Endometriosis is a condition in which cells similar to those lining the womb are found outside the womb in the pelvis. It is found in around 6% of women. The endometriotic deposits respond to a woman’s hormones causing inflammation and scarring in the pelvis.
Symptoms of endometriosis can be very variable. The commonest symptom of endometriosis is pelvic pain. Typically the pain starts before menstruation and stops some days after the period begins. However pain can occur at other times of the menstrual cycle and can become constant. Pains may be worse during sexual intercourse or with a full bladder or bowel.
Endometriosis can cause infertility; 30-40 % of women with the condition find it hard to get pregnant. What investigations might be required?
An internal examination can often detect signs of endometriosis. An ultrasound scan can detect ovarian endometriotic cysts, but will not be able to detect the typical small deposits in the pelvis. The best technique for diagnosis is a laparoscopy (a keyhole examination of the pelvis).
Treatment options vary between the conservative, medical and surgical options.
Conservative treatments consist of pain relief and chronic pain management strategies. Many women find treatments such as aromatherapy and acupuncture very useful.
Medical treatments all aim to suppress the menstrual cycle and stop ovulation. Therefore, while they are useful in the treatment of pelvic pain, medical options have no place in the management of the infertile patient with endometriosis. The common medical therapies consist of the combined oral contraceptive pill (COCP), progestogens or Gonadotrophin-releasing hormone antagonists. There are a numbers of newer drugs that look promising which are still being assessed. Most of the different drugs have similar success rates with the choice of treatment largely being governed by the side-effects of the hormones. There is a relatively high recurrence rate of symptoms after treatment is stopped.
Surgery is usually performed laparoscopically. The aim of treatment is to remove all endometriotic deposits either by cutting them out or by ablating them with diathermy or laser. Surgical treatment doubles a woman’s fertility and removes pain in 75-80% of cases, although the disease can recur in 20% of women 5 years after the operation. In severe cases, a woman may need a hysterectomy or possibly bowel surgery. The infertile woman with advanced endometriosis may need IVF to become pregnant.