Endometriosis



World over, the month of March is celebrated as Endometriosis month to create awareness in public regarding this disease. We call it a silent suffering as many women who have this condition often do not know about it and suffer with pain and heavy bleeding for years. Or they are just simply counselled that pain in periods or back discomfort is common and we all have to deal with it as part of being women. If endometriosis remains untreated, it is a common cause of infertility and long term pain & suffering.

WHAT IS ENDOMETRIOSIS
Tissue that is present in the lining of the uterus (endometrium) is sometimes present in other areas in the pelvis, which could be ovaries, fallopian tubes, cul-de-sac (behind uterus), intestines, rectum, and urinary bladder. Tissues in the lining of the uterus grows under the influence of hormones every month and then breakdown and bleed during the menstrual cycle. Similarly endometrial tissue outside the uterus also responds to changes in hormones. It also breaks down and bleeds like the lining of the uterus during the menstrual cycle every month. However the bleeding inside the uterus has a passage to come out as menstrual bleeding through vagina, but the bleeding in endometriotic site accumulates and forms cysts (chocolate cysts) or adhesions. This can cause pain, especially before and during period. One third of cases of infertility are due to endometriosis.

RISK FACTORS

  1. Started periods (Menarche) at a young age
  2. Women who never had children
  3. Heavy menstrual bleeding or very frequent periods.
  4. Suffer from Fibroids

WHO IS COMMONLY AFFECTED?

  1. Young women in the reproductive age group (20-40years)
  2. 30% of women with infertility may be suffering from endometriosis
  3. Women with uterine defects like septum or bicornuate uterus (double uterus)
  4. It can run in the family

WHAT ARE THE SYMPTOMS?

  1. Pelvic pain (pain in lower abdomen and back). Such pain is common few days before starting of menstrual cycle or during the bleeding days. It may also occur with sex, during bowel movements or urination.
  2. Heavy bleeding during menstrual cycle causing anaemia and weakness
  3. Feeling of bloating & fullness in abdomen around the periods.
  4. Some women with endometriosis may have no symptoms.

HOW DO WE DIAGNOSE?
The gold standard to diagnose is visual inspection & identification of the endometriotic lesions in the pelvis via a Laparoscopic or Robotic surgery. However if the disease is advanced then pelvic examination & Ultrasonography can pick up cysts in pelvis that may suggest endometriosis. There is no blood test that can confirm endometriosis. Serum levels of CA125 can suggest the presence of endometriosis.

WHAT ARE THE TREATMENT OPTIONS

Treatment for endometriosis depends on the extent of the disease, presenting symptoms, and whether one wants to have children. It may be treated with medication, surgery, or both. Although treatments may relieve pain and infertility temporarily, it is a recurrent problem and conservative treatment (medical or surgical) cannot provide permanent cure.

Medications- is used both to relieve pain and to keep the disease under control. Painkillers like paracetamol or mefenemic acid relieves the pain up to great extent. Hormones like progesterones or combined pills not only relieve the pain but also help to control the disease process. Hormonal injections or intrauterine contraceptive device with progesterone (Mirena) are also used in some situations. These medications cannot be used for long as women are not able to tolerate the side effects that these medications. Medications do not provide permanent cure.

Surgery - is done to remove endometriosis and the scarred tissue around it. In severe cases surgery is the best choice for treatment. Surgery is done almost always by minimally invasive technique (LAPAROSCOPY). During laparoscopy, endometriosis can be removed or burned away. Extent of surgery depends on the patientís needs and the surgeonís skill. If infertility is the issue then conservative approach and trying to save the normal tissues is attempted followed by active treatment for infertility. If the woman does not desire any more children the complete removal of uterus along with both ovaries and all endometriotic tissue is done.

Robotic assistance during laparoscopic surgery is the latest addition in approach to management of endometriosis. Da Vinci ģ surgical intervention is a new category of minimally invasive surgery that combines the best of open and laparoscopic surgery. Thus giving a better outcome in terms of pain relief and fertility. With the assistance of Robotic ARMS (controlled by the surgeon of course!), we can perform surgeries through small incisions with unmatched precision and control. Robot-assisted surgery allows superior 3D visualization of the surgical field with 10 times magnification. Advantages of Robotic surgeries are minimal scarring. Due to precise movement, tissue trauma is less and less blood loss. Better dissection in the right planes and the ability to suture more quickly, there is significantly less intra-operative blood loss. Robotic assistance also reduces the need for conversion to open surgery (laparotomy).

Endometriosis is a progressive disease. The source of the problem is the hormonal changes associated with menstrual cycles and presence of endometrial tissue at abnormal places. After conservative surgery the disease has every likely hood tocan recur. Patients who are treated with combination of both surgery and medications have extended symptom-free period. Endometriosis is less likely to come back if your ovaries also are also removed. The likely hood of the disease coming back in future depends on how well the surgery was done in the first place and the medical management that follows. Endometriosis is enigmatic & tricky disease and should be managed at centers that have the skill & facility to manage this.


FAST FACTS ENDOMETRIOSIS
    • An estimated 200 million women worldwide suffer fromendometriosis.
    • Endometriosis can also affect teenage girls.
    • Incapacitating painful menstruation probably due to endometriosis is one of the main cause for women to miss school or work.
    • Endometriosis is commonly undiagnosed or misdiagnosed.
    • Common estimates indicate that there is 6-10 years delay before it is correctly diagnosed.
    • Endometriosis is one of the top three causes of female infertility.
    • Endometriosis can be a source of chronic pelvic pain and disability.
    • Multiple medical opinions maybe needed before correct diagnosis of endometriosis is made.
    • There is no blood test to confirm the diagnosis of endometriosis.
    • Visual inspection of endometriosis lesions is the gold standard method for diagnosis.

    FAST FACTS ENDOMETRIOSIS

    Is extreme pain during periods a sign of endometriosis? Can Vomiting and passing out from pain be a sign of endometriosis?
    Often painful periods are passed off as normal by elders in the family. However one must remember that incapacitating pain is not normal and can indicates underlying disease that needs immediate medical care. Women should suffer with this pain as part of their biology should not be accepted and we now know that medical treatment works and one can have pain free life with dignity. Endometriosis is the leading cause of this discomfort. Severe pain due to endometriosis can also cause associated nausea and vomiting and young girls sometimes have giddiness and can pass out.


    Can painful sex be due to endometriosis?

    Yes it can be due to endometriosis. Some pain in the beginning can be normal but if it is persistent and especially deep which lasts for several hours later needs medical attention. Pain during menstruation or any other chronic pelvic pain should never be accepted as normal. This pain is mainly due to endometriotic deposits in the cul de sac (space between the uterus and vagina).


    Can my pain or disease return even after having a surgery for endometriosis?

    Endometriosis is often a progressive problem and it can always recur. Even after a surgery there is no guarantee that there will be 100% relief. Scientific evidence in peer-reviewed medical studies also suggest the same. However, even for the most severe cases, the surgical expertise of the operating surgeon can make a difference. Also the availability of infrastructure in terms of advanced laparoscopic instruments can make a difference in surgical outcome. Robotic assistance and availability of laser surgery a two advanced technology that can help in endometriosis surgery.


    Can I avoid a laparotomy open surgery even if my endometriosis is advanced stage or severe?
    The answer to this question is yes. It is feasible and possible to safely and thoroughly excise endometriosis implants even in most advanced cases by minimally invasive approach. But very few surgeons are skilled enough to be able to perform these very difficult minimally invasive surgeries. So one must choose the center and surgeon carefully. Severe endometriosis can affected the bowel, bladder, blood vessels, ureters, nerves, diaphragm, lungs, and liver, therefore a team approach with colorectal surgeons and urologists maybe needed


    I underwent laparoscopy 4 years back for endometriosis and I am not having any pain now, but a recent scan shows that the cyst has again grown considerably (8cm). Is second laparoscopy suggestible or not?

    The treatment of your endometriotic cyst depends on your age, problems at present or are you looking for pregnancy at the moment? If you are married and not able to conceive then a second laparoscopy to clear endometriosis to restore pelvic anatomy will improve the chances of your spontaneous conception. If you are not married at present and not having any symptoms, then you can have evaluation every 6 months, plan laparoscopy just before you plan conception or if it becomes painful since you just underwent laparoscopy 4 years ago. Endometriosis is a chronic problem, and repeated laparoscopy does not insure complete cure.




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