Endometrium is the tissue that lines the Uterus (the womb). During the menstrual Cycle the thickness of the endometrium increases in readiness for the fertilised Egg. If pregnancy does not occur the lining is shed as a 'period'.

Endometriosis (pronounced end-oh-mee- tree-oh-sis) is a condition where the cells that are normally found lining the uterus are also found in other areas of the body but usually within the pelvis. Each month this tissue outside of the uterus, under normal hormonal control, is built up and then breaks down and bleeds in the same way as the lining of the uterus. This internal bleeding into the pelvis, unlike a period, has no way of leaving the body. This leads to Inflammation, pain and the formation of scar tissue. Endometrial tissue can also be found in the ovary where it can form cysts, called 'chocolate' cysts.

You can also have endometrial tissue that grows in the muscle layer of the wall of the uterus. This is called adenomyosis. Each month this tissue within the muscle wall bleeds in the same way as the endometrial tissue in the pelvis bleeds. Adenomyosis can also be found in the muscle layer of the perineum - in the pouch of Douglas or cul de sac.

Endometrial deposits can also be found in more remote sites than the pelvis. Endometriosis can be found in or on the bowel, in or on the bladder, in operation scars and in the lungs. The only site that endometriosis has not been found is the spleen.

Endometriosis is not an infection.
Endometriosis is not contagious.
Endometriosis is not cancer.


Why does it occur?

The cause is unknown but several theories have been put forward.

Retrograde menstruation.
Lymphatic or circulatory spread
Genetic predisposition to the condition
Immune Dysfunction
Environmental causes - such as dioxin exposure

Of the theories and the most widely accepted is retrograde menstruation. According to this theory some of the menstrual blood flows backwards down the fallopian tubes and into the pelvis. Some of the endometrial cells, contained in the menstrual fluid, implant on 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.


Symptoms of endometriosis

The more common symptoms of endometriosis include:

Painful and or heavy periods
Painful sex
Infertility
Fatigue
Problems when opening bowels

Associated with the above women may report many other symptoms:

Pain

Painful periods
Pain starting before periods
Pain during or after sexual intercourse
Ovulation pain
Pain on internal examination


Bleeding

Heavy periods with/without clots
Prolonged bleeding
Pre-menstrual spotting
Irregular periods
Loss of dark or old blood before a period or at the end of a period


Bowel and Bladder symptoms

Painful bowel movement
Pain before or after opening bowels
Bleeding from the bowel
Pain when passing urine
Pain before or after passing urine
Symptoms of an irritable bowel - diarrhoea, constipation, colic


Other symptoms

Lethargy
Extreme tiredness

The majority of women with the condition will experience some of these symptoms. Some women with endometriosis will have no symptoms at all.

The amount of endometriosis does not always correspond to the amount of pain and discomfort. Chocolate cysts on the ovary can be painfree and only discovered as part of fertility investigations. A small amount of endometriosis can be more painful than severe disease. It depends, largely, on the site of the endometrial deposits.

All of the symptoms above may have other causes. It is important to seek medical advice to clarify the cause of any symptoms. If symptoms change, after diagnosis, it is important to discuss these changes with a medical practitioner. It is easier to put all problems down to endometriosis and it may not always be the reason.


How common is Endometriosis

Endometriosis is a very common condition affecting some 2 million girls and women in the UK.


Who gets Endometriosis?

The stereotypical woman with endometriosis has been described as in her thirties, a career woman who has delayed childbearing. Whilst we know that this picture is far from true the myth persists.

Endometriosis can occur at any time from the onset of menstrual periods until the Menopause. It is extremely rare for it to be first diagnosed after the menopause, but not unknown. For the majority of women the condition ceases at the menopause.


How is endometriosis diagnosed?

The only way to diagnose endometriosis is by a Laparoscopy. This is an operation in which a telescope (a laprascope) is inserted into the pelvis via a small cut near the navel. This allows the surgeon to see the pelvic organs and any endometrial implants and cysts. This is normally day surgery.

Occasionally diagnosis is made during a Laparotomy. A laparotomy is a major operation, which involves a cut into the abdomen.

Scans, blood tests and internal examinations are not a conclusive way to diagnose endometriosis.


Treatments

There is a range of treatments available to women with endometriosis. Unfortunately, none of the treatments offer a cure for the condition. The treatments on offer can help

Relieving pain symptoms
Shrinking or slowing endometrial growth
Preserving or restoring fertility
Prevent/delay recurrence of the disease

The treatment that a woman is offered should be decided in partnership between her and her medical advisors. The considerations about what type of treatment should be used depend on several factors


Age
The severity of the symptoms
The desire to have children
The severity of the disease

Many women are told that if they get pregnant it will cure their endometriosis. This is not the case. Women can have long periods without symptoms following pregnancy and breast-feeding. For many women their endometriosis does eventually recur.


Hormonal Treatments

Hormonal treatment aims to stop ovulation and allow the endometrial deposits to regress and die. They either put the woman into a pseudo-pregnancy or pseudo-menopause.

Drugs used include:


Testosterone derivatives

Danazol
Gestrinone (Dimetriose)


Progestogens

Medroxyprogesterone (Provera)
Norethisterone (Primolut)
Dydrogesterone (Duphaston)


GnRH analogues

Leuprorelin (Prostap)
Goserelin (Zoladex)
Nafarelin (Synarel)
Buserelin (Suprecur)
Triptorelin (Decapeptyl)


Combined Oral Contraceptive Pill
Mirena Coil
Depo-Provera

All the hormonal treatments have side effects. These vary from woman to woman.

All of the drugs above, except the oral contraceptive pill and the Mirena coil, have been shown in clinical trials to be equally effective as treatments for endometriosis.

With the exception of the Mirena Coil, Depo-Provera and the oral contraceptive pill, the drugs used to treat endometriosis are not contraceptives and barrier methods of contraception should be used during treatment.


Surgery

Conservative surgery seeks to remove and destroy the endometrial growths. This is either done by laparoscopy or by a larger open operation - a laparotomy.

Radical surgery may be necessary in women with severe endometriosis. Hysterectomy can be done with or without removing the Ovaries. If the ovaries are left in place then the chance of persistent disease is increased with some women needing a further operation to remove the ovaries at a later date. For radical surgery to offer hope of a cure for endometriosis then hysterectomy, the removal of the ovaries and removal of any endometrial growths should be done. Radical surgery should be the 'last resort' treatment and not contemplated until all other treatments have been tried or ruled out.


Complementary Therapies

Options include acupuncture, aromatherapy, Chinese herbs, Western Herbs, homeopathy, nutrition, reflexology, naturopathy, Reiki and osteopathy.

There are no clinical trials based on the efficacy of complementary therapies as treatments for endometriosis. However, many women do have improvement of their symptoms whilst using such therapies. It is probably wise to seek help from a qualified practitioner and not self medicate.