This article serves primarily to address the poor awareness of women of the reproductive age group of the debilitating condition called endometriosis. It affects roughly 1 in 9 of women between the ages of 14 to 50 years. About 12 million women in America are affected and probably a similarly high percentage in Africa, south of the Sahara. It does not have any predilection for races.
Endometriosis refers to abnormal implantation of the lining of the inside of the womb called endometrium, into organs or tissues outside the uterus. It can be found in any tissue of the abdominal cavity and even remote from the cavity. It is commonly found on the tube, the ovaries, the pelvic peritoneum, the vagina, cervix, vulva, bladder and the bowel. Remotely, it can be sited in the lungs, brain, and skin.
Menstrual pain is the commonest presenting symptom which may progressively get worse over time. The pain may radiate to the back and lower limbs and could be partially relieved by non-steroidal analgesic.
Pain during deep sexual penetration which tends to persist post-coital.
Pain during defecation or urination especially during menstrual flow.
Change in bowel habit, constipation or diarrhoea, nausea and vomiting
Difficulty in falling pregnant
The pathology of endometriosis
This explains the reasons behind endometriosis causing disease and infirmity in affected women. It is not a cancerous condition as some women are made to believe.
Endometriotic tissues, wherever they are found may bleed during the menstrual period in the same way as the lining inside of the uterus does monthly. This results in inflammation and swelling that may cause pressure symptoms and result in pain. The incessant repetitive bleeding can result in abnormal fibrotic healing called adhesions which may jeopardise the normal anatomy of rather free and loose pelvic organs and even blockage of luminal structures like the fallopian tubes.
Nulliparous (never been pregnant)
Prolonged and painful period
Short interval of menstrual cycles (e.g. 26 days or shorter)
A family history of a first-degree relative – mother, auntie, siblings with similar condition
A mechanical blockage of the normal outflow of menstruation
Causes or theories of endometriosis
Retrograde Menstruation: this occurs when menstrual blood that should normally flow out of the uterus flows into the pelvic cavity.
Genetics may play a role in its etiology, and there are efforts now to identify responsible chromosomes using genetic studies.
Endometriosis tends to flare up in the milieu of high oestrogen level
Immune disorders: abnormal immune functions whereby endometrial cells which got transported to an abnormal site and would otherwise have been destroyed by immune cells fail to do so. Other immune conditions like asthma, allergy, lupus, hypothyroidism, are commonly associated with endometriosis. There is equally higher incidence of cancer of the breast and ovary in endometriotic patients.
Cesarean section is a risk factor for endometriosis where endometrial cells could be inadvertently transmitted into another site.
This is a rather difficult concept as the condition is vastly linked to familial or genetic tendencies, it can hardly be prevented. However preventing high level of oestrogen in the body can reduce or ameliorate the symptoms. The following approaches have been noted to reduce the level of oestrogen.
Use of combined oral contraceptive pill or implants
Regular exercise for at least 6 hours per week. It reduces adipose tissues that convert to oestrogen.
Decrease alcohol intake as alcohol is known to increase circulating oestrogen
Avoidance of heavily caffeinated drinks that normally raise oestrogen levels.
History as above can raise the index of suspicion. Clinical pelvic examination of a cyst or scaring (cragginess) in the vagina fornices, and tenderness with the movement of the cervix (cervical excitation) connotes a strong suspicion of endometriosis.
Ultrasound will only pick up ovarian cysts of endometrioma especially during the transvaginal scan. Magnetic resonance imaging (MRI) is used but not advisable in a poor resource setting such as ours in Africa.
Empirical treatment: Hormonal birth control can help lessen pelvic pain during your period. A patient that positively responds to this hormonal treatment can conveniently be said to have endometriosis.
Gonadotropin-releasing hormone (GnRH) agonists that block oestrogen: Should the symptoms get better, a diagnosis can be inferred.
Laparoscopy. Laparoscopic visualisation of the endopelvic cavity is the hallmark of diagnosis of endometriosis. It is a minimally invasive procedure where a camera is passed through the umbilicus to see the structures of the abdominal cavity. Here the surgeon can see the sores or lesions of endometriosis. He can at the same time biopsy it or have it treated at the same setting.
Treatment of endometriosis
There is no cure for endometriosis but there are interventions to alleviate the symptoms and conditions that it may cause.
Combined oral contraceptive: this is for women not desirous of pregnancy. Any of the common pills will do; it may be a continuous cycle pill where you do not have periods for a while or an extended cycle pill where there are few cycles per year.
Progestogen impregnated IUCD reduces circulating oestrogen
Gonadotropin-releasing hormone (GnRH) agonist. This inhibits ovulation and endometriosis.
This in a modern setting, could be conservative minimally invasive. Endometriosis and endometriotic nodules could be excised in all the areas of affectation. An adjuvant medical hormone therapy or anti-inflammatory non- steroidal analgesic can be added.
Other alternative therapies include the use of acupuncture and chiropractic manipulations. Herbs like liquorice roots, minerals, and vitamins e.g. B1, B6, Omega 6 and Magnesium are also used.
Endometriosis symptoms are improved at menopause unless in women with oestrogen replacement therapy.
Endometriosis is quite common in the reproductive age group. The condition even though not curable, has a lot of intervention that could be deployed to alleviate the debilitating condition that may cause women the world over. Population awareness is crucial. Adequate and prompt diagnosis is essential with appropriate treatment modalities. Laparoscopic surgery is essential.