21 - endometriosis

Endometriosis introduction :

Endometriosis is a condition where tissue similar to the lining of the uterus (the endometrial stroma and glands, which should only be located inside the uterus) is found elsewhere in the body.
Endometriosis lesions can be found anywhere in the pelvic cavity: on the ovaries, the fallopian tubes, and on the pelvic sidewall. Other common sites include the uterosacral ligaments, the cul-de-sac, the Pouch of Douglas, and in the rectal-vaginal septum.
In addition, it can be found in caecarian-section scars, laparoscopy or laparotomy scars, and on the bladder, bowel, intestines, colon, appendix, and rectum.
In rare cases, endometriosis has been found inside the vagina, inside the bladder, on the skin, even in the lung, spine, and brain.
The most common symptom of endometriosis is pelvic pain. The pain often correlates to the menstrual cycle, but a woman with endometriosis may also experience pain that doesn’t correlate to her cycle. For many women, the pain of endometriosis is so severe and debilitating that it impacts their lives in significant ways.
Endometriosis can also cause scar tissue and adhesions to develop that can distort a woman’s internal anatomy. In advanced stages, internal organs may fuse together, causing a condition known as a "frozen pelvis."
It is estimated that 30-40% of women with endometriosis are infertile.
If you or someone you care about has endometriosis, it is important to research the disease as much as possible. Many myths and misconceptions about endometriosis still persist, even in medical literature. For many women, management of this disease may be a long-term process. Therefore, it is important to educate yourself, take the time to find a good doctor, and consider joining a local support group.

Symptoms of endometriosis :
The most common symptom of endometriosis is pelvic pain. The pain often correlates to the menstrual cycle, however a woman with endometriosis may also experience pain at other times during her monthly cycle.
For many women, but not everyone, the pain of endometriosis can unfortunately be so severe and debilitating that it impacts on her life significant ways.
Pain may be felt:
before/during/after menstruation
during ovulation
in the bowel during menstruation
when passing urine
during or after sexual intercourse
in the lower back region
Other symptoms may include:
diarrhoea or constipation (in particular in connection with menstruation)
abdominal bloating (again, in connection with menstruation)
heavy or irregular bleeding
fatigue
The other well known symptom associated with endometriosis is infertility. It is estimated that 30-40% of women with endometriosis are subfertile.
When a woman or a girl has decided that she wishes to discuss her symptoms with a physician, she may benefit from preparing for this consultation by using the aid, your first consultation, which highlights the questions a doctor may ask her. By assessing the responses, it will help her physician to evaluate her symptoms, and together they can decide the right treatment plan for her.


What causes endometriosis?
Several different hypotheses have been put forward as to what causes endometriosis. Unfortunately, none of these theories have ever been entirely proven, nor do they fully explain all the mechanisms associated with the development of the disease. Thus, the cause of endometriosis remains unknown.
Most researchers, however, agree that endometriosis is exacerbated by oestrogen. Subsequently, most of the current treatments for endometriosis attempt to temper oestrogen production in a woman's body in order to relieve her of symptoms. At the moment there are no treatments, which fully cure endometriosis.
Several theories have become more accepted, and reality is that it may be a combination of factors, which make some women develop endometriosis.
Metaplasia

Metaplasia means to change from one normal type of tissue to another normal type of tissue. It has been proposed by some that endometrial tissue has the ability in some cases to replace other types of tissues outside the uterus.
Some researchers believe this happens in the embryo, when the uterus is first forming. Others believe that some adult cells retain the ability they had in the embryonic stage to transform into reproductive tissue.
Retrograde menstruation


This theory was promoted by Dr. John Sampson in the 1920s. He surmised that menstrual tissue flows backwards through the fallopian tubes (called “retrograde flow”) and deposits on the pelvic organs where it seeds and grows. However, there is little evidence that endometrial cells can actually attach to women’s pelvic organs and grow. Years later, researchers found that 90% of women have retrograde flow. But since most women don’t develop endometriosis, some doctors have concluded that something else (perhaps an immune system problem or hormonal dysfunction) may be the trigger for endometriosis. The Retrograde Menstruation Theory also doesn’t explain how endometriosis develops in women who’ve had a hysterectomy or a tubal ligation nor why, in rare cases, men have developed endometriosis when they’ve been treated with oestrogen after prostate surgery.

Genetic predisposition

Studies have shown that first-degree relatives of women with this disease are more likely to develop endometriosis. And when there is a hereditary link, the disease tends to be worse in the next generation.
An ongoing worldwide study called the International Endogene study is conducting research based on the blood samples from sisters with endometriosis in hopes of isolating an endometriosis gene.
DEC 2006Significant evidence of one or more susceptibility loci for endometriosis with near-Mendelian inheritance on chromosome 7p13-15
OCT 2005Researchers identify one gene's critical role in the human embryo implantation process
AUG 2005First report of linkage to a major locus for endometriosis

Lymphatic or vascular distribution

Endometrial fragments may travel through blood vessels or the lymphatic system to other parts of the body. This may explain how endometriosis ends up in distant sites, such as the lung, brain, skin, or eye.
Immune system dysfunctions

Some women with endometriosis appear to display certain immunologic defects or dysfunctions. Whether this is a cause or effect of the disease remains unknown.
Environmental influences

Some studies have pointed to environmental factors as contributors to the development of endometriosis, specifically related to the way toxins in the environment have an effect on the reproductive hormones and immune system response, though this theory has not been proven and remains controversial.

Diagnosing endometriosis
There is no simple test that can be used to diagnose endometriosis. In fact, the only reliable way to definitively diagnose endometriosis is by performing a laparoscopy and to take a biopsy of the tissue. This is what is known as "the golden standard".
However, this is an expensive, invasive proceduce. Furthermore, if the surgeon is not a specialist in endometriosis s/he may not recognise the disease, which can result in a "negative" diagnosis.
In addition, the woman/girl may not want to have surgery.
This makes diagnosis a challenge, and therefore an experienced gynaecologist should be able to recognise symptoms suggestive of endometriosis through talking with the woman/girl and obtain a history of her symptoms. For this to be effective, it is important that the woman/girl is honest with her physician about all of her symptoms and the pattern of these.
To aid her in preparation for this consultation she can consult the questionnaire, your first consultation, which will help her in preparing for the questions her doctor may ask her - and, in turn, help him/her in determining whether her symptoms may be due to endometriosis (not all pelvic pain, nor fertility issues, are caused by endometriosis).
There are other tests, which the gynaecologist may perform. These include ultrasound, MRI scans, and gynaecological examinations. None of these can definitively confirm endometriosis (though they can be suggestive of the disease), nor can they definitively dismiss the presence of endometriotic lesions/cysts.
The fact that there is no non-invasive, definitive diagnostic method for endometriosis is as frustrating for clinicians as it is for women with the disease.

Treatments for endometriosis
Since the cause of endometriosis remains unknown, a treatment which fully cures endometriosis has yet to be developed, and there is no overwhelming medical evidence to support one specific type of endometriosis treatment over another.
Chosing a treatment therefore comes down to the individual woman's needs, depending on her symptoms, her age, and her fertility wishes. She should discuss these with her physician so that they, together, can determine, which long term, holistic, treatment plan is best for her individual needs. For many women, this can be a combination of more than one treatment over longer periods of time.
Pain killers
Pain is the most common symptom for many women with endometriosis.
Pain killers vary from simple analgesics (such as aspirin and paracetamol), through compound analgesics (which are a combination of either aspirin or paracetamol and a mild narcotic such as codeine) and narcotic analgesics (similar to morphine), through to non-steroidal anti-inflammatory drugs (such as nurofen, ponstan, voltaren, etc).
More about painkillers

Hormonal treatments
Most researchers agree that endometriosis is exacerbated by oestrogen. Subsequently, hormonal treatments for endometriosis attempt to temper oestrogen production in a woman's body and thereby relieve her of symptoms.
Hormonal therapy may include birth control pills, progestins, a class of drugs known as GnRH-agonists, and danazol (though this is seldom used any more).
The combined oral contraceptive pill
Progestins
Mirena
GnRH-agonists
Danazol
Aromatase inhibitors [still somewhat experimental]
Hormonal therapies have varying degrees of side effects, and unfortunately, whatever pain relief that is achieved tends to be only temporary for many girls and women.
TIPS for dealing with side effects associated with drug treatments


Surgery
Most doctors agree that laparoscopic surgery is the only definitive way to diagnose endometriosis. In many cases, the disease can be diagnosed and treated in the same procedure.
The success of surgery depends greatly on the skill of the surgeon and the thoroughness of the surgery. The aim is to remove all endometriosis lesions, cysts, and adhesions.
Today, most endometriosis surgery is being done through the laparoscope, although a full abdominal incision called a laparotomy may still be required in rare cases for extensive disease or bowel resections.
More about laparoscopic surgery
Although women with endometriosis are often told that hysterectomy is the “definitive” solution for endometriosis, the disease can recur even after a hysterectomy.
More about hysterectomy


Nutritional therapy
The correct balance of daily nutrients are essential for all of us. Proper nutrition helps improve our general health.
For a woman with endometriosis it may also increase her ability to tolerate medical treatments, increase her ability to deal with potential side effects of treatment, increase her energy, and enhance her ability to think clearly. Nutritionists can work with women and girls with endometriosis to put together an appropriate dietary plan.
More about dietary modification to alleviate endometriosis symptoms



Complementary therapies
Given the chronic and stubborn nature of endometriosis, there may be times when it is beneficial to explore therapies beyond the medical mainstream. Whilst there is no clinical evidence as to the effectiveness of these therapies, many women with endometriosis have had good symptom relief by using homeopathy, osteopathy, herbs, and Traditional Chinese Medicine.
Physiotherapists (physical therapists) can develop a programme of exercise and relaxation techniques designed to help strengthen pelvic floor muscles, reduce pain, and manage stress and anxiety. After surgery, rehabilitation in the form of gentle exercises, yoga, or Pilates can help the body get back into shape by strengthening compromised abdominal and back muscles.

A multi-disciplinary approach
To provide holistic treatment to women and girls with endometriosis, a team of medical professionals may be involved in providing care, including: - general practitioners- gynaecologists- surgeons (from a number of disciplines)- reproductive endocrinologists- immunologists- nutritionists/dieticians- nurses- psychologists- counsellors- pain specialists- physiotherapists
All of these disciplines can play an important role in providing an individualised treatment plan for a woman or girl with endometriosis.
Finally, please remember that endometriosis affects more than just the physical body. It often affects women and girls in profound emotional ways as well. Psychologists and counsellors can play an important role by helping women and girls cope with the feelings of confusion, disbelief, chronic pain, infertility, and frustration that often accompany this disease.
Support groups also play a vital role in learning to cope with endometriosis and may be able to provide information about national or regional centres, who specialise in the treatment of endometriosis.