Endometriosis - Types, Symptoms, Risk factors, Causes and treatment

Endometriosis meaning

Endometriosis is a word derived from the Greek word “endo,” which means “inside or within,” “metra,” which means “uterus,” and osis means “state of disease.” Commonly, most of the endometriosis is found on the:

• Ovaries
• Fallopian tubes
• Tissues that hold the uterus in place
• The outer surface of the uterus

Other sites for endometrial growths may include:

• Vagina
• Vulva
• Cervix
• Bowel
• Bladder or rectum

 Rarely, endometriosis may appear in

• Lungs
• Brain
• skin

Approximately 10 in every 100 women of reproductive age are affected by endometriosis. It is caused due to a combination of several genetic and environmental factors, which infers 24.7 crore girls and women globally.

It is estimated that endometriosis affects approximately 10-15% of women of reproductive age, as many as half of all women with decreased fertility, and 70-90% of women who are suffering from chronic pelvic pain. Surprisingly, endometriosis may be possible in males taking high doses of oestrogen, which is extremely rare.

Endometriosis prevalence in India

In the Indian population, various studies have shown the incidence of endometriosis to range from 34% to 48% as diagnosed by laparoscopy. A recent study found out that there are about 4.2 crore females in India. The significant incidence of endometriosis is thought to be in women aged 25-35 years. However, this condition is less common in younger females and post-menopausal women.

Endometriosis is characterised by the presence of endometrium (the inner lining of your uterus) such as tissue and lesions (stroma) outside the endometrium and myometrium (the muscular outer layer of the uterus) and is usually with an associated inflammatory process.

Most endometriosis is found inside the abdominal cavity and exists in three subtypes. The following are the three types of endometriosis:

• Superficial peritoneal endometriosis (pelvic endometriosis): Endometrial-like tissue develops along the lining of the abdominal cavity, which accounts for  around 80% of endometriosis.
• Ovarian endometriosis: These are cystic masses (abnormal growths or fluid-filled sacs) caused by the development of the endometrial tissue inside the ovary containing dark bloodstained fluid (chocolate cysts). These are also called endometriosis ovarian cysts or “endometriomas.”
• Deep infiltrating endometriosis: A severe form of endometriosis where the lesions penetrate deeper than 5mm below the peritoneal surface (membrane lining the abdominal cavity) found in the recto-vaginal septum, bladder and bowel).

Some of the other types of endometriosis include:

• Extra-abdominal endometriosis: Endometrium-like tissue outside the abdominal cavity (for example, thoracic, umbilical, brain endometriosis)
• Iatrogenic endometriosis: Direct or indirect dissemination (spreading) of endometrium tissue following surgery (for example, caesarean scar endometriosis).
  

Signs and symptoms of endometriosis may not be the same for all women and usually be cyclic and worsen at the time of menstruation because these endometriotic lesions are hormonally responsive. During anovulation periods, such as menopause, pregnancy, lactation, and hormone-induced amenorrhoea (not having regular periods), symptoms are usually reduced or eliminated.

• Endometriosis pain: It is the most common symptom in most women. The kind and intensity of endometriosis pain depends on endometriosis pain location. These include:
• Endometriosis ovulation pain: Very painful menstrual cramps: This type of pain may get worse over time.
• Endometriosis pelvic pain: Chronic pain in the pelvis area and lower back.
• Endometriosis pain during intercourse: It may describe as “deep” pain, which is not the same as the pain that a woman feels at the entrance of the vagina when penetration starts. It can also be seen after intercourse in some cases.
• Endometriosis abdominal pain: it is also called endometriosis intestinal pain.
• Endometriosis and bowel pain: Pain or painful bowel movements when the patient is urinating during menstrual periods. 
• Endometriosis vaginal bleeding or spotting: It may see in between the menstruation cycle that is caused by something other than endometriosis. In rare cases, patients may also find blood in urine or stool.
• Endometriosis heavy periods: The patient may have to use lots of pads or tampons, or the patient may bleed through the clothes.
• Endometriosis infertility: The main clinical symptoms of the disease are chronic pelvic pain and impaired fertility. It is significantly more common in patients with endometriosis, with a doubling of risk compared with women without endometriosis.
• Endometriosis and stomach problems: Endometriosis women may experience more abdominal pain, constipation, bloating, and flatulence, especially during menstrual periods.
• Silent endometriosis: Some women with endometriosis may not have any symptoms (asymptomatic endometriosis). They are usually surfaced upon examining any unexplained infertility.

Risk factors for developing endometriosis

Although the cause of endometriosis remains unclear, some environmental and genetic factors are considered endometriosis risk factors for its manifestation and progression. Several factors have been associated with the risk of developing endometriosis, including as follows:

• Early age at menarche (age below 11 years old): If the woman starts menstruation at a young age, usually before age 11, this may increase the risk of developing endometriosis due to more years of menstrual cycles in the woman's reproductive life.
• Shorter duration of menstrual periods (less than 27 days): The menstrual cycle length is not the same for all women and varies greatly from woman to woman (ranging from 21 to 35 days). The length of the menstrual cycle shorter than or equal to 27 days (SEQ27) raises the risk of endometriosis, and the length LEQ29 decreases the risk.
• Nulliparity (state of never being pregnant yet): As per the researchers, it was found that there is a twofold increased risk of endometriosis among nulliparous women, which might be linked with the early use of oral contraceptive pills (OCPs) (nulligravida endometriosis).
• Family history of endometriosis: If a woman's family has endometriosis, there is an increased risk of developing endometriosis.
• Hormonal status of the woman: When the hormones become unbalanced in women (high oestrogen levels and low progesterone), the body may increase the risk of developing oestrogen-dominant conditions such as endometriosis.
• Müllerian anomalies: Mullerian anomalies refer to abnormal anatomy that arises during the formation of female reproductive organs.
• Outflow obstructions: Outflow obstructions, such as a transverse vaginal septum, cervical stenosis, or an imperforate hymen, may cause this condition.

Research revealed that there are protective factors that act by decreasing the levels of oestrogen in the body or lowering the inflammatory process. The following are the protective factors that reduce the risk of endometriosis:

• Parity, protracted breastfeeding: Prolonged breastfeeding seems to suppress the development of endometriosis by causing postpartum amenorrhea (delay of menstruation after childbirth) but also with other mechanisms.
• Tubal ligation: Tubal ligation (a permanent form of contraceptive in which a fallopian tube of a woman is tied or blocked) is thought to be one of the protective factors because it decreases the chance of endometriosis by blocking the menstrual blood flow to reach the pelvic cavity.
• Current oral contraceptive use: Contraceptive use and parity (number of times a woman has given birth) may interfere with the occurrence of ovulation. Whenever ovulation occurs, it triggers inflammation and the release of specific cytokines in the body. These cytokines enhance cell growth and oxidative stress, increasing the production of substances that cause further discomfort and inflammation.
• Other factors: Additionally, primary amenorrhea (not having regular periods), being physically active, and other dietary and lifestyle habits such as increased intake of omega-3 fatty acids and smoking are linked with decreased risk of endometriosis. Surprisingly, smoking is associated with a reduced risk of endometriosis, where commonly, it has harmful effects on other health issues.
• Early adult body mass index (BMI): Early adult BMI is inversely proportional to endometriosis.

Studies demonstrated a risk of obstetrical complications (increased risk of placental complications) among women suffering from endometriosis. This could lead to an increased risk of obstetrical haemorrhage during labour as well as in pregnancy. A detailed list of complications which may be experienced by women with endometriosis include:

Fertility problems (endometriosis and pregnancy)

• The main problem with endometriosis could arguably be the difficulty in the patient to get pregnant (subfertility) or not being able to get pregnant at all (infertility).
• While endometriosis medication may not improve the fertility, there are cases of fertility promotion with surgery. Surgery may improve fertility by removing the endometriosis tissue.
• However, surgery is not guaranteed to allow the patient to get pregnant.
• All women with endometriosis may not face this problem, and some women will eventually be able to conceive without any treatment.
• If the patient is having difficulty getting pregnant, infertility treatments such as in vitro fertilization could be an option.

Adhesions and ovarian cysts

• Some women with endometriosis may develop adhesions (sticky areas of endometriosis tissue that can fuse organs together), and endometriomas (fluid-filled cysts in the ovaries) can sometimes become very large and painful.
• They may occur if the endometriosis tissue is on or near the ovaries (endometriosis ovarian cyst).
• These adhesions and ovarian cysts can be treated with surgery, but they may revert in the future if the patient gets endometriosis again.

Diagnosis of endometriosis might be challenging, as some studies show a delay in diagnosis by 4–10 years, resulting in disease progression and reduced quality of life. Therefore, timely diagnosis and initiation of management of endometriosis is vital in reducing painful symptoms, improving quality of life, and managing fertility. The common diagnostic tests include:

• Pelvic exam: Endometriosis pelvic examination may be used to feel the large cysts or scars behind the uterus.
• Endometriosis ultrasound: Gynaecologists may recommend ultrasound (endometriosis usg) to picture the reproductive organs and check for ovarian cysts from endometriosis.
• Magnetic resonance imaging (MRI): Pelvic MRI endometriosis is another common imaging test that can make an imaging of the inside of the body.
• Endometriosis medication: If the gynaecologist does not find signs of an ovarian cyst during an ultrasound, some hormonal medications may be recommended to check whether the pain is getting better or not to diagnose endometriosis.
• Laparoscopy endometriosis: It is a minimally invasive surgery (uses small incisions) used to look inside the pelvic area to see endometriosis tissue.
• Endometriosis biopsy test: In the endometrial biopsy test, a small tissue sample is extracted from the lining of the uterus (endometrium) which will be sent to the pathologist department for study. The pathologist then observes the endometrial tissue under a microscope to see if any abnormal cells are developed.

Endometriosis can be treated symptomatically with contemporary medicines and devices as the cure for endometriosis is yet to be discovered. The treatment of endometriosis depends on the patient’s decision to get or not get pregnancy.

• If the patient opts to be pregnant, then endometriosis drugs such as hormonal contraceptive are usually the first step of treatment. This may include:
• Extended-cycle or continuous contraceptives: These are available in the form of pills and help to reduce pain or to stop bleeding.
• Intrauterine device (IUD): It protects against pregnancy for up to 7 years. IUD helps reduce pain and bleeding. However, it may not be effective if the endometriosis occurs for a long time.
• If the patient opts not to be pregnant, endometriosis medication such as GnRH agonists may be prescribed by the gynaecologist. These medicines help stop the woman's body from secreting specific hormones responsible for ovulation, the menstrual cycle, and the growth of endometriosis.
• Endometriosis surgery: Endometriosis laparoscopic surgery may be recommended if the patient has severe symptoms, when hormones are not providing relief, or if the patient is having fertility issues.
• Surgery will be performed either to cut away patches of endometriosis tissue or to remove part or all of the organs affected by endometriosis. Other treatments are also recommended alone or with any of the following treatments:
• Endometriosis pain treatment: Over-the-counter medicines may be suggested to treat mild symptoms such as mild pain etc.

Endometritis and endometriosis are two different conditions. Endometritis is caused by a bacterial infection within the uterus, whereas endometriosis is never caused by an infection. Although these are not similar, both conditions affect the uterus. The following are the differences between endometritis and endometriosis:

Polycystic ovarian syndrome (PCOS) and endometriosis are gynaecologic disorders, but both are completely different conditions where the differences between them may include as follows: