Fertility

Endo-what?

ENDOMETRIOSIS IS A condition where the hormone-sensitive layer of tissue that normally lines the inside of your uterus, the endometrium, grows outside of your womb. Endometriosis most commonly occurs in the lining of the pelvis or on the ovaries but can also affect the bowel or bladder, and in rare cases occur in more distant sites such as the navel or lungs. Endometriotic tissue responds to hormones in a similar fashion as the normal endometrium – it thickens, breaks down and bleeds. However, that shed tissue has nowhere to go, so it becomes trapped. It can be extremely painful.

HOW COMMON IS THIS CONDITION?

“It’s estimated that 2 to 10 percent of women have endometriosis, but it’s more common in symptomatic women, with up to half of infertile women being affected. Young women can also be affected; more than half of women with endometriosis already have symptoms in their teen years,” explains Dr Annelize Barnard, specialist gynaecologist and obstetrician.

AM I AT RISK?

It’s not known what causes endometriosis, but there are several theories. “The most widely accepted theory is that some of the endometrial cells that are shed during menstruation may travel backwards through the fallopian tubes and start growing outside the uterus. Endometriosis does occur more commonly in women who have relatives with the condition, but it’s not inherited as such. To date there’s no proven way to predict or prevent endometriosis,” says Dr Barnard.

TYPICAL SYMPTOMS

The symptoms most often present as pain or infertility. This might be pelvic pain, painful menstruation, painful

intercourse or pain when passing stool or urine. Other symptoms can include bloating, diarrhoea or constipation that occur in a cyclical pattern. “In some women, the symptoms may be present throughout the menstrual cycle. For some, these symptoms can be very severe and have an enormous impact on their quality of life,” explains Dr Barnard. “In some women only the superficial lining of the pelvis and its organs is involved, in others the tissue may grow deeper with only the tip of the iceberg visible at laparoscopy. The latter is known as deep infiltrating endometriosis. Some women may have severe symptoms, with very little visible endometriosis and vice versa,” says Dr Barnard.

HOW DO I KNOW IF I HAVE ENDOMETRIOSIS?

Unfortunately, this is not one of those conditions that a blood test can confirm. “Endometriosis is usually suspected based on the symptoms. A gynaecological exam may be appropriate to exclude other causes of pain and to evaluate the pelvic organs for mobility and palpable endometriotic nodules or cysts. A transvaginal ultrasound is also useful to assess the ovaries for endometriotic cysts and, in expert hands, can help to identify deep infiltrating endometriosis,” explains Dr Barnard.

TREATMENT OPTIONS

Usually, treatment can be started based on a suspicion of endometriosis, but if symptoms persist or if deep infiltrating endometriosis is suspected, a laparoscopy may be needed to confirm the diagnosis. “In cases where severe endometriosis is suspected, more advanced scans, such as MRI, are sometimes needed to help plan appropriate surgery,” says Dr Barnard. The treatment is aimed at improving the symptoms. “While painkillers may be useful, hormonal treatment is usually advised to help control pain symptoms. Hormonal treatment includes contraceptive pills, progesterone injectables and the intrauterine contraceptive device. These work by blocking the cyclical changes in the endometrium, and similarly, in the endometriotic tissue,” she explains. In some women, surgical removal of endometriosis lesions may be appropriate. This is usually the case with deep infiltrating endometriosis, endometriomas (endometriotic cysts of the ovaries) or where the endometriosis has caused adhesions to form between the pelvic organs. “This type of surgery can be very challenging and it’s recommended that more advanced cases be referred to a specialist centre. It’s important to note that a hysterectomy is usually not a solution to the problem as endometriosis seldom involves the uterus itself,” cautions Dr Barnard.

CAN I STILL GET PREGNANT?

While endometriosis is a common cause of infertility, not all women with endometriosis are affected in this way and 50 percent can conceive spontaneously without needing treatment. “There are different theories about how endometriosis affects fertility. Inflammatory hormones are released by the endometriosis tissue. This leads to a decrease in fertilisation of the egg, or if the egg does fertilise the embryo has a lower change of implantation. Endometriosis scar tissue can distort the normal anatomy of the pelvis, which will lead to tubal obstruction or an altered ovarian tubal function; and endometrial tissue can destroy ovarian tissue, which in effect leads to a lower egg reserve. In other words, endometriosis leads to an inflammatory state of the pelvis which is suboptimal for either egg production, fertilisation or implantation,” explains specialist gynaecologist and fertility expert Dr Chris Venter of Vitalab. “The only proven treatment effective in treating endometriosis-related fertility is laparoscopic surgery in order to remove the endometriosis. If a patient doesn’t conceive within 6 to 12 months after surgery, then In Vitro Fertilisation (IVF) is indicated. It’s very important that patients should not go for repeated surgeries in order to improve their fertility, as this may cause more harm. IVF still remains the most effective method to treat endometriosis-related infertility. In most cases surgery is not even indicated if a patient goes directly for IVF,” explains Dr Venter.

ENDOMETRIOSIS DOES OCCUR MORE COMMONLY IN WOMEN WHO HAVE RELATIVES WITH THE CONDITION, BUT IT’S NOT INHERITED AS SUCH