Endometriosis – Glengarry Hospital, Perth

What is endometriosis?

Endometriosis (or endo) is where the tissue lining the womb gets outside the womb and implants elsewhere, typically in the pelvis. The endo then bleeds every month just like your normal menstrual cycle. As the blood can’t leave the body, it causes inflammation & scarring. Classic locations are the ovaries, behind the ovaries, at the top of the vagina and on the womb and it’s ligaments.

What symptoms does endometriosis cause?

• Painful periods
• Pain before the periods start
• Heavy periods with clots
• Infertility | subfertility
• Long periods
• Back pain at any time in the cycle
• Pelvic pain at any time in the cycle
• Abdominal pain at any time in the cycle
• Thigh pain
• Tiredness
• Bloating
• Pain during sex
• Aching after sex
• Pain or bleeding when urinating or opening bowels – during time of period
• Ovarian cysts full of endometriosis – chocolate cysts

How is fertility affected by endometriosis?

Endometriosis contributes to subfertility, with a third of women presenting with infertility, having endo at laparoscopy. The reasons are:

• Direct damage caused by inflammation & scarring of the Fallopian tubes and ovaries.
• Toxic effects of inflammation, affecting sperm and embryo implantation. 

Medical treatments are no good in infertility as they prevent ovulation. An exception to this rule is when we downregulate & suppress endometriosis, prior to an IVF stimulation attempt.

How is endometriosis diagnosed?

Ultrasound

Useful for detecting chocolate cysts on the ovary. Also now being used to diagnose nodules between the vagina and rectum, by filling the vagina with fluid. Won’t pick up any other of the usual endometriosis lesions however – they’re just too small.

CA-125

Slightly useful. Elevated if there’s lots of inflammation. However, lots of other conditions cause it to rise as well.

Laparoscopy

Laparoscopy is the gold standard method of diagnosis. It allows detection of very small lesions which are not seen on ultrasound scans.

Treatment by destruction & excision is almost always performed at the same time as diagnosis, for maximal safety, cost-effectiveness, and convenience. An exception to this is if the disease is severe, when a multi-stage laparoscopic treatment is appropriate, with other specialities like colorectal surgery needed in case of involvement of the bowel.

Medical Treatments

• Painkillers
• Tranexamic acid. clotting medication to reduce heavy bleeding
• Hormones eg the pill taken continuously or by tricycling, or high dose progestins like Provera, inhibit endometriosis and are useful
• Zoladex. Inhibit endometriosis. It’s a monthly injection used for 6 months.
• Mirena is helpful as it inhibits development of the endometriosis
• Visanne this novel hormonal treatment is effective at suppressing & even treating endometriosis.

Surgical Treatment of endometriosis

• Laparoscopy. Laparoscopic treatment is the gold standard, as it allows better visualisation of endometriosis, with accurate excision & destruction. Recovery is rapid, and scars are minimised.
• Hysterectomy. If fertility is not needed and the endometriosis is severe, then hysterectomy can be utilised. Ideally, the ovaries should be removed at the same time, to avoid reactivating any lesions. This ovarian removal has it’s own disadvantages, some of which can be solved with low dose HRT.

Natural treatments for endometriosis

• Agnus Casta | Chaste tree. This plant has hormonal effects that help with menstrual pain due to endo and PMS | PMT. Take 1g daily
• Vitamin E tablets. Vitamin E is useful for period pain due to endo, and is also used in IVF to enhance egg quality. Take 500-1000 units twice daily before & during the period.
• Vitamin B6. Useful for several menstrual problems such as endometriosis, period pain, PMS | PMT, and is used in IVF to enhance egg quality.
• Zinc. Zinc at normal doses may be helpful in endometriosis, if you have a poor diet.