WHAT IS ENDOMETRIOSIS?

Medically Reviewed by Dr. Sony Sherpa, (MBBS) - August 28, 2024

Every March Endometriosis Month takes place across the world, to increase awareness and highlight the symptoms of this debilitating condition that affects an estimated 176 million women worldwide.

Endometriosis refers to abnormal growth of the endometrium, which is the tissue that lines the inside of a woman's uterus.

It is normal for the endometrium to thicken each month before breaking down and exiting via the menstrual cycle - however, in the case of endometriosis, this tissue begins to grow outside of the uterus, spreading commonly to the fallopian tubes, ovaries, and other tissues lining the female pelvis. In a few patients with endometriosis, this abnormal tissue growth has been shown to spread beyond the pelvic organs.

As with the ordinary tissue growth that occurs during the menstrual cycle, the extra tissue that appears in endometriosis tends to grow in tandem with that cycle. Unlike normal tissue, the abnormal growth has no way to exit the body and thus forms deposits that begin to harden into fibrous bands; either creating cysts (especially in the ovaries) or thick bands of scar tissue after prolonged periods of irritation. These bands of scar tissue may cause organs or other tissues in the pelvis to stick together.[1]

Naturally, this condition often results in fertility problems as well as substantial pelvic pain that tends to get worse over time, particularly during menstruation. Luckily there are many ways to treat this condition.

Symptoms

The biggest giveaway of endometriosis is extreme pelvic pain during menstruation, which usually gets worse over time; as well as female infertility.

This is different from having heavy menstrual cramps, as the pain reported is significantly worse than the average woman with heavy menstrual symptoms. Women with endometriosis may experience cramping or period pains a few days before and after menstruation. Where the condition has progressed for a long time, lower back and abdominal pain can eventually occur without menstruation.

Symptoms of endometriosis include:

• Painful Menstruation
• Excessive menstrual bleeding
• Spotting (bleeding between periods)
• Painful bowel movements or urination (particularly during menstruation)
• Infertility
• Fatigue
• Diarrhea or constipation
• Nausea
• Bloating
• Chronic abdominal pain

The onset of endometriosis and its symptoms usually occur several years after menstruation begins. If the woman manages to fall pregnant, symptoms cease temporarily during pregnancy. After menopause, endometriosis symptoms subside entirely unless supplementing with hormones like estrogen.

Complications

The main complication of endometriosis is infertility. Between roughly 30-50% of women with endometriosis battle to fall pregnant. Abnormal endometrial growths tend to obstruct the fallopian tubes and uterus in general, preventing sperm cells from fertilizing egg cells. Endometriosis also may cause damage to both the egg and sperm while they are in transit.

In exceedingly rare cases, advanced endometriosis may develop into a type of cancer known as endometriosis-associated adenocarcinoma.

A word on Endometriosis and Endometrial Cancer

Endometriosis should not be confused with endometrial cancer. While endometriosis has the potential to develop into a very rare form of cancer, the abnormal tissue that grows in the condition does not produce malignant cancer cells or tumors.

Diagnosis

The first thing any doctor will do if endometriosis is suspected is a pelvic examination, where the doctor palpates the pelvic area to feel and listen out for any abnormalities.[2]

It is notoriously difficult to diagnose endometriosis as the above symptoms are common to several other conditions. Pelvic inflammatory disease, ovarian cysts, polycystic ovary syndrome, and irritable bowel syndrome are among a few conditions that can pose similar symptoms.

There are four stages of endometriosis: minimal, mild, moderate, and severe. Diagnosis usually only occurs in the late stages, as it is difficult to identify endometrial growth in the earlier stages (when there is less growth present).

To make matters more confusing, having severe pelvic and menstrual pain does not automatically mean endometriosis, nor does it mean you have a more advanced form of the condition. Some women with mild endometriosis have severe pain while others with advanced endometriosis have little to no pain at all. However, statistics suggest that ±75% of all women with endometriosis experience pain.

In most cases, endometriosis is diagnosed as a last resort after all other causes of infertility or pelvic pain have been ruled out.

Laparoscopy

The best method for deducing whether a patient has endometriosis or not is via laparoscopy, in which a surgeon uses sophisticated equipment to look inside a patient for abnormal endometrial growths. These growths typically appear as black, dark brown, or blue lesions on organs or other tissues inside the female pelvis.

After it is confirmed that there are internal pelvic lesions, a biopsy should be performed to confirm that endometriosis is the cause.

As this procedure is a rather costly and invasive way to diagnose the disease, doctors usually try to treat patients suspected of endometriosis with hormone replacement therapy first.

Ultrasound & MRI Imaging

Another technique used in conjunction with a laparoscopy is a simple ultrasound test. This involves the use of ultrasound equipment to acquire images of the pelvis and possibly identify endometrial growth. This technique is not as accurate as laparoscopy for identifying endometriosis but may prove useful in ruling out endometriosis before resorting to surgery.

MRI Imaging is very similar but with more accurate results, often used by a surgeon to predict where surgery should be done.

Causes

Nobody knows the exact cause of endometriosis. Seven of the best possible explanations are discussed below.

1. Retrograde Menstruation

Retrograde menstruation refers to menstrual blood flowing in the reverse direction. Instead of exiting, it pushes endometrial tissue up the fallopian tubes and into the pelvic cavity, eventually turning into endometriosis growths as the theory suggests. Women with abnormalities in their uteruses have an increased risk of developing endometriosis, further supporting this theory.

However, one needs to be aware that retrograde menstruation is actually very common, occurring in up to 90% of menstruating women!

Since not every woman gets endometriosis, this theory can't be all there is to developing the disease. There is also one reported case study of a woman with endometriosis who did not have a uterus due to a defect, adding to how this theory can't be the only cause.

2. Coelomic Metaplasia Theory

Coelomic Metaplasia theory states that the cells which line the inner side of the abdomen or coelom (peritoneal cells) begin to transform into endometrial cells due to an interaction between hormones or immune factors.

Both endometrium cells and coelom cells are formed from the same type of cells during embryonic development. Estrogen is namely responsible for the differentiation of these cells, which lead scientists to theorize that estrogen or other hormonal imbalances may cause coelom cells to switch back into endometrium cells.

3. Inflammation & Immune Disorders

It is possible that inflammation plays a role in the onset of endometriosis. Abnormal endometrial tissues have been shown to produce inflammation in the body and sites in the body that have higher amounts of inflammation have been shown to encourage abnormal endometrial growth.[3]

Since auto-immune and other immune disorders tend to produce excessive inflammation via the body's immune system, women with an immune disorder may have a higher chance of developing endometriosis.

4. Lymphatic and Blood Vessel Transport System

A few researchers hypothesize that endometrial tissue is transported via blood vessels or the Lymphatic system, implanting at other sites in the body. This is similar to how a tumor would metastasize, giving rise to multiple tumors all over the body. There is not sufficient evidence to support or debunk this theory.

5. Hormonal Imbalances

Endometrial tissues normally grow and exit as a result of hormonal flux during a woman's menstrual cycle. Once again, Estrogen is primarily responsible for the growth of endometrial tissue, whether normal or abnormal growth. Women with excessive levels of estrogen are at a higher risk of developing endometriosis.

6. Genetics

Women are more susceptible to developing endometriosis when it runs in the family. Genetic mutations that cause abnormal cell growth also appear to promote the onset of the disease.

7. Surgery & Scarring

Scar tissue is known to promote the formation of endometriosis as endometrial tissue can adhere to scar tissue. Women who undergo surgery in their pelvic region (such as hysterectomies or C-sections) are at a higher risk of developing endometriosis than those who do not.

Risk Factors

Risk factors that increase the chance of developing endometriosis include:

• Shorter menstrual cycles (under 27 days)
• Starting menstruation at an early age
• Beginning menopause at a later age
• Heightened levels of bodily estrogen
• Low body mass index
• Having relatives with endometriosis
• Abnormalities or defects related to the uterus
• Auto-immune diseases
• Heightened levels of inflammation
• Malnutrition or nutritional deficiencies
• A diet high in red meat and trans-fats
• Stress

Anything else that increases estrogen or inflammation in the body also counts as a risk factor.

Treatments

Treatment for endometriosis usually consists of hormonal balancing and pain management. In advanced cases, surgery is also employed.[4]

Hormonal Therapies

Once endometriosis is suspected, doctors will first prescribe some kind of hormone treatment before looking at invasive surgeries to treat the condition.

A number of hormonal treatments are available, including:

1. Oral Contraceptives

Seeing as menopause permanently halts the progression of endometriosis, many treatments revolve around hormonally emulating menopause.

Oral contraceptives suppress the activity of the ovaries which are responsible for heightened estrogen production in females as well as regulating hormones related to the menstrual cycle.

Using oral contraceptives to treat endometriosis is one of the most popular protocols, however, this treatment contributes to infertility by preventing pregnancy as well as may cause other side effects. Also, 20-25% of endometriosis patients who use oral contraceptives to treat their condition still experience their painful symptoms.

2. Hormone Replacement Therapy

Hormone replacement therapy is another option for treating endometriosis. The main hormone used is Progesterone, which acts to regulate estrogen and other hormones in our body, keeping them in check. This may result in endometrial and growth proliferation under the combined influence of both estrogen and progesterone.

With this type of therapy, one can opt for either bio-identical hormones or synthetically derived hormones. In terms of which offers the least side effects, bio-identical hormones appears to be more beneficial.

Before going for hormone replacement therapy, it is very important to opt for a blood test to get the levels of all hormones checked. That way the doctor can make sure not to cause an additional hormonal imbalance while designing the best supplement regime for the patient to follow.

3. GnRH Agonists

One side effect of GnRH (gonadotropin-releasing hormone) agonists is that they dramatically lower estrogen levels in the body, which should help to keep endometriosis under control.

Estrogen is required for proper menstruation, fertility, and maintaining bone health. When estrogen levels are low, it leads to loss of bone mineral density resulting in may cause osteopenia and osteoporosis. A low-dose estrogen supplement can help  to maintain bone mineral density, alongside other bone-healthy nutrients such as calcium, potassium, magnesium, and Vitamin D3.

4. Danocrine

Danocrine (aka Danazol) is another treatment option that is used to lower estrogen levels in the body. While this is a widely used and highly effective option to treat endometriosis, it is not advised.

This medication increases levels of testosterone, which can create additional hormonal imbalances on top of reducing bone mineral density. Side effects include weight gain, depression, reduced breast size, voice deepening, skin rashes and an increase in bodily hair. Some studies also show that Danocrine increases the risk of ovarian cancer.

Surgery

When medical interventions fail to produce the desired results or if endometriosis is severe, surgery is often employed to remove the growths. 

Laparoscopic ablation of implanted endometrial tissue is a surgical technique that has been shown to significantly reduce pain in 65% of all patient cases who underwent the procedure. Generally, additional therapy is still required for 60% of these cases until all pain subsides.

Another surgical intervention is a hysterectomy and removal of both ovaries, also called a bilateral salpingo-oophorectomy. This is a very dramatic course of action that      will destroy any chance of future pregnancy as well as requiring permanent hormone replacement therapy after the operation. Nevertheless, this is a very effective form of treatment - of all the women who have opted for this surgery, only ±10% still have recurring symptoms.

Lifestyle Considerations

Here are some important lifestyle considerations for those with endometriosis, which may help to lessen the risk and severity of the condition.

Diet

A diet rich in omega-3 fatty acids from cold-water fish[5], Vitamin D, as well as plenty of nutritious fruits and vegetables have been associated with a lower risk of developing endometriosis.

Dietary antioxidants such as Vitamins E and C may also help to reduce endometriosis-related pain, as one placebo-controlled trial has illustrated[6].

In experimental trials, green tea[7] and foods high in resveratrol[8] (such as dark red, black and blueberries) have also been shown to reduce bodily inflammation and endometrial growth. 

On the other hand, a diet rich in trans-fats was shown to increase endometriosis risk by up to 48%[9]. Red meat consumption was also associated with a higher endometriosis risk. Foods that create inflammation in the body should also be avoided or greatly minimized, such as allergens and sugary foods.

Stress Management & Support

Endometriosis and chronic pain tend to be stressful for those undergoing it, which also generates higher levels of bodily inflammation and may lead to depression.

A few studies have revealed that women with endometriosis who adopt positive coping strategies report having reduced pain levels, less stress, and decreased depression[10] [11]. Most of these strategies include some degree of emotional support and positive psychological intervention. Support groups for women with the condition may prove useful in dealing with chronic pain as well as getting valuable resources on how to cope.

Certain stress-reducing activities, such as yoga[12] and mindfulness meditation[13], have both been linked in preliminary studies to reducing pain and stress in women with endometriosis as well as effectively managing pain in general.

Final Thoughts

Endometriosis is an often painful and stressful condition to have. Diagnosis often occurs at the late stages of the disease and can be difficult to cope with without having appropriate advice, support, and medical interventions set in place. However, with proper treatment and a good support system, much can be done to help manage and treat this condition.

Treatment of Endometriosis usually requires a team of experts including Gynecologists, Endocrinologists, and even Gastroenterologists. To search for healthcare providers worldwide, please use the Mya Care platform.