Endometriosis and pelvic pain

Endometriosis can cause pain and subfertility over many years, affecting well-being and quality of life. Several treatments are available, but it is vital to work together to choose the best approach for your situation.

What is endometriosis?

Endometriosis is a condition in which tissue similar to the lining of the womb starts to grow in parts of the body outside the womb. Most commonly, it grows on the ovaries and on the surfaces of organs near the womb, but occasionally endometriosis can affect organs quite far removed from the womb, for instance the lungs. This tissue is sensitive to female hormones produced by the ovaries – just as the normal lining of the womb. Hence we find that endometriosis typically affects women in their reproductive years (when their ovaries are active) but ceases to be a problem after the menopause (when the ovaries stop releasing hormones to the same extent).

Women with endometriosis may suffer from a number of problems. It may cause pelvic and lower abdominal pain and be associated with difficulty in conceiving. Some women may suffer from very severe pain, including pain during and before periods and during intercourse. Some may find it very painful to open their bowels. Many women find they are tired all the time, despite leading a healthy lifestyle and others find their personal, social and work lives are badly affected by their symptoms.

I believe that endometriosis can have a serious damaging effect on a woman’s physical and emotional well-being. Accordingly, it is important to confirm a diagnosis of endometriosis at an early stage, establish the full extent of the disease and use all applicable measures at our disposal to help the woman.

Support for women living with Endometriosis can be found at http://www.endometriosis-uk.org/

How is endometriosis diagnosed?

In many cases, a suspicion of endometriosis is raised by the patient’s complaints of significant pain. Gynaecological examination may also provide useful information, particularly if areas of endometriosis (called ‘nodules’) can be felt by the doctor. However, some women with endometriosis find internal examinations very painful and I do not always perform one for this reason. In some women with endometriosis, the ovaries develop cysts filled with altered blood – these can be seen by a simple ultrasound scan, which may be helpful in diagnosis. These days, more and more reliance is placed on a method of imaging the body called MRI (Magnetic Resonance Imaging) which allows ‘pictures’ of the internal organs with great clarity. This can identify, not only cysts but also more subtle areas of endometriosis and in particular whether the bowel is likely to be involved.

The procedure that can diagnose, or rule out, endometriosis with the most reliability is Laparoscopy. This involves a general anaesthetic and the insertion of a camera through the belly button into the tummy. The doctor can examine the ovaries, fallopian tubes, womb and other organs. If endometriosis is present, it can be diagnosed and the full extent mapped. A major advantage of laparoscopy is that it allows the doctor to treat the endometriosis at the same time (provided of course the patient is prepared for this). However, laparoscopy is invasive and, like any surgical procedure, it carries a risk of complications. The balance of risk versus benefit varies from one individual to another, and my approach is to individualise the plan of investigation and treatment to suit your needs and clinical features.

How is endometriosis treated?

Surgery:

What does it involve?

All stages of endometriosis can be treated by operation, although it may not always be the best option. In most cases, operations can be carried out by the ‘keyhole’ method, using laparoscopy. This usually involves an incision within the bellybutton and two smaller cuts lower down, one on each side. The endometriosis can either be removed entirely, or destroyed by heat energy. In most cases this involves an overnight hospital stay, followed by a few weeks recovery. The small skin incisions are closed with absorbable sutures which do not need removal, but if they are irritating you skin they can be taken out after a week.

What are the risks?

Laparoscopic surgery is usually safe, but like any operation, it does carry some risks. In general, serious complications occur in around 1 in 1000 cases (0.01%), but in some women the risk is greater. This is especially so in women who have had previous operations on their abdomen or who are obese or very thin. Some types of endometriosis surgery, particularly where the surgeon is attempting to remove endometriosis from around the bowel or ureter, is also more likely to be associated with injury to these organs, which then requires major emergency surgery to put right.

Is it right for me?

My approach is to enable you to consider your options after being fully informed about them. If you are trying to conceive, hormone treatment is not appropriate as it prevents conception. In such cases, surgery is likely to be the better option. The same applies when there are large endometriotic cysts (‘chocolate cysts’) – drug treatment is unlikely to lead to these disappearing completely and surgery is usually needed. On the other hand, if you have previously had several operations for endometriosis or have other risk factors, then drug treatment may carry fewer risks than surgery. Like in most areas of life, the aim should be to work out the best choice for your needs, in your particular situation

Drug treatment

What does it involve?

Endometriosis is sensitive to the hormones produced by the ovaries and this means that manipulating these hormones can suppress the symptoms of endometriosis. A relatively simple hormonal treatment is the oral contraceptive pill, which has been shown to improve the pelvic pain and heavy periods associated with endometriosis. Similar benefits can also be obtained from using the Mirena Intra-Uterine System, a coil that releases a small amount of hormone within the womb.  A more profound suppression of the ovaries can be achieved by using drugs called GnRH analogues. These block the release of hormones from the pituitary gland that ‘drive’ the ovaries. An example of this type of drug is Zoladex and this is given by injection every 4 weeks for 6 injections.

What are the risks?

The combined pill and Mirena coil are widely used for contraception, but do carry a small element of risk. For instance, the pill should not be used in women over 35 who smoke, or those with focal migraines, liver problems or thrombosis.  Drugs like Zoladex can cause hot flushes and other menopause-like symptoms, as well loss of minerals from the bones. However, these problems can be largely avoided by using supplementary hormones tablets – this is called ‘add-back’ and makes the Zoladex easier to tolerate and safer, without compromising its efficacy.

Is it right for me?

Once again, this depends entirely on your situation and clinical features and my approach is help you individualise the treatment regime that suits your particular case. Clearly, if you are trying for a baby, drug treatment is not a good idea as it is contraceptive. However, in some cases where you are about to commence IVF treatment, a few months of GnRH analogue pre-treatment has been shown to improve the chance of a successful outcome. If contraception is needed, a trial of drug treatment is often a better and safer option than surgery.