The lining of the womb or uterus is called endometrium. Endometriosis is an estrogen hormone-dependent condition that is characterized by the presence of ectopic endometrial tissue in places within the body but outside of the uterus. The disease state and symptoms can be modified by pregnancy, breast feeding and menopause.
The pathogenesis of endometriosis remains an enigma in gynaecology and a topic of heated debate. There are 2 distinct entities:
Endometriosis (external – outside of the uterus)
Adenomyosis (in the muscle of the uterus).
A good clinical history and a thorough clinical examination help point in the direction of the correct diagnosis. To confirm the diagnosis, a woman will be advised to undergo a pelvic ultrasound assessment and laparoscopy (keyhole camera procedure) which is considered the “gold standard” tool. Other sophisticated tests such as MRI, intravenous urography (IVU), barium enema (X-ray procedure) may be required in some women with severe disease.
Endometriosis can be managed either with the help of drugs or with surgery. The drugs used for the management are geared towards reducing the impact of the oestrogen hormone.
Unfortunately, one cannot completely cure endometriosis or eradicate the disease by surgery or medications.
Following surgery for mild, moderate or severe disease, the chances of recurrence may be as high as 50% in 2 – 3 years. Also, symptoms of pain may recur once the medications are stopped.
Combined oral contraceptive pill (COCP)
Progesterone only pill
Gonadotropin releasing hormone agonist (GnRHa e.g. Zoladex, Prostap, Luprolide acetate etc)
Mirena IUS (Progesterone loaded IUCD)
Initial management of pain symptoms is generally with painkillers or analgesics. If a woman is not desirous of fertility and pain is her main symptom, the use of the combined oral contraceptive pill continuously for 3 – 6 months followed by short breaks of 7 days could help relieve the symptoms.
In women that are overweight or obese, those that have a family history of blood clots, or those that smoke and those with an altered liver function, the use of oestrogen containing pills is contraindicated. In such cases, one may use the progesterone only pill continuously for 3 – 6 months.
GnRH analogues are injections that will be given to cases with moderate to severe endometriosis. These injections are given either or a monthly or 3 monthly basis. The GnRH analogues temporarily switch off the ovaries thereby reducing the impact of oestrogen on the endometriotic deposits and causing a regression in their size and improvement in the pain symptoms. Women may need to use a small dose of hormone replacement therapy (HRT) during the GnRH analogue treatment to combat symptoms of low oestrogen such as hot flushes, night sweats, mood swings and irritability.
The Mirena IUS is a progesterone (levo-norgestrel) loaded intra-uterine device that has been found to have a beneficial impact on symptoms of pain.
Unfortunately, none of the above will allow a woman to conceive or fall pregnant during treatment.