Once a woman begins to experience painful menstruation, it points to some conditions, one of which is Endometriosis; this is often experienced by mostwomen.The pain is often mistaken for that of the menstrual cycle. Some women generally experience pain alone during their period but I will be talking about painful menstruation withassociated symptoms as it relates to Endometriosis for the purpose of awareness and not for self medication or treament.
Some Women sometimesexperience pains around the lower abdomen during the menstrual cycle, this is due to the contraction of the womb (Uterus) during her menstrual periodin order to expel the clot of blood in the womb. Some women do not feel this pain.
The pain associated with Endometriosis can be felt at different parts of the body depending on where the endometrial tissue is located.The endometrial pain could arise from theabdomen, or theback (back pain), or right side ofabdomen like thepains associated withAppendicitis.
A pain which seems to have acyclicalpattern and located at abdomen, back, or right lower part of the abdomen and which does not subside even after takingpain relievers (analgesics) likeIbuprofen, Aspirin or panadol is likely cause byEndometriosis.
What is Endometriosis?
It is a medical condition in which the tissues of the womb (Uterus) are found in other parts of the body likethe ovary, the human appendix, the abdomen, umbilicus(navel), lungs (organs for breathing), or rectum (internal part of the anus).The womb (uterus) is affected by differentfemale hormones likeestrogen and progesterone; these hormones regulate themenstrual cycle. Therefore,any tissueof the uterusthat becomesdeposited in another part of the body outside of the body will also be affectedby these 2 hormones. Therefore, whenever the abnormal endometrial tissue outside of the womb start shedding as a result of alteration by the female hormones,pain is often experienced and this pain is cyclical because the hormones bring about the cyclical pattern of menstruation.
Endometriosis is very common among Women but only a few know of it
Itis a very common disease affecting women. In every100 women, about 7 to 10 would have endometriosis but few women know of it and only a few come to the hospital.The age rangeof women mostly affected bythis disease is from 34 to44 years (that is, women in their 3rd and 4th decades of life), though it can still affect women atany ageof reproduction.
Causes of Endometriosis
The cause of endometriosis is Unknown but some doctors have made theory on how they think endometriosis comes about. THe theories include:
- The flow of Menstrual bleeding is fromwomb towards the outside via the vagina; this however is not the case with some women,rather, theirsflowbackwards into the fallopian tube and some uterine tissues may become deposited at the ovary.
- In women with strong immune system,whenever abnormal tissues are deposited in some partsof the body, theimmune cells will “eat up”the abnormal cells. But this is not the case with women that their immune cells are low, hence, this disease is found commonly (but not always) in those with immune suppression. This is just a scientific postulate, it is not yet an establish theory and does not hold true for all women with endometriosis.
Although the cause of Endometriosis is not yet known, a woman might likely have the diseasedue to the followingrisk factors:
- Female gender:Since it occurs more in women,it means women are more at risk. The only time that a man could have endometriosis is when he is on treatementfor prostate cancer and keeps taking oestrogen.
- Positive Family history of Endometriosis: if awoman’s relatives have the disease, then there is a chance that she could come down with it too. Please note that the disease is not transmissible, but what this means is that their genetic make up are likely predispose to having this medical condition. The closer the relative is to the woman, the more she is at risk (that is, she is more at risk if a sibling has than when a cousin or aunt has).The Oxford Endometriosis Gene Study (OXEGENE) has confirmed familial continuity in the onset of symptoms.
- narrowing of the cervix or menstrual outflow tract: Whenever there is an obstruction to flowduring menstruation, there will be a back flow of blood clot.This leads to animmune response that causes inflammation and pains. Hence women having narrow cervicalopening will likely suffer more from Endometriosis.
- Concentration ofOestrogen in the body:High oestrogen levels have been found to aid the development of endometriosis. This is why drugs used for treatment of endometriosis alwaysinhibit the production of oestrogen and it is also the reason why girls that have not reach puberty are not found with this condition but rather it is only found in women of child bearing age.
- A woman is at risk if her mum had usedDiethylstilboestrol (DES),a drug earlier used for the prevention of miscarriage.
Signs and symptoms of Endometriosis
The signs and symptoms dependon the location of the abnormal endometrial tissue, however, it is good you know that the severity of the symptoms does not always correlate with that ofthe disease. You could have less severe symptoms such as mild pains but yet you may have the severe form of the disease. Knowing the severity of this disease is by a process known aslaparoscopy, which is the visual observation of the deposits by using an instrument calledlaparoscope.
Symptoms and Signs of Endometriosis according to the body systems affected:
- Reproductive tract symptoms:
– painful menstruation, typically involving abdominal cramps (called dysmenorrhea) and which does not reduce even with pain relieverssuch as non-steroidal anti-inflammatory drugs (NSAIDs) e.g Ibuprofen which is commonly used by women.
– lower abdominal pains or pelvic pains that occur in a cyclical pattern.
– severe pains during sexual intercourse that may cause problems in marriage.
-menorrhagia: an abnormal heavy bleeding during menstruation making the woman to use more sanitary pads.
– irregularity in menstrual cycle: women with this could menstruate today and still menstruate after 2 weeks or may take longer. The periods are not just regular. Though some women have irregular periods which are still normal, there areirregularities that point to abnormality. If you are in doubt, just see your physician.
– Infertility: this is a serioussign that determines howsevere the condition is. Most times, the woman maynoteven know that the infertility could be as a result of the endometriosis.
- Urinary tract symptoms of endometriosis include:
-painful urination, sometimes withblood in urine;
– pains in the loins (from the waist to the lower ribs).
- Gastrointestinal tract symptoms associated with endometriosis: this could affect the rectum causing difficulty and pains while passing stool(known medically asdyschezia) or it could cause bleeding around the anus. This bleeding is also cyclical.
- Respiratory symptoms:Difficulty in breathing and coughing of blood are the symptoms due to the deposition of abnormal endometrial tissue in the lungs.
- cyclical pains or bluish discoloration of the umbilicus is another symptom/sign too.
Due to the pains that the woman may be experiencing, she may also have problemsin sleeping (insomnia).
With all the symptoms mentioned above, there are some women that may never show any sign but still have this disease and are only diagnose accidentally when they come for something different in the hospital, this group of women are knownasAsymptomatic (without symptoms) patients.
These symptomsmay occur in organs that the abnormal endometrial tissue had been deposited in, and a woman must not have all the symptoms before she isdiagnosed ofit. The abnormal tissue could be deposited in any of the organs mentioned above.
In order for the doctor to know what condition you have, he/she needs to ask some questions and subsequently do an examination and also perform a laboratory test to confirm the diagnosis. For the diagnosis of this disease, the doctor will ask you questions and afterwards order for a laboratory investigation. The process of trying to know what is wrong with you is called History taking. That is, the doctor is taking the history of the disease. Likely questions may be:
- If you complain of pains, further questions would be for how long, the nature of the pain, what do you do to relieve the pains? is the pain cyclical? does it affect your day to day activities?
- There would be more questions depending on the organ affected. So if you complaint of problem with breathing, the next question would be if there is a cough, if there is, then is it dry or produces mucus? is there associated blood in the cough? for how long has the cough been?
In order to understand what you present with, you have to answer the questions correctly.
The diagnosis of endometriosiscannot be made by taking the history, alaboratory investiagtionmust be conducted to confirm the diagnosis. This laboratory investigation is called Laparoscopy. It is a test in which a thin tube containinglight at the end,is used to viewthe internal organs by making a small incision(cut) on the abdomen. The abdominaland pelvic cavity areviewed and if any abnormal structure is found (scars, fluids, cysts, tissues, clots etc), a small piece of the tissue is cut (biopsy) and sentto the histopathology laboratory for further investigation where it is viewed with a microscope to see if the cells are of endometrial origin.
Other diseases could mimic the condition, hence the laparoscopy and biopsy is essential to differentiate this disease from others such as:
- Pelvic inflammatory disease due toinfections by various organismsmay mimick the symptoms ofendometriosis.
- Adenomyosis is another condition that is similar to endometriosis; This is explained below.
- Cancer of the ovary have some symptoms similar to endometriosis
- Cancer of the colon or rectum (anal area) could also present as endometriosis
- Ectopic pregnancy (pregnancy that is not located in the right part of the womb) may also show similar signs and symptoms like endometriosis.
Treatment of Endometriosis
The earlier the disease is treated, the better the outcome! Creating awareness on endometriosis is vital to preventcomplications and to live a quality life. While treating this, there could be some temporary and permanent changes that the woman may experience due to side effects of the drugs butyour wishes are well respected and couples should discuss together before treatment is started especially for women who might still want to conceive again.
The purposeoftreatment is to help ensure that the pain is reduced, sexual intercourse ceases to be painful, stopabnormal bleeding and to possibly be able to give birthagain. Hence, there should be mutual agreement from the couple first and the complications of treatment (or side effects of drugs) wouldalways be discussed by the doctorbefore treatment.
The treatment could be bydrugs orsurgery.
- Treatment of endometriosis with drugs: As mentioned at the beginning, oestrogen is the stimulant for the growth of endometrial tissue. Inhibition of oestrogen production is actually the basis for alltreatment using drug. However, the use of drugs to inhibit oestrogencomes with some unwanted side effects as oestrogen is important in the woman’s body especially in regulating menstrual cycles.
– UsingCombined Oral Contraceptive Pills(COCPs): these are used for the mild form of the disease.Side effects include weight gain, severe bleeding from the vagina may occur, migraine headaches are often experienced, and there could be mood changes. The pills are taken tricyclically which means three packets to be used continuously followed by 1 week break.
–Use ofProgestogenssuch asMedroxyprogesterone, duphaston and depo-provera:these drugs makethe endometrial tissues to shrink.Theyare taken daily for 90 days followed by one week break. Adverseeffects of taking thesedrugs include bloating (fullness of stomach with gas), breast pains(pains on touch) and also weight gain.
– Danazol:it is a drug that stops a woman from ovulating and therefore starves the endometrial tissue. Thedrug has adverse effects that make the woman have some features of a man due to the fact that the drug was madefrom the male hormone,Testosterone.
The adverse effects of using Danazol include: deepening of the woman’s voice that may remain permanent, increased hair growth and mood changes. The dosage normally taken is usually 600 mg to 800 mg per day for six months.
– use ofGestrinone(ethylnorgestrienone):this is a steroid and long term use may causeimmune suppression and it also has the side effects that are similar to danazol mentioned above with additional effects such as growth of hair on the face in women (hirsutism), change of appetite, excess oil on skin and acne.
The drug is given at a dose of 2.5 mg twice weekly starting on day one(the first day your menses starts) of menstrual cycle.
– Use ofGonadotrophin releasing hormone (GnRH)analogues:This group of drugs ismore reliable and more efficient but the adverseeffects include: hot flashes in your body, vaginal dryness may be experienced, loss of sexual drive, tenderness of breasts, sleeplessness (Insomnia), depression, decrease in skin elasticity, and softening of bones (osteoporosis) that could easily break.
Examples of the Drugs in this group include:
:-Leuprolide acetate,thisis administered at adosage of 3.75 mg as a depot together with another drug called Goserelinthat is given as injectionat a dose of3.6 mg every month for a minimum of 6 months and longer in exceptional cases.
:-Nafarelinnasal spray can also be used at a dose of200 or 400 mg twice daily.- Use ofNon-steroidal anti-inflammatory drugs(NSAIDs) such as diclofenac, ibuprofen and mefenamic acid (prostaglandin synthetase inhibitor) may only reduce the pain but will not cure the disease. The pains would be felt after the drug wears out.
- Surgical treatment: this is most appropriate for severe forms of the disease. It involves removal of the woman’s uterus. This should only be done if and only if the woman agrees.
- Combination of surgery and drugs may be required to treat in some cases.
- Irradiation:menopause could beinduced by irradiation to enable the starvation of the abnormalendometrial tissues.
- Psychotherapy:Counselling could be done to help the woman cope till menopause.
Complications of Endometriosis
When left without treatment, complications may arise.The most common being:
- Infertility: endometriosisis theleading cause of infertility among women and about 40 out of 100 women having endometriosis may not be able to conceive. The infertility could be treated by use of assisted reproduction techniques. Another way is by surgery if and only if there is a blockage of thereproductive tract which prevents the movement of the spermatozoatowards the ovum. Drugs could also be used to suppress immune response if it is caused by immune attack.
- long term (chronic) pelvic pain: without treatment, awoman continues to suffer from the pains that mayreducethe quality of lifestyle and preventher from doing her day to day activities.
- Pelvic adhesions:the inflammation associated with the condition makes healing to occur by forming fibrose tissue (scar) which binds together one organ toanother onecausing adhesions, depending on the organs that have been adhered together.
Causes and treatment of Adenomyosis
Adenomyosis is another form ofEndometriosis, but this is due to the presence of endometrial tissue within the muscular layer of a woman’s uterus(womb), this muscular layer is called theMyometrium in medicine.The causes and risk factors are entirely different from endometriosis and thetreatmentis also different even though both have similar symptoms.
Risk factors of Adenomyosis
- Repeated pregnancies always predispose a woman to having adenomyosis
- Extreme curettage bywhich the endometrial layer of the womb is scraped off, also predisposes a woman to adenomyosis.
Symptoms and signs of Adenomyosis
- Heavy menstrual bleeding (menorrhagia): the flow becomes increased.
- Painful menstruation that is progressive, which means that the pain increases with age.
- Painful sexual intercourse : this may also be a sign of cervical cancer.
- The womb becomes enlarged, smooth and symmetrical
Treatment of Adenomyosis
Adenomyosis currently does not have effective drugsfor treatment but the use of some drugs that are usedinendometriosis could relief the pain temporarily. However, surgery is the only treatment for now but it involves the removal of the womb (hysterectomy) which means the woman cannot give birth again, hence this should be done on a woman that has completed her family size. It is good the woman shoulddiscuss this with her partner first.
Endometriosis and Adenomyosis areserious diseases that affectwomen which when treated promptly, the complications can be reduced.