Endometriosis is a condition that affects a woman’s reproductive health. According to the KK Women’s and Children’s Hospital’s website, it is a common condition that affects about 10% of women and that as many as 30% of women who complain of severe menstrual pain are found to be suffering from endometriosis. So what exactly is it?
What Is Endometriosis?
“Endometriosis is a condition that usually affects a woman’s reproductive organs,” says Dr. Fong Yang, Fertility Specialist, Gynaecologist & Obstetrician at Virtus Fertility Centre. “The name, endometriosis, comes from the type of cells that line the uterus or endometrium. When these cells grow in places outside the uterus (on and around the pelvic and abdominal organs) this is known as endometriosis.”
In essence, the endometrium, which is the womb lining responsible for menstruation, somehow ends up outside of it, most commonly in the ovaries, the fallopian tubes and the pelvis. “When a woman has her period, the blood flows out of the vagina, but also backwards along the fallopian tubes into the pelvis,” explains Dr Fong. “In most women, the back-flow of blood, which will contain endometrial tissue, just gets absorbed or broken down and causes no symptoms. However, in women with endometriosis, this endometrial tissue starts to grow.”
A Tricky Condition
Endometriosis is, however, a rather difficult condition to diagnose and is often under diagnosed, because of its tricky symptoms or the lack of any. “Symptoms of endometriosis vary from woman to woman and include painful periods, pain during intercourse and premenstrual spotting,” Dr Fong shares. “Pain is a key symptom of endometriosis and is not related to how severe the disease is, but to the location of endometrial tissue. When the endometriosis is mild, the pain symptoms may be more common for the first couple of days of a period but as it progresses the symptoms may last longer during the month.”
“Some women may not have any symptoms at all, and only discover they have endometriosis when they are having some exploratory surgery for another reason or they have not been able to become pregnant. If you experience these symptoms and are also having trouble conceiving naturally, you should see a doctor.” The condition is also tricky as there is no known cause.
“Endometriosis affects women in their reproductive years,” says Dr Seng Shay Way, Specialist in Obstetrics & Gynaecology & Consultant at Raffles Fertility Centre and Raffles Women’s Centre. “The exact prevalence of endometriosis is now unknown, since many women may have the condition and have no symptoms. “While most cases of endometriosis are diagnosed in women aged between 25 to 35 years, endometriosis has been reported in girls as young as eleven years of age. Endometriosis is rare in postmenopausal women.”
While there’s no specific cause of endometriosis, there are some women who have a higher chance of suffering from it. According to Dr Fong, “Women whose mother or sister have endometriosis are 7 to 10 times more likely to also suffer from endometriosis.” It is also more common in women over thirty who have not yet had children.
Getting A Diagnosis
There are several ways of diagnosing endometriosis, with the most reliable way being laparoscopic surgery. “Endometriosis can be suspected based on symptoms of pelvic pain and findings during physical examinations in the doctor’s office,” says Dr Seng. “Occasionally, during a rectovaginal exam (one finger in the vagina and one finger in the rectum), the doctor can feel nodules (endometrial implants) behind the uterus and along the ligaments that attach to the pelvic wall. At other times, no nodules are felt, but the examination itself causes unusual pain or discomfort.”
Unfortunately, neither the symptoms nor the physical examinations can be relied upon to conclusively establish the diagnosis of endometriosis. Imaging studies, such as ultrasound, can be helpful in ruling out other pelvic diseases and may suggest the presence of endometriosis in the vaginal and bladder areas, but still cannot definitively diagnose endometriosis. “For an accurate diagnosis, a direct visual inspection of the pelvis and abdomen, as well as tissue biopsy of the implants, are necessary. As a result, the only accurate way of diagnosing endometriosis is at the time of surgery.”
Once the condition is diagnosed, it is also then possible to conclude its extent. “A number of different classification systems have been developed for staging endometriosis,” says Dr Seng. “Although the stage of endometriosis does not relate to the severity of clinical symptoms, it may be useful in predicting a woman’s chances of fertility. “Typically, endometriosis is classified as minimal, mild, moderate or severe, based upon visual observations at the time of surgery.”
Unfortunately, endometriosis is also a common cause of infertility, especially in a severe form.
“Severe endometriosis can distort the tubes and ovaries and cause the body to resist foreign material – such as sperm,” Dr Fong explains. “Endometriosis may also block the egg’s release by producing mucus or in fact prevent the sperm reaching an egg. The endometrial cells may release chemicals that interfere with sperm-egg fertilisation, affect the development of the embryo in its early stage or affect the attachment of the embryo to the womb.”
But all is not lost, as it is still possible for women with endometriosis to have children.
“Endometriosis is more common in infertile, compared to fertile, women,” says Dr Seng. “However, the condition usually does not fully prevent conception. Most women with endometriosis will still be able to conceive, especially those with mild to moderate endometriosis. It is estimated that up to seventy percent of women with mild and moderate endometriosis will conceive within three years without any specific treatment.”
“Treatment options for infertility associated with endometriosis are varied, but most doctors believe that surgical treatments are superior to hormonal or medical treatments for endometriosis when the goal is enhancement of fertility. Assisted reproduction techniques may also be used when appropriate in combination with surgical therapy.” Surgery is certainly the recommended option. “Laparoscopic surgery is a minimally invasive treatment for endometriosis, as well as other gynaecological conditions such as fibroids, uterine or tubal problems,” Dr Fong explains. “The surgeon looks inside the abdominal cavity through a small incision in the navel to confirm endometriosis and can then treat it at the same time.
“In many cases, surgery may be the only treatment required to increase natural fertility. It can also increase the success rate of reproductive treatments such as IVF. Occasionally, medication may be prescribed in addition to surgery to clear the endometriosis thoroughly, especially if fertility is desired. In women who have completed childbearing, medication may help to control pain until menopause sets in.”
The good news is that, if you have endometriosis and do get pregnant, generally speaking, you won’t have any additional problems during pregnancy that can be attributed to the condition. “It is thought that the hormones produced during pregnancy may have a positive effect on the symptoms of endometriosis,” says Dr Seng. “This effect may continue after delivery and while breastfeeding. This is not because the endometriosis has been cured – the symptoms have merely subsided.”
Dr Fong adds, “However, some studies suggest that in ladies with a particular form of endometriosis (adenomyosis) in which the uterus is enlarged due to the accumulation of endometriotic tissue in the womb muscle, there may be a higher risk of miscarriage in the first trimester.”