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Endometriosis

Endometriosis occurs when tissue similar to the lining of the uterus (endometrium), is found in areas outside of the uterus, in other words, where the tissue should not be, and can cause pain (e.g. period pain), abnormal vaginal bleeding, and/or infertility.

Generally, endometriosis is found in the pelvic cavity. It is still not exactly certain what causes the condition. It can attach to any of the female reproductive organs (uterus, fallopian tubes, ovaries), the uterosacral ligaments, the peritoneum, or any of the spaces between the bladder, uterus, vagina, and rectum. It causes a chronic inflammatory reaction that may result in pain, the formation of scar tissue (adhesions, fibrosis) within the pelvis and other parts of the body.

About 1 in 10 women worldwide suffer from endometriosis.

When you menstruate, the endometrium inside your uterus is shed. If you have endometriosis, your body cannot remove the endometrial-like cells that have grown outside your uterus. These cells bleed and cause inflammation and can create scar tissue over time.

Endometriosis may cause pain, particularly when you are menstruating, and it can reduce your fertility. Sometimes there are no symptoms and the woman may be unaware she has endometriosis.( an estimated 40% have no pain)

Symptoms of endometriosis

Apart from pain and infertility, endometriosis can cause other symptoms such as:

  • Period pain: mild to severe
  • Pain with bowel movements particularly at period time
  • Deep pain with penetrative sex
  • Diarrhoea or constipation
  • Bladder symptoms
  • Nausea
  • Tiredness / lethargy
  • Heavy and/or irregular periods

Painful periods are not normal. If you have very painful periods and are missing school, work or other activities it’s important to see your doctor, as it can be treated.

A specialised transvaginal ultrasound (Deep Infiltrative Endometriosis or DIE scan) may assist in diagnosis and surgical planning. The DEEP INFILTRATIVE ENDOMETRIOSIS (DIE) scan is a specialised, dynamic transabdominal and transvaginal ultrasound examination. It aims to look for deposits of disease on pelvic organs and other pelvic structures, including bowel. It also assesses for indirect signs of endometriosis such as specific site tenderness and mobility of the pelvic organs.

The examination is performed by a dedicated gynaecological sonographer and assessed by a women’s ultrasound specialist trained in diagnosing endometriosis.

Superficial endometriosis can be difficult to identify on imaging and if medical management has not been effective, a diagnostic laparoscopy can be performed with a plan for excision of any areas suspicious for endometriosis at the time. This operation is performed under a general anaesthetic. 

While there is no cure for endometriosis, it can be managed in a number of ways.

When we treat endometriosis, we treat all the symptoms that come with it, such as the pelvic pain or infertility. These can be treated with pain education, manual therapy, medication or surgery.

Endometriosis with no symptoms of pain or concerns with fertility:

This can be managed with observation and no treatment. Less than 2% of ovarian endometriotic cysts can result in a malignancy and hence, surveillance is recommended. Intervention can be individualised based on symptoms, the projected difficulty of the surgical procedure and level of tumour markers in the blood.

The risk of surgical removal of the endometriosis is about equal to the risk of surveillance.

Endometriosis with pain but no fertility concerns

Depending on how severe your symptoms are, you can choose from a few different treatments for pain caused by endometriosis:

  • Physiotherapy or osteopathy: These can help alleviate pelvic pain. Because they are hands-on, non-invasive approaches, they are often the first option we recommend.
  • Medication: your body’s normal physiological response to the pain (nervous system sensitivity) can greatly contribute to your pain and there is a variety of medication options you can discuss with your specialist GPs or specialists to help get your pain under control.  These may be hormonal or non- hormonal and are recommended before surgical options.
  • Surgery: We might use laparoscopic surgery (keyhole surgery) to remove your endometriosis, or discuss more extensive surgical options. If endometriosis is severely affecting your quality of life – for example if you are experiencing abnormal uterine bleeding not responding to medical management – your doctor might suggest a hysterectomy with or ovarian preservation and discuss the risks and benefits of the same.

Endometriosis with fertility concerns but no pain

If you are not experiencing pain, but have concerns about your fertility, it is best to try to avoid surgical treatment. This is because we want to avoid removing normal ovarian tissue, so that your number of eggs is not reduced.

We will check the patency (openness) and mobility of your fallopian tubes. If we find a blockage, surgery might be necessary – with every effort to keep access to the ovaries for egg pick-up open.

Endometriosis with pain and fertility concerns

If your endometriosis is causing you pain and you have fertility concerns, we will do everything we can to reduce your pain, while limiting the damage so that there is no impact on your fertility.

  • Non-surgical pain management: We can help to alleviate your pain with medication, physiotherapy, or osteopathy.
  • Surgery: Sometimes, surgery is recommended. Your gynaecologist will take great care to preserve your reproductive organs, while removing as much of the endometriosis as they can to minimise your pain.

NON-SURGICAL TREATMENTS

Hormonal treatments work by shrinking the endometriosis and preventing its growth. Hormonal treatments include the oral contraceptive pill, or progesterone, which can be given via the Mirena® intrauterine device or as an oral tablet.

Non hormonal medications such as paracetamol, non-steroidal anti-inflammatories, and stronger pain relievers may help to manage the pain symptoms. Pelvic physiotherapy and/or osteopathy may help to manage chronic pelvic pain.

Some women find pain relief with acupuncture, meditation, behavioural modification (clinical psychology) and exercise. Being active and eating healthy foods is helpful in combating pain and fatigue from endometriosis. Botox injections into pelvic muscles may help women with tense pelvic floor muscles contributing to their chronic pelvic pain.

SURGICAL TREATMENTS

Surgery for endometriosis is usually performed by laparoscopy (keyhole surgery), where the surgeon carefully excises or removes the endometriosis. Laparoscopic surgery causes less scarring, less pain, less time in hospital, and better visualizes the areas where endometriosis can grow, than laparotomy (open surgery).

In cases of severe endometriosis involving the bowel and/or other pelvic structures, a bowel resection and or/open surgery may be required to remove the diseased tissues.

You should be aware of the different kinds of treatments, and their possible effects and side effects or complications. A combination of treatments may be necessary to relieve the symptoms associated with endometriosis.

Dr Desai is experienced at removing endometriosis with surgery and works in close association with gynaecological oncology surgeons, colorectal surgeons, and urologists where a multidisciplinary approach is needed for advanced endometriosis. She also works closely with a multidisciplinary team including physiotherapists, psychologists, dietician and fertility specialists, who can be of great assistance in managing the pain and other problems associated with endometriosis.

Adenomyosis

Adenomyosis is a common benign condition of the uterus that is defined by the presence of endometrial tissue (inner lining of uterus) within the myometrium (muscle of the uterus). Adenomyosis can cause menstrual cramps, lower abdominal pressure, bloating before menstrual periods, and can result in heavy and painful periods. The condition can be located throughout the uterus or localized in one or some spots.

Though adenomyosis is considered a benign condition, the frequent pain and heavy bleeding associated with it can have a negative impact on a woman’s quality of life.

It is most often diagnosed in middle-aged women and women who have had children. Some studies also suggest that women who have had prior uterine surgery may be at risk for adenomyosis. Some women have excessive bleeding and pelvic pain that may prevent them from enjoying normal activities such as sexual intercourse.

Women with adenomyosis are also at an increased risk of anaemia due to the increased blood loss, which leads to iron deficiency. This can cause fatigue, dizziness, and moodiness.

The condition has also been linked with anxiety, depression, and irritability.

A transvaginal pelvic ultrasound is the first line of investigation. Other tests may include a blood test (to check for other causes of abnormal bleeding and to look for anaemia), and a biopsy of the lining of the womb (to rule out other causes of abnormal bleeding such as endometrial hyperplasia or cancer).

If a woman is asymptomatic no treatment is indicated. If symptoms are present, there are several potential treatment options, medical (hormonal) or surgical treatment. Treatment options will be discussed based on individual woman’s symptomatology and interest in future fertility. Adeno myomectomy is a procedure to reduce the bulk of the adenomyosis when childbearing is desired and adenomyosis is impacting fertility.  

The only way to cure this condition is to have a hysterectomy. This involves complete surgical removal of the uterus. A hysterectomy is considered a major surgical intervention and is recommended in severe cases and in women who don’t plan to have any more children. For support and educational events see the following organisations or download further information about endometriosis here.