What is endometriosis?
The lining of the womb is called endometrium; if endometrial-type tissue is found outside the womb it is called endometriosis. Endometriosis is most commonly found in the pelvis notably on the ovaries and behind the uterus (Figure 23.2). It can involve the bowel and urinary tract. The diagnosis is confirmed by direct visualisation usually by laparoscopy. There is a very large spectrum in the severity of endometriosis: It may consist of no more than a few tiny spots or at the other extreme, there may be extensive disease with cysts filled with a chocolate-like material and scar tissue around the pelvis. The chocolate cysts are derived from blood released by the endometriosis at the time of menstruation. Endometriosis is essentially a condition occurring in the pelvis. There are rare occasions when it may occur elsewhere such as in the lung.
How can endometriosis be treated?
Medical treatment takes account of the dependence of endometriosis on sex hormones by reducing oestrogen levels or by creating a largely progestogenic or androgenic (Q 2.9) environment. It is not yet clear whether treatments designed to reduce menstrual flow exert their benefit by reducing the activity of the endometriotic deposits or by suppressing retrograde menstruation ( 6) and hence deposition of endometrial cells.
- Reducing menstrual flow by the combined oral contraceptive pill0804 or with the LNG-IUS (Mirena) for example may be beneficial.
- Progestogens (Q33.10) or danazol (Q33.13) can be prescribed daily for several months to suppress the menstrual cycle.
- The LNG-IUS (Mirena) is effective in the treatment of chronic
pelvic pain (CPP) associated endometriosis, although no differences
were observed between it and GnRH. Among the additional advantages of
the LNG-IUS is the fact that it does not provoke hypoestrogenism and
that it requires only one medical intervention for its introduction
every 5 years. This device could therefore become the treatment of
choice for CPP-associated endometriosis in women who do not wish to
conceive.0502Insertion
of an Lng-IUD after laparoscopic surgery for symptomatic endometriosis
significantly reduced the medium-term risk of recurrence of moderate or
severe dysmenorrhea.0301
- Intrauterine progestogen (Mirena-LNG-IUS) is effective in symptom control throughout the 5 years on the device, and discontinuation is greatest between 3 and 6 months. For those patients with improvement in symptoms, it is an acceptable long-term alternative.0503 TheMirena is effective in symptom control throughout the 3 years on the device, and discontinuation is greatest between 3 and 6 months. For those patients with improvement in symptoms, it is an acceptable long-term alternative. The levonorgestrel intrauterine system is an effective hormonal option for treating symptomatic endometriosis (minimal to moderate). It also alters the American Fertility Society staging of disease. With a continuation rate of 68% after 6 months, it has the potential for providing long-term therapy in a substantial number of sufferers, although this would require further study and verification.0401 The Mirena greatly reduces pain associated with endometriosis and adenomyosis and delays disease recurrence. Irregular bleeding and spotting is the main side effects. Administration of GnRHa in advance does not improve the bleeding symptoms.0603
- Endometriosis tends to disappear after the menopause. A relatively new set of drugs called gonadotrophin releasing hormone analogues (GnRH –gonadotrophins) provide a temporary menopause like state and they have proven value in the treatment of endometriosis. They should usually be used for a maximum of six months at a time as there is concern that prolonged suppression of oestrogens may have an adverse effect on the bones and arteries. In some circumstances it may be appropriate to continue GnRH analogues in combination with add-back HRT therapy (Q 27.27).
- Exercise is associated with a reduction of oestrogen and sometimes helps.
- It is acceptable to provide a trial of medical treatment for presumed endometriosis without performing a diagnostic laparoscopy first ( laparoscopy).
- Some gynaecologists treat endometriosis by laser or diathermy during laparoscopy. Studies are currently underway to compare the relative merits of GnRH analogues and laser therapy. Almost invariably, removing the ovaries will cure endometriosis and this may be the operation of choice combined with hysterectomy (hysterectomy) once your family has been completed.
- The relationship between endometriosis and pelvic pain is open to debate. It is a common observation that the severity of symptoms and the severity of the endometriosis do not correlate. Some with severe pain have just a few tiny spots of endometriosis whilst others with severe endometriosis may be symptom free. In a series of 33 patients having a second laparoscopy for persistent pelvic pain after laser therapy, more than half had no evidence of residual endometriosis. We should therefore be cautious in assuming that when endometriosis is discovered that it is necessarily the cause of pain. Failure of symptoms to respond to treatment may suggest that the endometriosis is not the cause of the pain rather than that the treatment of the endometriosis is not effective.
- The classic, unproven dogma that ovarian endometrioma should be
removed in all infertile women prior to IVF has been recently
questioned. Both endometrioma-related injury and
surgery-mediated damage may be claimed to be involved and the
relative importance of these two insults remains to be clarified.
Convincing evidence has emerged showing that responsiveness to
gonadotrophins after ovarian cystectomy is reduced. Conversely, the
impact of surgery on pregnancy rates is unclear since no deleterious
effect has been reported. Of relevance here is that surgery exposes
women to risk related to a demanding procedure whereas risks
associated with expectant management are mostly anecdotal or of
doubtful clinical relevance. Juan et al0807 recommend proceeding directly to IVF
to reduce time to pregnancy, to avoid potential surgical
complications and to limit patient costs. Surgery should be envisaged
only in presence of large cysts, or to treat concomitant
pain symptoms which are refractory to medical treatments, or when
malignancy cannot reliably be ruled out.
Guideline for treatment - ESHRE
Related Medical Abstracts - Click on the paper title:-
- Treatment strategies for endometriosis.(2008-01)
- Clinical effects of the levonorgestrel-releasing intrauterine device in patients with adenomyosis.(2008-02)
- Management of the pain associated with endometriosis: an update of the painful problems. (2006-01)
- Recurrence rate of endometriomas following a laparoscopic cystectomy. (2006-02)
- Effects of levonorgestrel-releasing intrauterine system on pain and recurrence associated with endometriosis and adenomyosis.(2006-03)
- The role of the levonorgestrel-releasing intrauterine device in the management of symptomatic endometriosis. (2005-01)
- Randomized clinical trial of a levonorgestrel-releasing intrauterine system and a depot GnRH analogue for the treatment of chronic pelvic pain in women with endometriosis.(2005-02)
- The efficacy, side effects and continuation rates in women with symptomatic endometriosis undergoing treatment with an intra-uterine administered progestogen (levonorgestrel): a 3 year follow-up.(2005-03)
- The evaluation of the effectiveness of an intrauterine-administered progestogen (levonorgestrel) in the symptomatic treatment of endometriosis and in the staging of the disease.(2004-01)
- Comparison of a levonorgestrel-releasing intrauterine device versus expectant management after conservative surgery for symptomatic endometriosis: a pilot study. (2003-01)
- Modern combined oral contraceptives for pain associated with endometriosis. (2002-02)
- Use of a levonorgestrel-releasing intrauterine device in the treatment of rectovaginal endometriosis (2001)
- Post-operative GnRH analogue treatment after conservative surgery for symptomatic endometriosis stage III-IV: a randomized controlled trial. (2001-02)
- Long-term use of gonadotropin-releasing hormone analogs and hormone replacement therapy in the management of endometriosis: A randomized trial with a 6-year follow-up (2000).
- A gonadotrophin-releasing hormone agonist compared with expectant management after conservative surgery for symptomatic endometriosis. (1999)
- Low-dose danazol after combined surgical and medical therapy reduces the incidence of pelvic pain in women with moderate and severe endometriosis. (1999)
- Add-back therapy and gonadotropin-releasing hormone agonists in the treatment of patients with endometriosis: Can a consensus be reached? (1999)
- Randomized clinical trial of two laparoscopic treatments of endometriomas: cystectomy versus drainage and coagulation. (1998-02)
- Effectiveness of tibolone on hypoestrogenic symptoms induced by goserelin treatment in patients with endometriosis (1997).
- Progestins for symptomatic endometriosis: A critical analysis of the evidence (1997)Treatment of endometriosis with the antiprogesterone mifepristone (RU486) (1996-01).
- Prognostic application of magnetic resonance imaging in patients with endometriomas treated with gonadotrophin-releasing hormone analogue (1996-02).
- The need for add-back with gonadotrophin-releasing hormone agonist therapy (1996-03).
- Laparoscopy versus laparotomy in conservative surgical treatment for severe endometriosis (1996-04).
- Comparison of the gonadotropin-releasing hormone agonist goserelin acetate alone versus goserelin combined with estrogen-progestogen add-back therapy in the treatment of endometriosis (1995).
- Gonadotropin-releasing hormone analogue (goserelin) plus hormone replacement therapy for the treatment of endometriosis: A randomised controlled trial (1995).
- A multicentre comparative study of gestrinone and danazol in the treatment of endometriosis (1995)
- Endoscopic versus laparotomy management of endometriomas (1994)
- Very low dose danazol for relief of endometriosis-associated pelvic pain: a pilot study (1994)
- relating personal experiences,
- listening to others' experiences,
- providing sympathetic understanding and
- establishing social networks.
- http://www.4woman.gov/faq/endomet.htm
- http://www.centerforendo.com/
- http://www.endocenter.org/
- http://www.endometriosisassn.org/
- http://www.endo.org.uk/
- http://www.endozone.org/
- http://www. Infertilityalabama.com/
- http://www. Ivf.com/endoassn.html
- http://www. Medstudents.com.br/ginob/ginob3.htm
- http://www.nlm.nih.gov/medlineplus/endometriosis.html
- http://www.obgyn.net/endo/endo. Asp
- Pelvic Pain. Is this a common problem?
- What are the common causes of pelvic pain in women?
What are the more common gynaecological causes of pelvic pain?
What are the more common non-gynaecological causes of pelvic pain?
What are primary and secondary dysmenorrhoea - painful periods?
What is retrograde menstruation?
How can dysmenorrhoea - painful periods be treated?
What are ovarian cysts?
How do ovarian cysts cause pain?
How are ovarian cysts diagnosed?
How are ovarian cysts treated?
I think I may be pregnant and I have some pelvic pain. What should I do?
What is pelvic inflammatory disease and how can it be treated?
- 3 What are the more common gynaecological causes of pelvic pain?
- 4 What are the more common non-gynaecological causes of pelvic pain?
- 5 What are primary and secondary dysmenorrhoea - painful periods?
- 6 What is retrograde menstruation?
- 7 How can dysmenorrhoea - painful periods be treated?
- 8 What are ovarian cysts?
- 9 How do ovarian cysts cause pain?
- 10 How are ovarian cysts diagnosed?
- 11 How are ovarian cysts treated?
- 12 I think I may be pregnant and I have some pelvic pain. What should I do?
- 13 What is pelvic inflammatory disease and how can it be treated?
FIBROIDS
- What are Fibroids?
I have Fibroids. What difficulties might they cause for me?
How are Fibroids diagnosed?
How could my Fibroids be treated?
I have Fibroids. What difficulties might they cause for me?
How are Fibroids diagnosed?
How could my Fibroids be treated?
- 16 How are fibroids diagnosed?
- 17 How could my fibroids be treated?
ENDOMETRIOSIS
- 18 What is endometriosis?
- 19 How prevalent is endometriosis?
- 20 What causes endometriosis?
- 21 How can my endometriosis be treated?
- 22 How can my doctor determine the cause of my pelvic pain?
- 23 What investigations might be recommended by my gynaecologist to investigate my pelvic pain?
- 24 What is laparoscopy?
- 25 What are pelvic adhesions?
- 26 I have chronic pelvic pain. Could this be related to adhesions?
- 27 What is uterine retroversion (retroverted uterus)?
- 28 Does a retroverted uterus cause symptoms?
- 29 How is a retroverted uterus treated?
- 30 What is pelvic congestion?
- 31 What causes pain associated with sexual intercourse (dyspareunia)?
- 32 How can painful sexual intercourse (dyspareunia) be treated?
- 33 What is a pelvic mass?
- adenomyosis
IRRITABLE BOWEL SYNDROME - IBS
- 34 What is irritable bowel syndrome?
- 35 How can we find out if I have irritable bowel syndrome?
- 36 Is irritable bowel syndrome (IBS) a common condition?
- 37 What causes IBS?
- 38 What is the pain associated with IBS like?
- 39 Can IBS be mistaken for gynaecological problems?
- 40 How can my IBS be managed?
- 41 What other treatments are available for IBS?
- 42 What can be done to reduce the amount of bowel gas(flatus)?
- 43 What is constipation?
- 44 What causes constipation?
- 45 How can constipation be treated?
- 46 How could we summarise the treatments that are available for my pelvic pain?
- 47 Where can I obtain more information?
- 48 Support Groups.
Support Groups
National Endometriosis Society
50 Westminster Palace Gardens
1 7 Artillery Row
London SW1pRL
Tel: 020 7222 2781
Endometriosis Support Groups:
Members of a support group, provide each other with various types of help and information for a particular shared difficulty.
The support may take the form of providing relevant information,
A support group may also provide ancillary support, such as serving as a voice for the public or engaging in advocacy.
Support groups maintain interpersonal contact among their members in a variety of ways.
Support groups also maintain contact through printed information rich newsletters, telephone chains, internet forums, and mailing lists.
Support groups offer companionship and information for people coping with diseases or disabilities. Support groups may not be appropriate for everyone, and some find that a support group actually adds to their stress rather than relieving it.
Evaluation of the quality of Web sites is discussed in (Q4.27). You may find that several general women's health sites may help you (internet information). The following are more specialised relevant Web sites:-
Please click on the required question.
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This is the personal website of David A Viniker MD FRCOG, Consultant Obstetrician and Gynaecologist at Whipps Cross University Hospital, London - Specialist Interests - Reproductive Medicine including Infertility, PCOS, PMS, Menopause and HRT.
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