Diagnosis most often occurs in women aged 25-40 years. Endometriosis can affect almost any part of the body. Abnormal sites for endometrium include pelvic organs such as the outside of the womb, the vagina, fallopian tubes and ovaries. It can also include abdominal organs such as the liver, stomach or intestines and also the thorax with the lung being involved although this is rare.

The endometrium which lines the uterus undergoes monthly changes of thickening and breakdown if no pregnancy occurs. This breakdown leads to menstrual blood loss to empty the uterus in preparation for the next cycle. The endometrium present in other abnormal sites undergoes the same process of thickening and development initially, followed by breakdown and bleeding. However, as there is no outlet for these cells and blood, symptoms of pain, swelling and bleeding develop in these areas. This eventually leads to irritation of the surrounding tissues and organs with inflammation and scar tissue formation. As with many conditions, symptoms vary in severity in different women from mild to severe.

Typical Symptoms

Many women have no symptoms and the condition is diagnosed incidentally. But, common symptoms include;

• Painful periods (dysmenorrhoea)
• Heavy periods (menorrhagia)
• Pelvic or lower abdominal discomfort and pain
• Pain during sex (dyspareunia)
• Pain at other times in the menstrual cycles
• Back pain
• Failure to conceive
• Less commonly, women also complain of;
• Pain on urination or difficult with urinating
• Rectal bleeding
• Blockage of the bowel
• Coughing up blood (haemoptysis)

The presence and severity of these symptoms depends on where your abnormal endometrial tissue is located.

Causes of Endometriosis

The exact cause of endometriosis remains unclear, but possible explanations include;

1. Retrograde Menstruation: when endometrial tissue breaks down, most leaves through the cervix and vagina as menstrual blood. But it is thought that some flows upwards through the fallopian tubes and into the abdomen. Once there, the endometrial cells embed themselves onto the surface of pelvic and abdominal organs.
2. Genetic: endometriosis is commoner in Asian women, less common in Caucasians and least common in Afro-Caribbeans. It can also be traced in families suggesting a genetic link.
3. Spread via the blood or lymphatic circulation: endometrial cells may spread via these circulatory systems and travel to distant parts of the body. This may explain how cells are found in the eyes or the brain, although this occurs rarely.
4. Metaplasia: this is when one cell type changes to another cell type. It has been postulated that there may be a developmental problem in the foetal womb, thereby giving rise to endometriosis in later life. Uterine cells may be responsible for cell transformation.
5. Immune disorder: it is thought that affected women have a deficiency in their immune system. They are therefore unable to clear these abnormal cells from their bodies.

Diagnosing Endometriosis

Diagnosis is usually suspected from the clinical symptoms which women have. For confirmation, a procedure known as a laparoscopy is done under general anaesthetic. A thin tube with a light and camera is inserted into the appropriate area (usually the lower abdomen and pelvis) to view the inside of the body. Any suspected areas are biopsied (a small sample is taken) for analysis.

Treatment of Endometriosis

Treating this condition can sometimes be difficult as there is no one specific cure. Treatment aims to reduce the symptoms and sometimes to reduce the areas of endometrial patches in different abnormal locations. The various methods used for this are outlined as follows;

1. Pain Management: standard pain killers such as paracetamol or codeine containing preparations can be used to reduce and relieve pain. In addition, anti-inflammatory medication such as ibuprofen, diclofenac or mefenamic acid tablets may be used to reduce areas of swelling and inflammation which cause pain.
2. Hormone therapy: there are various types of hormonal drugs that are used to block the development of abnormal endometrial activity. These aim to reduce the effects of oestrogen which are crucial in driving the condition. These hormones therefore enable a body to either mimic an artificial pregnancy or the menopause. The main hormone treatments are;
   • Progestogens: these stop ovulation
   • Anti-progestogens (testosterone derivatives): induces a menopause like state by reducing oestrogen and progesterone.
   • Combined oral contraceptive pill (COC): this can help with mild endometriosis symptoms by stopping ovarian function and block the menstrual cycle.
   • Gonadotrophin releasing hormone (GnRH) analogues: cause a menopause like state.
3. Surgery: this can be used either to remove individual areas of endometrial tissue using laparoscopic surgery or by removal of the uterus (hysterectomy) if no further children are planned.
4. A watch and wait approach can be tried for those women with mild symptoms as occasionally, the condition resolves by itself. If it does not, any one of the above options can then be tried.