Endometriosis Awareness week took place last week in an effort to highlight the condition and make women and health professionals alike aware of risk factors for the condition and methods of treatment. This often painful disease occurs when the endometrium is found outside the uterus.
As the tissue responds to hormones in the same way as the normal lining of the uterus, it bleeds during menstruation, causing scarring and tissue damage. It is mostly diagnosed in women in their mid-20s to 40s, who often may have symptoms for years before a definitive diagnosis is made.
According to the Endometriosis Association of Ireland (EAI), the condition is often diagnosed incidentally, during an operation or investigation for something else.
The EAI stated that based on the amount and location of endometriosis seen during a laparoscopy, it is graded as minimal, mild, moderate or severe (stage I, II, III or IV). Some mild types of endometriosis may come and go over the years, and may never cause any significant problems. In severe cases, the disease can behave in a more aggressive manner, and may spread to surrounding tissues, causing significant pain and infertility.
While endometriosis is not a malignant condition, it can cause both physical and emotional suffering, the EAI said. Unfortunately, it is not possible to identify which will progress and which will not at the time of laparoscopy.
Figures approximate that it will improve without any treatment in one-third of women, there will be no change in another third and the disease may worsen in the remainder.
The EAI states that symptoms include painful periods, which persist even when on the contraceptive pill; pain at ovulation, which occurs mid-cycle; and deep pain during and after intercourse.
Further symptoms include painful bowel motions, rectal bleeding, constipation or diarrhoea, or painful urination, all particularly at time of menstruation. Many women also complain of general tiredness and pre-menstrual type symptoms, the EAI noted.
The Association also stated that endometriosis is found in approximately one-third of women with fertility problems. Severe endometriosis can lead to blocked fallopian tubes and ovarian cysts, both of which in turn can lead to infertility. However, the EAI said, “while mild degrees of endometriosis are found in many women who have difficulty becoming pregnant, it has not yet been proven whether the endometriosis is actually the cause or not. There is currently a view that very mild forms of endometriosis may in fact be ‘normal’ for some women.”
Research published in 2007 by the European Society of Human Reproduction and Embryology (ESHRE) aimed to develop recommendations for the diagnosis and treatment of endometriosis and its associated symptoms.
Findings were based on results from a working group comprising practising gynaecologists and experts in evidence-based medicine in Europe, as well as endometriosis self-help group representatives.
It concluded that in women with symptoms suggestive of endometriosis, a definitive diagnosis of most forms of the condition requires visual inspection of the pelvis at laparoscopy as the “gold standard” investigation.
However, pain symptoms suggestive of the disease can be treated without a definitive diagnosis using a therapeutic trial of a hormonal drug to reduce menstrual flow.
In women with laparoscopically confirmed disease, suppression of ovarian function for six months reduces pain. The ESHRE added that all hormonal drugs studied are equally effective, although their side-effects and cost profiles differ. Ablation of endometriotic lesions reduces endometriosis-associated pain and the smallest effect is seen in patients with minimal disease; there is no evidence that also performing laparoscopic uterine nerve ablation (LUNA) is necessary.
The ESHRE’s review continued to say that, in minimal to mild endometriosis, suppression of ovarian function to improve fertility is not effective, however ablation of endometriotic lesions plus adhesiolysis is effective compared to diagnostic laparoscopy alone. There is insufficient evidence available to determine whether surgical excision of moderate to severe endometriosis enhances pregnancy rates. IVF is appropriate treatment, however, especially if there are coexisting causes of infertility and/or other treatments have failed, but IVF pregnancy rates are lower in women with endometriosis than in those with tubal infertility.
Though there is yet no cure for the condition, many treatments exist. Each method depends on the individual’s symptoms, age, whether pain is experienced, or infertility.
The EAI warned: “Sometimes it can take years to have endometriosis diagnosed, and because of the many different symptoms, it can mean that more than one type of treatment is needed.
“Unfortunately, in many cases the disease will reoccur when the treatment ceases. The aim of drug treatments is to stop the endometriosis from progressing; none cure the disease,” it continued.
According to the EAI, the aim of medical treatment is to suppress the hormonal stimulation of endometriosis, which allows the pelvis to rest and heal. This involves stopping menstruation and initially lasts for three to six months. The Association noted that between 80 and 90 per cent of women notice a “dramatic improvement in symptoms”.
Commonly used drugs have some side effects, including the patient entering a menopause-like state.
Surgical treatment involves a procedure which removes the endometriosis deposits or burns them off using laser or diathermy. The EAI advises that surgical treatment is “probably superior” to medical treatment for endometriosis that is deeply implanted or where there is a lot of scar tissue.
The Institute for the Study and Treatment of Endometriosis (ISTE) advises of the possibility that endometriosis can recur and that patients should keep in mind that repeated surgeries cause adhesions and destruction of healthy ovarian tissue and may adversely affect fertility.
Otherwise, EAI suggests, women with severe symptoms who have already had a family or who do not wish to conceive could opt for a hysterectomy.
References on request
Endometriosis Awareness Week took place from March 7-13. See www.endo.ie
