The endometrium is the tissue that lines the inside of the uterus (womb). Endometriosis is a condition where endometrial tissue is found outside the uterus. If symptoms develop they typically begin between the ages of 25-40. Sometimes symptoms begin in the teenage years. Endometriosis can affect any woman. However:

  • Endometriosis is more common in close blood relatives of affected women.
  • Endometriosis is rare in women past the menopause.
  • The oral contraceptive pill reduces the risk of developing endometriosis.

What causes endometriosis?

The exact cause is not known. It is thought that some cells from the lining of the uterus get outside the uterus into the pelvic area. They get there by spilling backwards along the fallopian tubes when you have a period. The cells respond to the female hormone oestrogen, just like the lining of the uterus does each month. Throughout each month the cells multiply and swell, and then break down as if ready to be shed at the time of your period. However, because they are trapped inside the pelvic area, they cannot escape. They form patches of tissue called endometriosis.

What are the symptoms of endometriosis?

  • Many women with endometriosis have no symptoms.
  • Painful periods.
  • Painful sex.
  • Pain in the lower abdomen and pelvic area.
  • Other menstrual symptoms may occur. For example, bleeding in between periods.
  • Difficulty becoming pregnant (reduced fertility).

How is the diagnosis of endometriosis confirmed?

Endometriosis is usually confirmed by a laparoscopy. This is a small operation that involves making a small cut in the abdominal wall below the umbilicus under anesthetic. A laparoscope (like a thin telescope) is pushed through the skin to look inside. Patches of endometriosis can be seen by the doctor.

How does endometriosis progress?

If endometriosis is left untreated, it becomes worse in about 4 in 10 cases. It gets better without treatment in about 3 in 10 cases. Complications sometimes occur in women with severe untreated endometriosis. For example, large patches of endometriosis can sometimes cause an obstruction (blockage) of the bowel or of the ureter (the tube from the kidney to the bladder).

What are the aims of treatment?

The main aims of treatment are to improve symptoms such as pain and heavy periods, and to improve fertility if this is affected.

Not treating as an option
If symptoms are mild and fertility is not an issue for you then you may not want any treatment.
Painkillers for endometriosis

Hormone treatments for endometriosis

There are several options. They all have similar success rates at easing pain. However, they do not improve fertility.

The combined oral contraceptive pill ('the pill'). The pill stops ovulation which reduces the amount of oestrogen made by the ovaries. Periods are also lighter and less painful. Other symptoms such as painful sex, and pain in the pelvic area may also improve.

The intrauterine system (IUS) The IUS is a small device made from plastic and contains a progestogen hormone called levonorgestrel. The IUS is put into a woman's uterus (womb) by a doctor or nurse. It is a popular type of contraceptive. However, it can also reduce endometriosis-associated pain. It also greatly reduces or even abolishes bleeding of periods. Once put in place, it can remain effective (for contraception and to ease pain) for up to five years.

GnRH (gonadotrophin releasing hormone) analogues These drugs block the pituitary from releasing gonadotrophins. There are several GnRH analogue preparations which include buserelin, goserelin, nafarelin, leuprorelin, and triptorelin. Some preparations are taken as a nasal spray, some are given by injection. A six month course is usual.

Progestogen hormone tablets These reduce the effect of oestrogen on the endometrial cells which causes the cells to 'shrink'. Progestogens also prevent ovulation which lowers the oestrogen level. Progestogen hormone tablets include norethisterone, dydrogesterone and medroxyprogesterone.

Danazol and gestrinone These drug works mainly by reducing the amount of gonadotrophins that you make. This has a 'knock-on' effect of reducing the amount of oestrogen that you make. Side-effects commonly occur including: weight gain, hair growth, acne, and mood changes.

Surgery for endometriosis

Sometimes an operation is advised to remove some of the larger patches of endometriosis. There are various techniques that can be used. Most commonly, a thin telescope-like instrument (a laparoscope) is pushed through a small cut in the abdomen. The surgeon then uses the laparoscope to see inside the abdomen and to direct heat, or a laser, or a beam of special helium gas to destroy patches of endometrium. Cysts can also be removed via this kind of 'laparoscopic surgery' (key hole surgery). Sometimes a more traditional operation is done with a larger cut to the abdomen to remove larger patches or cysts.

Success of treatment and side-effects

Overall, the hormone treatment options all have about the same success rate at easing pain. However, some women find one treatment better than others. Also, the treatments have different possible side-effects.

Age and plans for pregnancy

Symptoms often improve during pregnancy. Also, the longer you have endometriosis, the greater the chance of reduced fertility. You may need to take this into account if you have plans for having children. If your family is complete, and symptoms are severe, then hysterectomy (removal of the uterus) may be a good option.

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