What is endometriosis?

Endometriosis is an often painful disorder in which tissue similar to the tissue that usually covers the inside of the uterus - the endometrium - grows outside the uterus. Endometriosis usually involves the ovaries, fallopian tubes and the tissue lining the inside of the pelvis (peritoneum). Rarely, tissue similar to the endometrium can be found beyond the area where the pelvic organs are located. Σendometriosis, the endometrial-like tissue works like endometrial tissue - it thickens, breaks down and bleeds with each menstrual cycle. But because this tissue has no way out of the body, it becomes trapped. When endometriosis is localized in the ovaries, cysts called endometriomas can form. The surrounding organs may become irritated, resulting in the development of scar tissue and adhesions. Endometriosis can cause pain - sometimes severe - especially during menstruation. Infertility may also be observed. Fortunately, there are effective treatments.

What are the most common symptoms of endometriosis?

The main symptom of endometriosis is pelvic pain, often associated with menstruation. The pain may also increase over time. The most common symptoms of endometriosis are:

• Painful periods (dysmenorrhea): Pelvic pain and cramps may start before and last for several days after menstruation. Back pain may also occur.
• Pain on contact: Pain during or after sex is common in women with endometriosis.
• Pain during bowel movements or urination: You are more likely to experience these symptoms during a period.
• Excessive bleeding: You may occasionally experience heavy periods or bleeding between periods (inter-cycle bleeding).
• Infertility: Sometimes, endometriosis is first diagnosed in those seeking treatment for infertility. 
• Other signs and symptoms: You may experience fatigue, diarrhea, constipation, bloating or nausea, especially during your period.

The severity of pain is not necessarily a reliable indicator of the extent of the condition. You could have mild endometriosis with severe pain or you could have advanced endometriosis with little or no pain. Endometriosis is sometimes confused with other conditions that can cause pelvic pain, such as pelvic inflammatory disease (PID) or ovarian cysts. It can be confused with irritable bowel syndrome (IBS), a condition that causes bouts of diarrhoea, constipation and abdominal cramps. IBS may accompany endometriosis, which can complicate the diagnosis. Endometriosis can sometimes be a difficult condition to manage. Early diagnosis and understanding your diagnosis can lead to better management of your symptoms.

What are the possible causes and risk factors for endometriosis?

Although the exact cause of endometriosis is not certain, possible explanations have been reported:

• Retrograde menstruation: In retrograde menstruation, menstrual blood containing intrauterine cells flows back through the fallopian tubes into the peritoneal cavity instead of out of the body. These endometrial cells stick to the various organs where they grow and continue to thicken and bleed during each menstrual cycle.
• Peritoneal cell transformation: In what is known as the 'induction theory', experts suggest that hormones or immune factors promote the transformation of peritoneal cells - cells that line the inside of your abdomen - into cells similar to the endometrium.
• Embryonic cell transformation: Hormones such as oestrogen can turn fetal cells into cells similar to the endometrium during puberty.
• Postoperative implantation in a scar: After surgery, such as a hysterectomy or caesarean section, endometrial cells can adhere to a surgical incision.
• Transfer of endometrial cells: Blood vessels or the lymphatic system can transport the intrauterine cells to other parts of the body.
• Disorder of the immune system: A malfunction of the immune system can make the body unable to recognise and destroy endometrial-like tissue that grows outside the uterus.

Several factors increase the risk of developing endometriosis, including:

• Atakia
• Starting your period at an early age
• Menopause at an older age
• Short menstrual cycles - for example, less than 27 days
• Heavy menstrual periods lasting more than seven days
• Higher levels of estrogen in the body or greater exposure to estrogen produced by the body during your lifetime
• Low body mass index
• Heredity [one or more relatives (mother, aunt or sister)] with endometriosis
• Any medical condition that prevents blood from passing through the body during menstruation
• Disorders of the reproductive tract

Endometriosis usually develops several years after the onset of menstruation. The signs and symptoms of endometriosis may improve temporarily with pregnancy and may go away completely with menopause, unless you are taking oestrogen.

How is endometriosis diagnosed?

Diagnosis of endometriosis can be difficult, as its symptoms may mimic other gynaecological conditions. However, there are several methods used to diagnose endometriosis, such as:

Medical history and physical examination: The gynecologist will ask about the patient's medical history and symptoms and will perform a pelvic examination to check for signs of endometriosis, such as sensitive nodules in the pelvic area.

Imaging: Imaging tests, such as ultrasound or MRI, can help visualise the reproductive organs and detect any abnormal lumps, cysts or lesions that may be indicative of endometriosis.

Laparoscopy: This is a surgical procedure in which a small camera is inserted through a small incision in the abdomen to visualise the pelvic organs and detect any focus endometriosis.

Biopsy: A biopsy involves removing a small piece of tissue and examining it under a microscope for evidence of endometriosis. It is important to note that the only definitive way to diagnose endometriosis is through laparoscopy and biopsy. However, imaging tests and physical examination can provide valuable information that may indicate the presence of endometriosis. Women should discuss their symptoms and concerns with their gynecologist to determine the best individualized diagnostic approach.

How is endometriosis treated?

Endometriosis can be treated in different ways depending on the severity of the symptoms and the extent of the disease. Some common treatments include:

→ Painkillers: Non-prescription analgesics such as ibuprofen or naproxen can help manage the pain associated with endometriosis.

→ Hormonal therapy: Hormonal treatments such as birth control pills, progestin-only therapy or gonadotropin-releasing hormone (GnRH) agonists can help manage pain and slow the growth of endometrial tissue.

→ Surgical treatments: Open, laparoscopic and robotic surgery is often used to remove endometrial tissue and can provide pain relief and improve fertility in some cases. In severe cases, a hysterectomy (removal of the uterus) may be needed.

→ Assisted reproductive technologies: In cases where endometriosis affects fertility, in vitro fertilisation (IVF) or other assisted reproductive technologies may be recommended. It is important to discuss treatment options with your doctor who can help you plan the right treatment approach for you.

Cancer and endometriosis

Ovarian cancer occurs at higher than expected rates in people with endometriosis. But the overall lifetime risk of ovarian cancer is low. Some studies show that endometriosis increases this risk, but it is still relatively low. Although rare, another type of cancer - adenocarcinoma associated with endometriosis - can develop later in life in those who have had endometriosis.