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Endometriosis

 


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Class
Women's health
Description
Endometriosis affects more than 2 million women in the UK, usually between the ages of 25 to 40. In some cases endometriosis is just like simple period pain but in others it can be a debilitating condition that severely affects all aspects of the woman's life.

Endometriosis is a condition in which cells that line the inside of the uterus (endometrium) become established outside the uterus. This can take place anywhere in the body, but particularly in the pelvic area around the ovaries, fallopian tubes, vagina, bladder, bowel or on the pelvic wall itself. These cells, like those inside the uterus, respond to the changes in hormones that take place every month. During the monthly menstrual cycle, the hormones stimulate the endometriosis cells to grow and then to break down, bleed and be shed in the same way as cells in the uterus. However, because these cells are trapped inside the pelvic area, they cannot escape as they would normally do with a period. The internal bleeding causes inflammation and severe pain, while the cells may become sticky and spread causing organs to stick to each other or to the pelvic wall (adhesions). If the cells lodge and develop in the ovaries they form swellings called ovarian cysts.
Causes
Endometriosis is not caused by an infection and it is not a form of cancer. Although its exact cause is unknown several theories have been put forward:
  • Retrograde menstruation.
  • Lymphatic or circulatory spread
  • Genetic predisposition to the condition
  • Immune dysfunction
  • Environmental causes
  • Metaplasia
Of the theories, the most widely accepted is retrograde menstruation. According to this theory some of the menstrual blood flows backwards up the fallopian tubes and into the pelvic area. There, some of the endometrial cells contained in the menstrual fluid become lodged onto the reproductive organs or other areas in the pelvis. These implanted cells cause endometriosis. What is not known is why these endometrial cells implant in some women and not in others.

In lymphatic or circulatory spread, it is thought that the endometrial cells are carried in the lymphatic system or blood stream from the uterus to other areas around the body. This could explain why, in rare cases, endometriosis also affects the lung, brain or eyes.

A genetic cause may also be responsible, increasing the chances of having endometriosis or possibly making the immune system less able to deal with endometriosis.

In metaplasia, the cells in the pelvic area are thought to revert spontaneously to the cells from which they originally developed and then change to endometrial cells.
Symptoms
Pain is the most common symptom of endometriosis. The intensity of pain varies from person to person, such that in some women it is like a period pain, while in others pain may be so intense as to be debilitating and interfere with their life. The severity of pain appears to depend on where the endometriosis is located, rather than to the amount of endometrial tissue involved. Pain is usually experienced during periods but can occur throughout the monthly cycle including during ovulation, bowel movement and intercourse. Other common symptoms include heavy or irregular periods, pain when urinating and feelings of fatigue and depression. Long-term consequences of endometriosis include difficulty in becoming pregnant because adhesions can form in the fallopian tubes blocking the passage of eggs from the ovaries to the uterus.

As the symptoms are common to many other conditions, endometriosis can be difficult for doctors to diagnose. Endometriosis UK, the charity that supports women living with endometriosis, estimates that the average time between a woman first seeing her doctor with symptoms and being told that she has endometriosis is a staggering 8 years.
Treatment
There is no cure for endometriosis. Treatment is aimed at reducing the severity of the symptoms and improving the feeling of well-being. Unfortunately, many of the treatments for endometriosis also affect a woman's fertility and this can create problems for women who want to start a family or have another baby. Consequently, the choice of treatment will depend on the woman's age, whether she wants to have children, the severity of symptoms and individual response.

The types of treatment available include the use of analgesics such as paracetamol and ibuprofen to ease the pain. There are also hormonal treatments that aim to interfere with the menstrual cycle and so stop the endometrial cells from growing and allow them to shrink. These treatments include the combined oral contraceptive pill, progestogens such as dydrogesterone, medroxyprogesterone and norethisterone, and the androgen-like drugs called danazol and gestrinone. Other hormonal treatments include the GnRH analogues such as buserelin, goserelin, leuprorelin, nafarelin and triptorelin that create conditions similar to the menopause. They suppress oestrogen to such low levels that the endometrial growth can no longer be sustained and the tissue gradually gets smaller.

If endometriosis is severe and there is a risk of infertility, surgery may be an option. Using a technique called 'key hole' surgery during a laparoscopy, small amounts of tissue can be removed by the use of a laser. Organs that have been stuck together by adhesions can also be separated. If endometriosis has not responded to drug treatment and the woman does not intend to have more children or start a family, more radical surgery may be performed where the uterus, ovaries, fallopian tubes and cervix are removed.
When to see your pharmacist
If your symptoms are mild, your pharmacist will be able to recommend simple analgesics to relieve the pain. Your pharmacist is not allowed to supply any of the hormonal treatments for endometriosis without a prescription. Your pharmacist will be conscious of the fact that endometriosis carries the risk of infertility and, if he or she thinks it appropriate, will advise you to see your doctor who will be able to confirm the diagnosis and prescribe an appropriate course of treatment.
When to see your doctor
Visit your doctor if you suspect you have endometriosis and have not yet been diagnosed. Painful periods or pain throughout the cycle may be a sign of endometriosis or an ovarian cyst. Your doctor may decide to refer you to a specialist who will use a technique called laparoscopy to look for endometrial tissue in your pelvic area. The earlier the condition is diagnosed the better chance of avoiding long-term problems such as infertility.
Living with endometriosis
If you are experiencing any of the symptoms described above and you think that you may have endometriosis, keep a diary of your symptoms. Keeping a record of the severity of pain, when you experience pain, the nature of your periods and when they occur, whether you have any bowel or bladder problems, or are experiencing depression and fatigue will all help your doctor in making a diagnosis and managing your condition appropriately.

Similarly, if your doctor decides to send you to a specialist, go prepared. Make a record of your symptoms, write down a list of questions that you want to ask and, if you want to do so, take someone along with you for support. Make notes of things that the specialist says as it will help to remind you later.

Get to understand the medicines that may be prescribed for you. Some of the treatments for endometriosis will affect fertility and your chances of having a baby. If this is important to you, discuss the options with your doctor. Equally, although some of the medicines do affect fertility, not all of them can be relied on for contraception. With certain medicines it is important to use non-hormonal methods of contraception, such as the condom or the diaphragm, during treatment to avoid becoming pregnant.

There are many other things that you can do that will help your treatment and ease your symptoms. There are self-management courses that enable you to take control of endometriosis rather than it taking control of you. The courses help you understand your condition and help you adapt to living with a long term condition. For further details see www.expertpatients.nhs.uk

There are specialist pain clinics that provide advice and guidance on controlling pain, while you may also find that some simple measures such as hot baths, exercise, relaxation classes and physiotherapy will all bring some degree of relief.
Advice to carers and partners
Try to be supportive of female members of your family who have endometriosis. Getting to understand that endometriosis can affect them both physically and emotionally will do much to show that they are not alone. Taking an interest in what they do, joining in activities whenever practical, and providing whatever support you can will all be of great help. Discuss with them any fears that they may have about infertility, or about seeing their doctor or specialist, or about any examinations or procedures that may need to be performed. All of these things will be of great comfort and help them cope with their condition.

Based on information supplied by: Endometriosis UK
Telephone: 020 7222 2781
Helpline: 0808 808 2227
http://www.endometriosis-uk.org

Reviewed on 6 May 2010


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