Dr Ahmed Ismail

Consultant Gynaecologist & Fertility Expert

08 Feb 2010

What is Endometriosis?

The endometrium is the tissue that lines the inside of the womb (uterus). Endometriosis is a condition where endometrial tissue is present outside the uterus. It can grow anywhere in the pelvis, in the abdomen and less frequently in other areas of the body. Symptoms differ depending on where the endometrial tissue grows, however there are more frequent sites than others, such as around the ovaries and the ligaments around the uterus. They can also be found in abdominal scars from previous surgeries, such as Caesarian sections.

This endometriotic tissue responds to the female hormone oestrogen, just as the lining of the uterus does. The tissue builds up through the month and at the time of menstruation it breaks down as if to shed. However as it is not in the uterus, it does not have an access to outflow and therefore gets confined within the body in patches or cysts that may bleed each month with the period. Accumulated blood is dark brown and can form into what is known as a “chocolate cyst” or endometrioma in the ovaries. If this cyst ruptures then it can cause acute severe pain. These patches can also stick organs together, such as sticking the bowel to the uterus. The medical term for “stick” is adhesions. In some cases, the adhesions can become so extensive to the point that the pelvis becomes somewhat glued together, known as a “frozen pelvis.”

What causes Endometriosis?

The cause of endometriosis is not fully known. It is thought that when you menstruate, the lining does not shed out of the vagina but rather tracks back into the pelvis and some other areas of the body.

Another theory is that tissue which is similar to the endometrium but not identical, grows within the pelvis. This tissue also responds to oestrogen during the menstrual cycle and bleeds at the time of menstruation.

Genetic studies have also shown some degree of inheritance, that if one female in the family experiences endometriosis then it is possible another will.

What symptoms will I experience?

Below are the symptoms one might experience with endometriosis:

  • Lower abdominal pain – this usually coincides with the period, particularly the few days prior to menstruation. Pain usually correlates poorly with the degree of disease. Some patients may have no pain at all and are only found to have endometriosis incidentally at a laparoscopy for another reason.
  • Pain during sexual intercourse – this pain is experienced deep in the pelvis.
  • Pain on passing stool during the period.
  • Subfertility – couples may have difficulty conceiving as the endometriotic patches may deposit in the fallopian tubes and disrupt the passage of the egg to the uterus.
  • Other rarer symptoms include blood in the urine and blood from the back passage, but such symptoms indicate more severe disease.
  • If there is a chocolate cyst present and it bursts then this can give severe acute pain in the abdomen, which this may be the first presenting symptom.

How is my endometriosis treated?

Endometriosis can be treated medically and surgically. It is important to highlight that patients may come to see the doctor due to the pain and some may present with no pain at all but an inability to conceive. Mr. Ismail controls the problem with the patient and the treatment is dependent on whether the patient has fertility aspirations or not. Mr. Ismail manages with medication initially and then proceeds to surgery if needed. Below are the treatment options that are trialed in order:

  1. Hormonal treatment- this is based on the fact that endometriosis regresses during pregnancy and menopause. If there is no immediate desire for pregnancy then the combined oral contraceptive pill “The Pill” is also suitable to reduce pain, with the added benefit of contraception for such women
  2. Down regulation – this involves nasal spray and/or injections. This form of treatment is abbreviated to GnRH analogues and is given to prevent ovulation and therefore prevent the effects of oestrogen on the endometriotic patches. This can only be used for a short period of time, as long use may lead to osteoporosis. Mr. Ismail uses this when the endometriosis is causing subfertility, where a short course of GnRH analogues provide a window of opportunity for pregnancy. Despite this, Mr. Ismail does not give this as first-line therapy due to the unwanted side effect profile.
  3. Although, the above two lines of treatment seize the symptoms, such as pain, the most definitive form of treatment is surgery. Mr. Ismail performs key-hole surgery, otherwise known as laparoscopy. The procedure is known as adhesiolysis, splitting of the adhesions. Mr. Ismail preferentially uses a laser to break these adhesions apart and has had worldwide success in treating endometriosis, whether to treat the pain or to ensure a pregnancy.
  4. A further assessment can take place in reference to age, parity and symptoms. If the patient is above the age of 40, has completed her family and experiences severe symptoms of endometriosis, then there is an option for considering surgical clearance and possible hormonal therapy.
  5. Treatment of the pain can be assessed according to the severity at the time of your consultation, to establish whether u require any pain relief during the active treatment of your endometriosis or rather to abstain from it. The types of pain relief will be discussed with Mr. Ismail.

Endometriosis is quite common; 1-2% of the female population suffer from it and up to 20% of women have been coincidentally found at laparoscopy, whether diagnostic or operative, to have the lesions (patches) albeit with no symptoms. Patients may choose not to get their endometriosis treated as it does not trouble them too much, however if left untreated it becomes worse in 4 in 10 women. Nevertheless, it does improve in 3 in 10 women and the remaining 3 in 10 women stay the same. Once the treatment options have been discussed with you in depth with Mr. Ismail it is ultimately your choice how you are managed. Please bear in mind that if you have a desire to conceive you may potentially be in the 40% of women that the endometriosis gets worse, inevitably reducing your chances further. The doctor advises anyone with any of the above symptoms to book an appointment as soon as possible to avoid progression of the disease.

Endometriosis Operation

34 years old lady has been experiencing progressive pelvic pain, period starting few days before period, painful intercourse, and has been trying for a baby for 18 month.

Examination there was severe tenderness of the internal genital organs, cervical excitation and left ovarian cyst. Pelvic ultrasound, Doppler, 3D revealed Endometriotic cyst moderate in size on the left ovary.

Treatment carried out in form of Operative Laparoscopy, Ovarian Cystectomy, cautery of Endometriotic deposits on the Ovary, and Uterosacral Ligaments.using monopolar and bipolar cautery., alternative methods we use contact fibre or free beam laser endoscopic surgery. Chocolate cyst .



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