Endometriosis Questions & Answers , Dr. Sandhya Saharan
Center Head : So Dr. Sandhya, I just would like to ask you that what exactly is endometriosis.
Dr. Sandhya : See, endometriosis as the name suggests, it originates from the word endometrium. So what is endometrium? Endometrium is the lining which is within the uterus and now this lining grows every month and then when it is ripe, it sheds, and the patient gets her menstruation. Now when this lining grows any other place beside the uterus, that is suppose it grows in the ovaries or in the fallopian tubes or any other place within the abdomen and that is abnormal growth, so that causes pain and swelling and that is called endometriosis.
Center head: Okay, and like, what are the symptoms of endometriosis?
Dr. Sandhya: Yes, so the most important symptom which patients come is pain. They say that the menstruation is very painful, we call it dysmenorrhoea, the pain during menses, and also in many patients the bleeding is very excessive. Now these deposits, as we know that they swell up and then they cause the pain, inflammation and also more of bleeding because they keep growing. Every month when the patient menstruates, the deposits keep growing. So basically, the chronic pain that we see, that is the most aggravating symptom that we see in endometriosis.
Center head: I guess pain during menses is a very common thing but then how common is endometriosis?
Dr. Sandhya: Right, see now pain during menstruation, a little bit of it is normal that is like a physiological pain but when it is excess, like suppose the patient has pain while passing urine, while passing stools, and also when the pain is you know sometimes while having intercourse and it can also cause infertility. So, almost 11% of women in the reproductive age group, that is between 15 and 44, they suffer from this kind of a endometriotic pain, it is not the usual kind of dysmenorrhoea.
Center head: So, 11% of reproductive age group females is quite a big number.
Dr. Sandhya: Yes.
Center head: So, what are the causes of it and why the endometrium grows like that or why the pain is there?
Dr. Sandhya: Absolutely, firstly, I would like to say that this is not a cancerous disease because the most important apprehension everyone has, whether it will cause cancer, this kind of a… when we say any growth outside the uterus, patients start worrying about cancer, so this is not cancerous. Now, there are many theories, you know, but there is no exact kind of an aetiology which has been documented or which has been actually studied and said that this is the reason. But there are so many hypotheses, one is like the peritoneal lining which is within the abdomen that can undergo a change, we call it metaplasia, a noncancerous change and it starts forming into that endometriotic tissue, so this grows in different places in the abdomen, it can grow also on the ovaries, fallopian tubes, on the what we call as supports of the uterus. The most important part of the uterosacral ligaments, which basically the uterus sits on, that is the area which is the most common site for endometriosis.
One is the important theory which we have studied and which holds true even today is called the retrograde menstruation theory, that is when you are bleeding then the bleeding comes out from the cervix into the external environment. At the same time, there is bleeding within the abdomen through the fallopian tubes into the pelvis, now this blood starts collecting within the abdomen at different places and sometimes in the ovary it can form cysts. Now since this is a blood that is collected, the cysts are dark coloured, so we call them something called chocolate cysts. They are bluish, grey, or black in colour, and predominantly they are called chocolate cysts of the ovaries. So these are the two theories which are very common. The third, they say, is through the lymphatic spread. As we know, the lymphatic system is incharge for taking care of our immune system, so through that also it spreads to different parts of the body. And fourth is the immune theory. Immune theory, our immune system takes care of any tissue which is supposed to be outside its normal zone and get rid of it, that is called macrophages, so if they do not function properly then there is something called as growth of the endometriotic tissue outside its normal place of occurrence. So these are by and large the 4 theories which are postulated to be causing endometriosis.
Center head: So how to diagnose it, like once a female or a girl starts getting that kind of pain, it is aggravated pain or leading to endometriosis, how to know about it?
Dr. Sandhya: Yes, see now, what happens is many times the girls who are very young, so they are brought by their mothers and the mother feels that the pain is a little too disproportional to the kind of pain which we usually see. And the gynaecologist by and large takes a detailed history and on history itself, we can come to a sort of a narrow down to what it could probably be. The second thing is a sonography, so in young girls sometimes we do not do a pelvic examination. In older women we do a pelvic examination, a per vaginal examination does give us quite a bit of an idea whether it could be endometriosis because there are certain areas that is, just the area behind the uterus that is called the fornix. If we can feel a certain thing like a nodule or tenderness in that area or even big ovarian cysts, sometimes they can be palpated so that gives us an idea. Definitively, a sonography will show us if there are any endometriotic cysts in the ovaries. And the main, the gold standard for diagnosis, if all this fails is an MRI or a laparoscopy. Now, laparoscopy as we know, it is a kind of a telescope, it is an endoscope which we insert through the anterior abdominal wall into the pelvis. So this directly visualises the endometriotic deposits, the chocolate coloured cysts or the powder burn kind of appearance which we see on the uterus, ovaries, tubes, or in the uterosacral ligaments, so we can actually see the endometriotic tissue, so that gives you 100% diagnosis.
Center head: So, I think parents also should be little more, not worried, but more focused towards all such kind of symptoms if the girl is telling the mother.
Dr. Sandhya: Yes.
Center head: Fine, I mean now we know the diagnosis is quite approachable. So, what is the treatment, I mean is it surgical or medical, conservative?
Dr. Sandhya: Right… now as we know, this is a disease which is oestrogen dependent. The more the hormone oestrogen in the body, the more will be the aggravating symptoms and oestrogen is responsible for growth of the deposits, so we have to lower the oestrogen content. So naturally the girls, if they are on the heavier side, if obesity is a problem, we advice that there should be a diet restriction and weight loss, also exercise lowers the oestrogen levels. Secondly, we can give hormonal treatment to lower the oestrogen levels, now it all depends on the patient, whether she wants children at that particular age group, if she is in the reproductive age group or not. If child bearing is not desired then we can give low-dose birth control combination pills, they reduce the oestrogen levels and cause a pseudo kind of a hormone situation where the levels are kept under control and these endometriotic deposits start drying up. Third is if the patient wants a child bearing, if she is keen to have children, we try and do controlled ovarian stimulation with specific drugs, so that the oestrogen level does not go up. And as we know during pregnancy, then definitely there is no menstruation, so the deposits will not increase in size and the pain, swelling everything goes away. So this is the various modalities, these are in cases when the endometriosis is mild or just moderate, which can be managed by just palliative treatment or by hormonal treatment. If it is severe endometriosis, if the cysts are more than say 4-6 cms causing incapacitating pain then the best thing is to first remove those endometriotic deposits. This can be done through a laparoscope, so we can easily… there is something called fulguration of the deposits by cauterization, there is laser fulguration or laser cautery. And third is excision of the cysts. Now, excision is very important because the entire lining is removed. So, once the lining is removed then there are very low chances of recurrence. But we do take into account that this disease can recur, so we do give maintenance medical therapy even after surgery for say 3-6 months and we council the patient accordingly.
Center head: So though a percentage of recurrence is calculated, still we have the treatment which one can go or help it. As you say like it is common between the reproductive age…
Dr. Sandhya: Yes.
Center head: So does it affect the fertility, like does it cause infertility or that thing?
Dr. Sandhya: Definitely, because these deposits, sometimes what happens is they block the fallopian tubes. If the tubes are blocked then there is no access to the egg, the sperm cannot access the egg. Secondly also, ovarian cysts, because they are large in number and they hamper ovulation, so both these factors are very important for fertility, ovulation as well as the functioning of the endometrium. Thirdly, the endometrium becomes hostile in patients like this, so it is not conducive for implantation. So we have to tackle all these three problems, and accordingly, then we give ovulation induction. First try and get rid of the cysts and then monitor the ovulation cycles and patients are by and large able to conceive.
Center head: So, I think, the take-home message is though the word endometriosis is little scary word but we do have treatment, diagnosis, and all types of modalities available.
Dr. Sandhya: Absolutely.