passing wind or pain when passing a bowel motion.
- Constipation or diarrhoea
- Constant tiredness
- Premenstrual syndrome
- Depression and mood disturbances
- Pain before or while passing urine or recurrent urinary tract infections.
The severity of symptoms experienced is not always related to the extent of the disease, eg: some women with mild endometriosis can suffer severe symptoms, and vice versa. Not every woman with endometriosis will have regular monthly symptoms.
The tissue that lines inside uterus is known as the endometrium. From onset of puberty until menopause, a monthly rise in hormones causes the endometrium to thicken. When hormone levels drop the lining sheds as menstruation.
Endometriosis is a condition in which endometrial tissue is found outside the uterus. The collection of tissue (often referred to as an "implant") is usually found in the pelvic region (the ovaries, fallopian tubes, and surfaces of the uterus, bowel and bladder). Endometrial implants can also be found outside the pelvic region but this is uncommon.
Endometrial implants respond to hormones in the same way that endometrial tissue inside the uterus does - they grow with the rise in hormone levels and then bleed when the hormone levels drop. Problems occur because the blood produced by the endometrial implants cannot exit from the body in the usual way. This internal bleeding leads to pain, inflammation and scarring.
The precise causes of endometriosis are not fully understood but there are a number of theories as to why it develops.
One theory is that during menstruation some of the endometrial tissue ‘backflows’ through the fallopian tubes and into the abdomen, instead of exiting the body through the vagina. This is called retrograde menstruation. While most women have some degree of retrograde menstruation, no one knows why some women go on to develop endometriosis and other women don’t.
It is also thought that the immune systems of women with endometriosis may not be functioning as well as they should. This may mean that the immune system is unable to remove the stray endometrial tissue as efficiently and so predispose the women to developing endometriosis.
Another theory is that endometriosis develops from tissue remnants left over from prenatal development.
It appears that endometriosis can run in families. If a woman’s mother or sister has the condition, then her likelihood of also developing endometriosis is increased.
Women with short menstrual cycles (under 28 days) and those who have long or heavy periods also seem to be more likely to develop endometriosis. Endometriosis is also more common in those women who have no children or start their families later in life.
Endometriosis can be difficult to diagnose because the symptoms are often similar to those of other gynaecological conditions. To aid diagnosis the doctor will take a detailed medical history, assess signs and symptoms and will perform a pelvic examination.
Endometriosis can only be definitively diagnosed with a laparoscopy. This is a minor surgical procedure performed under a light general anaesthetic by a specialist gynaecologist. The gynaecologist inserts a laparoscope (a long thin tube with a tiny camera at its tip) through a small incision in the abdomen. The laparoscope allows the inside of the abdominal cavity to be viewed on a television monitor. The abdominal cavity is inflated with carbon dioxide gas to improve visibility. The gynaecologist uses the laparoscope to examine the abdominal and pelvic cavities for endometrial implants and scarring.
Endometriosis can be staged or graded to indicate its severity. It is often classified as minimal, mild, moderate or severe; or recorded in clinical notes as stage or grade I to IV based on American Society of Reproductive Medicine guidelines:
- Minimal / mild (stage I or II) endometriosis appears as small patches or surface lesions scattered around the pelvic cavity.
- Moderate (stage III) endometriosis appears as larger, more widespread disease found on the ovaries and in other tissue. Sometimes there is also significant scarring and adhesions.
- Severe (stage IV) endometriosis affects most of the pelvic organs, often with distortion of the anatomy and adhesions
Treatment of endometriosis is aimed at relieving symptoms and minimising complications. The type of treatment chosen depends on a number of factors, including:
- The severity of the condition
- How much the woman’s life is affected by the symptoms
- Her age
- Whether she wishes to have children in the future
It is important to discuss treatment options with your GP or specialist in order to weigh up the advantages and disadvantages of each. Treatment options include:
Medical treatment focuses on relief of symptoms through the use of analgesic (pain relieving) medications and hormone treatment. For mild cases of endometriosis, pai relieving medications alone may be sufficient to adequately relieve symptoms.
Hormone treatment aims to decrease the amount of oestrogen in the body and so reduce the growth of the endometrial implants. The effectiveness of hormone treatment varies and it appears to work best in cases of mild endometriosis. There are a number of different types of hormone treatment that can be used including tablets (such as Provera) or injections (such as Zoladex).
Surgery can be used to treat the symptoms of endometriosis and to help slow the progression of the condition.
Endometrial implants and scar tissue can be removed during a laparoscopy procedure. They are either cauterised (burned using an electrical current) or cut out. This surgical treatment is usually used in cases of mild-moderate endometriosis, and for women who would like to preserve their fertility and improve their chances of pregnancy.
In cases of severe endometriosis where symptoms significantly impact on a woman's life, and when the woman doesn’t wish to become pregnant in the future, more extensive surgery may be recommended. Surgery can involve the removal of the uterus (hysterectomy
), fallopian tubes, deep endometrial implants and scar tissue. The ovaries may also be removed to prevent fluctuation of oestrogen levels, which may cause any remaining endometrial implants to continue to grow. In these cases it may be necessary to commence hormone replacement therapy after surgery.
Lifestyle modification and alternative treatment
Regular exercise and adequate rest are important factors in managing symptoms. Dietary changes - monitoring and avoiding foods that a woman is sensitive to - may also help in managing bowel related symptoms.
Treatment with acupuncture, homeopathy, massage and naturopathy provide relief from symptoms for some women. Treatment with certain combinations of vitamins has also proved effective in some cases.
It is important to discuss treatment options with the specialist in order to weigh up the advantages and disadvantages of each.
Endometriosis New Zealand offers support, information and education for women with endometriosis and their friends and families. They also provide links to other endometriosis resources.
Endometriosis New Zealand
Information and support line: 0800 733 277
Fertility New Zealand offers support and education for couples with infertility problems.
Fertility New Zealand
Freephone: 0800 333 306
Endometriosis New Zealand (2013) Endometriosis explained. www.nzendo.co.nz/endometriosis-explained.html
Fertility New Zealand (2010) Endometriosis and infertility, Christchurch
Liddell, H. (2005) Diagnosis and management of endometriosis. In New Zealand Family Physician. Volume 32, Number 3, June 2005.
Slon, S. (2006) Endometriosis. The Gale Encyclopedia of Medicine. Third Edition. Jacqueline L. Longe, Editor. Farmington Hills, MI: Thomson Gale.
Last Reviewed – 10 May 2013