ENDOMETRIOSIS
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1. What is it ?
2. What are the symptoms ?
3. What causes it ?
4. Who gets it ?
5. How might it affect me ?
6. Should i see a doctor ?
7. How is it diagnosed and followups ?
8. Complementary options ?

What is it?
Endometriosis is a puzzling disease and the exact cause of it is not known. It is a disease occurring in women in which cells from the lining of the womb (endometrium) find their way into another part of the body (see the diagram at the bottom of this page). If they survive there, they continue to behave as they would do in the womb during each menstrual cycle – growing and bleeding. This will cause swelling, bleeding and scarring at the location of the endometriosis which looks like spots, nodules, growths or cysts.

Endometriosis is found (see the diagram below):

• Mainly in the pelvis. It is commonly found on the membrane that lines the abdominal and pelvic cavity (peritoneum). The peritoneum also partially wraps itself around the bladder and the rectum (both near to the womb).
• On the ovaries, where it may form cysts known as chocolate cysts (endometrioma). These cysts are called chocolate cysts because the fluid inside them looks like melted chocolate. This fluid results from the bleeding that occurs in the cysts.
• Embedded in the muscle tissue of the womb (adenomyosis).
• On the ligaments supporting the womb.
• On the cervix (neck of the womb).
• In the vagina.
• Rarely, it can be found in an abdominal surgical scar (eg Caesarian section scar) and
• even the lungs
  
  
                                     
                                                          Anatomy Labels
  

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What are the symptoms?
You don’t necessarily have any symptoms. Endometriosis has been found in about half of all of women having an abdominal operation for other reasons, eg during a hysterectomy or when being sterilized. Many of these women did not complain of any problems.

Pain
When problems arise from endometriosis the commonest symptom is pain. The nature of the pain depends largely on where it is and may depend on the extent of the disease.

• Lower abdominal pain
  You may have pain that is not related to the periods and you may have persistent niggling pain and pelvic discomfort.
• Pain related to sexual intercourse (dyspareunia)
  There may be pain during lovemaking. This pain is usually felt deep in the vagina and the lower abdomen. It may persist for a few hours after or rarely for a few days after.
• Pain elsewhere
  Endometriosis can cause pain at any site where it is found. Therefore there may be pain in your back passage (rectum), in your vagina and in your perineum (the tissue between the vagina in front and the back passage behind). There may also be back pain, painful bowel movements and pain when passing urine (dysuria). The clue to the cause of the pain in sites other than the pelvis or abdomen is in the cyclical nature of the pain. The pain tends to be related to the menstrual cycle.
• Pain related to the menstrual period (dysmenorrhea)
  This pain usually starts a few days before your period begins. It continues during the period and for a few days after the period. It then disappears or gets better until the next period is due.

Heavy periods (menorrhagia)
Heavy periods may occur especially if the endometriosis is embedded in the muscle tissue of the womb (adenomyosis).

Irregular periods
You may have these if you have endometriosis on your ovaries.

Diarrhoea and other bowel problems during the menstrual period
You may get bleeding from your bowel but you must discuss this with your doctor. A cycle of diarrhoea and constipation can also occur with endometriosis, with constipation before a period and diarrhoea during it.

Infertility
Endometriosis can cause problems getting pregnant. This may occur because of scar tissue formation leading to blockage of the fallopian tubes. The endometriosis in the ovaries may also affect your body’s ability to produce eggs.

Sometimes the relationship between endometriosis and infertility may not be obvious and it is thought that there are more complex reasons why it may cause infertility. There is no strong evidence that treating mild endometriosis improves the chance of pregnancy.

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What causes it?
The exact cause of endometriosis is not known but several theories have been proposed:

1. The oldest and most popular theory is that of menstrual blood flowing backwards through the fallopian tubes into the pelvis during a period. The endometrial cells in the blood then implant into the tissues and continue to survive and function. This can also occur during pelvic operations like Caesarian section. The operation scar can also be contaminated with endometrial tissue leading to the development of endometriosis in the scar. Endometriosis can also get implanted in any abdominal operation scar if a woman already has endometriosis in the abdomen.
2. A different theory is that one cell type changes to another cell type. It is believed that endometriosis may be caused when this sort of change occurs in any of the sites where endometriosis is found. The cells here change into cells resembling the lining of the womb. The presence of menstrual blood may be a trigger for this change to occur.
   
3. A third theory is that endometrial cells are found in the blood stream and lymphatic vessels (lymphatic vessels transport fatty substances) around the body. It is believed that these cells can be transported to any part of the body where they can survive and continue to thrive. This theory would explain the presence of endometriosis in some of the rarer sites such as the lungs and the brain.
   
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Who gets it?
It is not known how many people have this as many women remain symptom- free and some with mild symptoms may not visit their doctor or be investigated. However, it could be up to 45 per cent of women.

The majority of women diagnosed with endometriosis are between the ages of 20 and 50 years, but it is seen increasingly in teenagers. This may be because of the increased demand for the investigation of pelvic pain and the availability of better and more sophisticated ways of making the diagnosis.

There is some suggestion that endometriosis may be genetic and therefore inherited, but no specific genetic abnormality has been found. You are more likely to have endometriosis if you have a sister who has it.

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How might it affect me?
The symptoms associated with endometriosis tend to be cyclical in relation to menstrual periods. However, you may feel varying degrees of pain throughout your menstrual cycle. The pain may be incapacitating. Work and schooling may be affected.

Your relationship with your partner may be affected because of severe pain during sexual intercourse.

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Should I see a doctor?
Some degree of pelvic and abdominal pain during a period is common in many women. Other problems may also cause abdominal pain during a woman's menstrual cycle. However if the pain becomes persistent especially with a pattern, you should see your doctor.

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How is it diagnosed?

Laparoscopy
This is a method of diagnosis using a special telescope to look inside the pelvis. It is performed under a general anaesthetic and can be done as a day case unless there are other medical problems. The gynaecologist can have a good view of the pelvis and abdomen and be able to inspect all the pelvic organs.

Biopsy
Many experienced gynaecologists can recognise endometriosis by sight but the most reliable evidence is by taking a sample from the tissue (biopsy), which is then examined under the microscope. Endometriosis may appear as red, black or blue spots. It may also appear as scar tissue, defects in the peritoneum or as areas of increased blood supply. An endometrioma (endometriotic cyst) in the ovary can be recognised.

Follow up
If you are known to suffer from endometriosis, the disease may progress and new symptoms may appear. It may also come back and your symptoms may get worse. In these situations you need to see your doctor. You may be advised to have another laparoscopy to assess the situation. However, this is not usually necessary. Follow up by clinical assessment and improvement of your symptoms is often enough.

You should see your doctor earlier rather than later if you have been diagnosed with endometriosis and you are finding it difficult to get pregnant.

Treatments
There is no permanent cure for endometriosis and treatment must be carefully planned and suited to the individual. Factors that need to be considered are your age, severity of symptoms, the site and extent of the disease and wish to have children. Treatment may not be necessary and a wait-and-see approach may be adopted.

The aim of treatment is:

• to relieve pain
• to permit satisfactory lovemaking
• to control abnormal bleeding
• to promote the possibility of pregnancy if that is a problem.
  

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Complementary options
There is surprisingly little research into complementary therapies in endometriosis. However it may be that complementary therapies can help alleviate some of the symptoms, in particular pelvic pain and period pain and heavy periods. Infertility is often a problem with endometriosis and numerous therapies exist to address this problem, often with very little scientific basis.

Dietary supplements

Pelvic pain
Preliminary studies suggest that the essential fatty acids found in fish oils, linseed oils and evening primrose oil may be extremely helpful in reducing painful periods as well as promoting hormone balance.

A large study some years ago found that the combination of vitamin B3, vitamin C and the flavonoid rutin seemed to help women with painful periods. Calcium supplements do not seem to reduce menstrual pain.

Heavy periods
Vitamin A was found to be very effective in one small study of women with heavy periods. However you should not take vitamin A if you are pregnant or may become pregnant.

Both vitamin C and flavonoids protect capillaries (small blood vessels) from damage. In so doing, they might protect against excessive blood loss. In one very small study women who took vitamin C and flavonoid supplements found that their periods were lighter.

Iron supplements may be needed if bleeding is severe and you are iron deficient.

However it is not clear whether these supplements are of use if the heavy periods are due to endometriosis.

Other supplements that have been recommended in endometriosis are zinc, vitamin E and selenium.

Dietary changes
If you consult a naturopath they may suggest changes to your diet and lifestyle. General suggestions include increasing intake of whole grains, fresh vegetables, and essential fatty acids. They may suggest using an elimination diet to see if there are trigger foods. In particular they will suggest eating foods that are rich in the following vitamins and minerals:

• Iron rich foods include leafy-green vegetables, dried apricots and sardines and meat.
• Vitamin A is found in liver, dairy products and fish oils. Its precursors, the carotenes, are found in carrots, spinach, watercress and broccoli.
• Vitamin C is widely found in fruit and vegetables. Particularly good sources are Brussels sprouts, citrus fruits and blackcurrants.
• Flavonoids are found in a wide range of foods; flavanones are in citrus, isoflavones in soy products, anthocyanidins in wine and bilberry, and flavans in apples and tea.
• Vitamin E is best found in oils such as wheatgerm, sunflower, safflower, soya or maize and all leafy-green vegetables.
• Zinc is found in shellfish, especially oysters, liver, brewer’s yeast, fish and meat.
• Essential fatty acids are found in cold-water fish, nuts and seeds.

Herbal medicine
Western herbalists, ayurvedic herbalists and practitioners of traditional Chinese medicine will also work with your diet and lifestyle. Many herbs are known to affect hormone levels but their safety is not always so clear.

One of the best studied is Vitex agnus castus (chaste tree berry or chasteberry). It has mostly been studied for use in pre-menstrual syndrome. However it appears to be both safe and effective for women with heavy periods and may be of use in endometriosis.

Herbalists often suggest herbs such as milk thistle that support liver function. Theoretically this will help restore normal hormone levels. Milk thistle has been extensively studied and its beneficial effect on liver function is well known. However it has never been studied in endometriosis.

Corydalis contains several powerful substances that may help menstrual pain. Another traditional remedy, black cohosh, has been helpful in reducing menopausal symptoms.

Other herbs that have traditionally been used for menstrual problems include cinnamon, yarrow, goldenseal, linden flower, shepherd’s purse and false unicorn root for heavy periods, and cramp bark, vervain and dong quai for menstrual pain. There is little scientific evidence for their benefit and none of them should be taken if you are pregnant.

Remember also that herbs may interact with conventional medicines. Always ensure that both your doctor and your herbalist are aware of exactly what you are taking.

Homoeopathy
Homeopathy is safe and can be used. However there is no real evidence for its use. A very small trial into pre-menstrual syndrome suggested that it may be better than placebo. A similar trial of women with period problems showed no improvement.

Acupuncture
This may be a useful therapy in the treatment of pelvic pain associated with endometriosis. A number of studies have reported that acupuncture can help painful periods, including a study that compared real acupuncture with sham acupuncture (using fake acupuncture points). It is less likely however that TENS (transcutaneous electronic nerve stimulation) helps.

Other therapies
Stress management and relaxation training may help in alleviating symptoms and coping with pain.

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