Endometriosis is defined as a condition where tissue which normally lines the inside of the uterus (endometrium) is found elsewhere in the body. Endometriosis is most commonly found in the ovaries, the tissue lining the pelvis, or the bowel.
Frequently Asked Questions
- 1What is the Definition of Endometriosis?
- 2What are the different treatment options available for Endometriosis?
- 3What is the Biology and Pathophysiology behind Endometriosis?
- 4What are the Symptoms related to Endometriosis?
- 5What are the risk factors associated with developing Endometriosis?
- 6How is Endometriosis diagnosed?
- The displaced endometrial tissue continues to behave like normal endometrial tissue, meaning it thickens, and then breaks down and bleeds with every menstrual cycle. The bleeding causes irritation and inflammation and will eventually lead to scar tissue and adhesions.
- The growth of this misplaced endometrial tissue can cause a lot of pain, especially during menstruation or sexual intercourse. It can also cause fertility problems, gastrointestinal or urinary problems and abnormal vaginal bleeding.
- Endometriosis is oestrogen-dependant and often progressive, resulting in worsening pain as well as other symptoms over time.
- There are many different treatment options available, depending on a number of factors, including the extent of the disease, the patients’ desire to fall pregnant, and the cost of treatment.
- These are a few of the treatment options that are available:
- 1. Conventional Treatments:
- Anti-inflammatory medication/Pain medication
- Other pharmaceuticals
- Surgery might be necessary in some cases to reduce the pain and restore fertility.
- These treatments are not always effective, and may have side effects such as weight gain, irregular bleeding, and changes in the uterine tissue.
- Pain Management
- Pain relieving medication, such as non-steroidal anti-inflammatory drugs (NSAIDs) - can help to reduce the pain and inflammation.
- NSAIDs can lead to gastric ulcers and may inhibit ovulation.
- Symptoms of endometriosis are often resolved during menopause and pregnancy.
- Oral contraceptives are a popular treatment option, but fails to control the pain of endometriosis in 20-25% of patients.
- Gonadotropin-releasing hormone (GnRH) agonists –Used in patients who cannot obtain relief with NSAIDs and oral contraceptives after 6 months of therapy.
- GnRH agonists lowers oestrogen levels, which may benefit patients with endometriosis, as oestrogen stimulates the growth of endometrial tissue
- GnHR agonists can cause significant bone loss, which is partially reversible. When adding small amounts of oestrogen to the treatment a low, stable oestrogen level can help retain bone density.
- Danocrine – Is a synthetic hormone which creates a lower oestrogen, higher androgen environment resulting in a reduction of endometriosis lesions.
- Danocrine can cause weight gain, depression, reduced breast size, deepening of the voice, skin rash, increased body hair, and may also increase the risk of ovarian cancer.
- Progestins (synthetic progesterone-like drugs) –E.g. Provera are synthetic versions of progesterone.
- Progestins can cause weight gain, depression, bloating, irregular bleeding, and also increases the risk of ovarian cancer.
2. Bio-identical Hormone replacement therapy – BIHRT:
- Maintaining hormonal balance will help ensure that endometrial tissue, either normal or ectopic, does not grow in an unchecked fashion.
- Regular blood testing and appropriate bioidentical hormone replacement therapy may help patients achieve such a hormonal balance.
- BIHRT is designed to be identical to the hormones that the body produces.
- Doctors can check for hormonal imbalances and design a natural bioidentical hormone regimen, to maintain hormone levels in the right proportions.
- Progesterone is a key hormone for endometriosis, as it counters the effects of excess oestrogen.
- Using bioidentical progesterone may be an effective approach to the treatment of endometriosis, with fewer side effects.
3. Targeted Natural Interventions:
- Curcumin –Has anti-inflammatory, anti-oxidant, and anti-proliferative properties. Curcumin has shown anti-endometriotic effects by acting on cellular signalling pathways and inducing apoptosis in endometriomas.
- Vitamin D3 – A healthy Vitamin D3 level inhibits excessive inflammation while a deficiency in Vitamin D3 promotes inflammation.
- Omega-3 Fatty Acids – Has anti-inflammatory properties which may help prevent the development of endometriosis. Studies have shown that patients who consumes high amounts of omega 3 fatty acids are less likely to develop endometriosis.
- Vitamins E & C –Oxidative stress, which is caused by reactive oxygen species (ROS), contributes to several aspects of endometriosis. These vitamins have a lot of antioxidant properties, and will reduce oxidative stress. Increasing the consumption of antioxidants can benefit patients with endometriosis and will reduce the inflammation and oxidative stress in the peritoneal fluid. Studies have also revealed that patients with endometriosis have lower levels of Vitamin C in their follicular fluid, as well as low levels of the endogenous antioxidant, superoxide dismutase (SOD) in their plasma. Using a combination of Vitamins E & C can cause a reduction in pelvic pain, pain with menstruation, and pain during intercourse.
- Glisodin – Provides an orally absorbable form of the endogenous antioxidant SOD. SOD has potent antioxidant and anti-inflammatory properties.
- N-Acetyl Cysteine (NAC) – NAC is a modified form of the natural amino acid cysteine. NAC is a potent antioxidant and helps bolster the body’s intrinsic ability to combat oxidative stress, aiding the production of the endogenous antioxidant glutathione. NAC causes a significant reduction of the size of endometriotic cysts.
- Green tea – Is rich in compounds called polyphenols, which benefit woman with endometriosis. Polyphenols can decrease the growth of endometrial implants and reduces the formation of new blood vessels to ectopic endometrial tissue.
- Resveratrol – Is a polyphenolic compound found in certain foods, such as grapes, peanuts, some berries, and red wine. Resveratrol can reduce endometrial implants by 60% and the volume of lesions by 80%. Resveratrol inhibits angiogenesis in endometriotic lesions.
4. Dietary and Lifestyle Considerations:
- Diet – Dietary factors can influence the risk for endometriosis. Foods which promote inflammation such as saturated fats, dairy, wheat and sugar should be avoided. Long chain omega-3 fatty acids decreases inflammation and the risk of endometriosis, while a diet rich in trans-fats (fried foods) increase inflammation and the risk of endometriosis. A diet rich in antioxidants from fresh fruit and vegetables will lower the risk of endometriosis.
- Support Groups – Endometriosis is a complex disease, causing significant pain, and it is difficult to treat. Diagnosis is often slow despite multiple trips to the physician. Support groups provide a connection to others suffering from similar symptoms. Patients can learn more about the disease and strategies for coping with, and treating the symptoms.
It is characterised by the presence of endometrial tissue in parts of the body where it should not normally be present.
- The pelvic peritoneum (membrane that covers the organs within the pelvis), ovaries, and rectovaginal septum (area between the rectum and vagina) are most susceptible.
1. Retrograde Menstruation
- Endometriosis occurs via a process known as “retrograde menstruation”
- This is when endometrial tissue leaks into the peritoneal cavity during menstruation, which allows endometrial tissue to implant into other sites in the pelvis.
- Congenital anatomical abnormalities that impair the flow of menses from the uterus into the vagina have an increased risk of endometriosis.
2. Coelomic Metaplasia
- This is the development of Endometriosis.
- Endometriosis occurs when cells lining the coelom, the cavity between the body wall and intestines, change their cell type to form endometrial tissue.
- Cells of the Endometrium and coelom arise from the same cell type during embryonic development, and their differentiation is under the control of hormones, primarily oestrogen.
3. Blood and lymphatic dissemination
- Viable endometrial cells may travel from the endometrium through lymphatic or blood circulation.
- These cells may implant at other sites and grow, giving rise to endometriosis in a manner similar to the metastasis of tumour cells.
- Plays an important role in Endometriosis.
- Endometriotic tissue produces excess inflammatory mediators such as prostaglandin E2 and Prostaglandin F2a.
- Endometrial tissue implants grow in other parts of the body, inflammation may also play a role in the pain caused by endometriosis.
- Areas outside the uterus can trigger an immune response that can cause the release of large amounts of inflammatory cytokines.
- These cytokines can increase the activity of immune cells, like mast cells, which can affect the nearby nerves to contribute to pain.
5. Hormonal Imbalance
- Can contribute to the development of endometriosis.
- During the menstrual cycle, endometrial tissue grows and then regresses.
- Oestrogen is responsible for the proliferation of the endometrial lining.
- Growth and progression of endometriosis is also dependant on oestrogen and can be treated by suppression of excessive oestrogen levels.
- Progesterone can help stop the growth of abnormal ectopic endometrial tissue.
- Genetic mutations that cause abnormal cell growth also promote endometriosis
- Endometriosis is more common in woman with a first-degree relative (mother or sibling) with endometriosis.
- Most common symptom is pelvic pain. May occur during menstruation, sex, and/or present as chronic pain.
- 75% of all women with symptomatic endometriosis will experience pain.
- Other symptoms – Lower back pain, constipation, diarrhoea, bloating, fatigue, and abnormal menstrual bleeding
- Bladder and bowel symptoms are usually worse around the time of menstruation
- Endometriosis causes impaired fertility.
- Woman with Endometriosis have a 2-10% chance of becoming pregnant each month, compared to the 15-25% chance of a healthy woman each month.
- 30-50% of women that have endometriosis have fertility problems, they are also less likely to have a live birth.
- They also have a higher rate of complications during pregnancy, including preeclampsia, pre-term birth, abnormal vaginal bleeding, and an increased rate of Caesarean-section delivery.
- Resistance to progesterone and amplified oestrogen production may also render the uterus unsuitable for supporting a pregnancy.
Family History is an important risk factor.
- Women who have a first-degree relative with endometriosis have a 6-7 fold increased risk of developing the condition.
Early menarche and never having been pregnant.
- Women who have not had children, experienced menarche at an early age, and those having shorter menstrual cycles, have an increased risk of developing endometriosis.
- For mothers, higher number of children and longer periods of lactation are associated with a decreased risk of endometriosis.Menarche after age 14 appears to greatly reduce the risk of endometriosis.
Lifestyle, dietary, and environmental
- Exposure to certain pesticides, increases the risk of endometriosis.
- Women with endometriosis tend to have a lower body mass index than women who are more physical, and have a lower risk of endometriosis.
- Diet, low in vegetables and Omega-3 fatty acids, and high in red meat and trans- fats may lead to an increased risk for endometriosis.
- Diagnosis can be difficult, as it may initially be suspected based on signs, symptoms and medical history,
- A physical exam should be performed.
- Pelvic tenderness and enlarged ovaries are suggestive of endometriosis.
- Doctors may diagnose endometriosis once other causes of pelvic pain or infertility have been ruled out.
- The best way of determining if you have endometriosis, is with a visual inspection via laparoscopy.
- Laparoscopy is a surgical procedure which allows surgeons to look for ectopic endometrial tissue, which appears as black, dark brown or blue lesions, and resembles a powder burn.
- Lesions can be visually seen on the ovaries, peritoneum, and/or other structures within the pelvis or abdomen.
- Laparoscopy can also determine the extent of the endometriosis.
- The accuracy of this procedure depends on the location of the lesions, extent of endometriosis, and the experience of the person doing the procedure.
- Suspicious lesions seen on the laparoscopy should be sampled by performing a biopsy.
- This is an invasive procedure.
- Doctors will first treat a woman, with hormonal therapy before resorting to laparoscopy.
- Transvaginal ultrasound can also help detect severe disease and may be useful as a test before laparoscopy.
Stages of Endometriosis
Endometriosis is classified in four stages:
Minimal: This stage has isolated implants of ectopic endometrial tissue with no adhesions.
Mild: Characterised by the presence of endometriotic implants on the peritoneum and ovaries cumulatively totalling less than 5cm in size, no significant adhesions are present at this stage.
Moderate: Multiple implants are present; some deeply penetrate the pelvic tissue and can cause significant adhesions.
Severe: Has many deep implants and may have large masses called endometriomas.