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Introduction

Endometriosis is a confusing disease which may affect as many as one in ten women during their childbearing years. It is especially common in women who have difficulty achieving pregnancy, and in women who experience pelvic pain.

What is endometriosis?

It is a condition in which endometrial cells, which normally line the inside of the uterine cavity (womb), grow outside of the uterus. It usually presents as small spots or clusters in the pelvis – typically on the ovaries, fallopian tubes, bladder, pelvic side walls and rectum. Endometriosis can also cause cysts on the ovaries. These cysts contain some dark brown fluid – and are sometimes called chocolate cysts. In rare circumstances endometriosis may be found in other parts of the body such as the lungs, liver and kidneys. For the most part it is a benign disease that does not lead to cancer.

How does it occur?

There are a number of theories which have been suggested to explain how endometriosis occurs. One of the most common is that during menstruation there is backflow of blood and cells through the fallopian tubes into the pelvis. The theory is then that some of these cells, which are still viable, grow inside the pelvis. As these deposits grow, they respond to the hormones produced by the ovaries, and release chemicals which cause local inflammation and pain. It has also been suggested that it is a faulty immune system which allows these endometrial cells to grow where they should not be growing. It has also been suggested that the disease may start before birth when a baby girl is developing in the womb. Endometrial cells from the uterus may stray out of the womb into the pelvis – and lie quietly there until the teenage years when the ovaries start producing estrogen – which may stimulate them to grow and cause inflammatory changes in the pelvis. Another theory is that endometrial cells may travel in the bloodstream, and deposit themselves in vulnerable areas.

What are the symptoms?

Although there may be no symptoms at all, common symptoms include the following:

  1. Painful periods – dysmenorrhoea.
  2. Heavy periods – menorrhagia.
  3. Painful sexual intercourse – dyspareunia.
  4. Painful ovulation – mid-cycle pain.
  5. Infertility.
  6. Recurrent pregnancy losses.
  7. Chronic pelvic pain.
  8. Pain with bowel movements.
  9. Pain when voiding urine.
  10. Rarely – coughing up blood during menstruation.
  11. Chronic fatigue, low energy levels, mood swings, premenstrual tension, backache and depression. 

How can endometriosis affect your life?

Like any chronic illness, women may find it difficult to live with endometriosis. It may not only affect them, but their partners, children, friends and family. Family life and careers may suffer. Relationships are particularly vulnerable, because in many cases women find sexual intercourse painful and unrewarding – and therefore prefer to avoid it. The pain associated with menstruation can cause significant mood disturbances.

How is the condition diagnosed?

The symptoms described above should alert you and your physician that you may have endometriosis. Sometimes on clinical examination, a nodularity can be felt behind the uterus during a vaginal examination. This is very typical of endometriosis. Ultrasound may sometimes be helpful – particularly if there are cysts on the ovaries.

There is a blood test called CA-125 which can also be used as a marker for both endometriosis and ovarian cancer. The most definitive test for evaluating the pelvis and diagnosing endometriosis is a procedure called a laparoscopy. This involves a general anesthetic, and passing a small telescope through the bellybutton into the pelvic cavity.

What treatment is available?

There are a number of different options which are available. These may be either medical or surgical:

  1. Complementary approaches – this includes regular exercise, meditation, vitamin supplements, acupuncture and diet.
  2. Surgery – this may be either conservative or radical. Conservative surgery is normally done laparoscopically – and involves either cutting out or burning the endometriosis which is visible. Aggressive surgery would involve a hysterectomy with or without removing the ovaries.
  3. Non-hormonal therapies. The most commonly used medications in this group include non-steroidal anti-inflammatory drugs such as Ponstan, Advil, Anaprox and aspirin, which are used to control the pain associated with menstruation.
  4. Hormonal medications. These are the most commonly prescribed treatments for endometriosis. They are usually prescribed for periods between six months and two years. Common prescriptions include the following:
  1. GNRH analogues. These are medications which are given by monthly injections. They shut down the ovaries and thereby reduce the levels of estrogen. Endometriosis is dependent on estrogen. This has the effect of starving the endometriosis tissue. Menopausal symptoms such as hot flashes, moodiness, sleep disturbances, vaginal dryness and bone pain are fairly common.
  2. The birth control pill may be used in a variety of ways. It is most effective if taken continuously (no 7-day break every month) to stop menstrual cycles completely. This will help the endometriosis from bleeding and becoming inflamed.
  3. Danazol. This is a male hormone that is often prescribed for endometriosis. It is very effective in shrinking endometriosis and improving pain. However, it does have significant male hormone-like side effects – particularly weight gain, greasy skin, hair growth and occasionally may lower the voice an octave.
  4. Progesterone. This can either be given by injection in the form of Depo Provera or orally on a daily basis. Like all medications it can have some side effects. More common side effects include mood disturbances, occasional weight gain and greasy skin.

Summary:

It is important that you have a good relationship with your physician – in order that you understand the disease, the extent of it, and the different options for treatment.