Urogynaecology & Pelvic Reconstructive Surgery,
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What Is Endometriosis?

Endometriosis is not a cancer. It is a very common affliction; it affects about 10% of women of reproductive age. Among women with infertility, endometriosis is found between 20% and 30%, and among women with painful period, 40% to 60% have the disease. For women who suffer chronic pelvic pain, 30% to 80% have endometriosis. It is extremely rare after the menopause. Endometriosis occurs when the endometrium (which is the cell-lining of the womb cavity) is found outside the womb (where it usually is); being deposited as groups of endometrial cells on the tubes, the ovaries, the bowel, the bladder and the side walls of the pelvis. These cell aggregates behave as they would in the womb, and under the influence of the hormones, they would grow and bleed in phase with the women’s menstrual cycle.

Types Of Endometriosis


Peritoneal Endometriosis

The superficial lesions may be the classical blue-black "powder burn", or the non-classical clear or red "flame-like" lesions, the white lesions, or the "Allen-Masters" peritoneal window/defect.

Ovarian Endometriosis (Endometrioma)

Appear as variable size pseudo-cysts. They contain a dense, brown chocholate-like fluid, formed by invagination of the endometriosis on the ovarian surface.

Deep Infiltrating Endometriosis

A nodular blend of fibromuscular tissue and adenomyosis. The lesions are primarily found in the uterosacral ligaments or the cul-de-sac. It may involved the recto-vaginal septum.

Time to Diagnosis averages 7.5 years in the United Kingdom

In 2017, the UK National Institute of Clinical Excellence printed its first guideline on Endometriosis. One stark finding was that women suffered the symptoms of endometriosis for an average of 7.5 years before they were diagnosed. NHS doctors are now encouraged to "listen to women" regarding their pelvic pain in young females.

What Causes Endometriosis?
Does It Arise From A Single Factor?

We do not know what causes endometriosis. Endometriosis mainly occur in women during the reproductive age. With the onset of natural menopause, or when the ovaries were removed for various reasons, the endometriosis phenomenon regresses. Years of research have suggested that formation of endometriosis is guided by genetic, hormonal, immunological and anatomical factors. Of the three hypotheses regarding what initiates endometriosis development, the most plausible is the back flow of the menstrual content into the pelvis through the tubes. In the predisposed women, this phenomenon will trigger the ectopic growth of endometrial islands. The genetics of vulnerability has yet to be defined. The cyclical changes in the endometrial islands release chemicals that cause pain, and create a hostile micro-environment that provokes the body’s defense response to contain it. The response causes adhesions and scarringas over time, which can in turn lead up to chronic pain. Most women with endometriosis initially have problems with pain at the time of the periods. After many months and years, scar tissues form at the sites affected; and if the ovary is affected, ovarian “chocolate” cysts will arise. At this advance stage of the disease, the pain will be felt throughout the menstrual cycle, often described as a chronic pelvic pain syndrome. Many women present with inability to conceived, which can occur in both "mild" to severe spectrum of the condition.

Factors That Reduces The Risk Of Endometriosis

  More number of children
Longer period of breast feeding
Tobaccon exposure in uteru
Increased Body Mass Index
Cigarette smoking
Diet high in vegetables/fruits

Factors That Will Increased The Risk Of Endometriosis

  Difficulty in getting pregnant
Early age of starting menstruation
Shorter menstrual cycle
Periods that have heavy flow
Family history of a first degree relative having endometriosis
Exposure to DIOXIN or PCB (toxins)
High intake of alcohol and caffeine
Having other auto-immune disorders

Do I Have Endometriosis?
What Are The Diagnostic Tests?

Endometriosis has always been a diagnostic challenge. It is reputed to be a chronic and debilitating painful disease. Yet majority of the visually proven endometriosis may be asymptomatic or present with atypical symptoms. The famous classic triad of dysmenorrhea, dyschezia (pain during defecation), and dyspareunia, are infrequently encountered.

Associated Clinical Manifestations

There may not be one pathognomonic symptom for endometriosis. Instead, the disease presents as a variable cluster of clinical features, differing between age groups and types of endometriosis.

Pelvic Endometriosis

Young Girls

Painful periods
Irregular periods
Prolong heavy periods
Lower abdominal pain (non-cyclical)

Adult Women

Painful periods
Irregular periods
Prolong heavy periods
Lower abdominal pain (non-cyclical)
Deep pain during intercourse

Extra-pelvic Endometriosis

Intestinal Endometriosis

Diarrhea or constipation
Perimenstrual changes in bowel habits
Rectal bleeding
Pain with defecation>br> tenesmus, abdominal distension
Small caliber stools or colicky abdominal pain
Symptoms of a bowel obstruction.

Urinary Tract Endometriosis

Urinary urgency, frequency and incontinence Lower abdominal pain
Blood inthe urine
Recurrent UTI (86%) Flank or back pain
Lump at the kidney site

Thoracic Endometriosis

Chest pain
Shortness of breath

Diagnosing Endometriosis

Endometriosis presents with multi-variate complaints. It could be a disease with a wide spectrum of symptom severity. On the other hand, endometriosis could have two unique sub-types; namely a mild form and an aggressive form.

Clinical Assessment

Endometriosis is largely a pain syndrome. Being often a disseminated disease, the pain may be pelvic or outside the pelvis. The pain may start as a cyclical menstrual pattern and evolve to a persistent non-cyclical pain that is not link to the menses. Physical examination may yield normal findings in half of those with confirmed endometriosis. In some, there may be signs suggestive of the disease, such as tender nodules at the back of the lower uterus, the presence of tender ovarian cysts, or the loss of mobility of the uterus.

Non-Invasive Testing

- Ultrasound

A transvaginal or trans-rectal ultrasound may help to identify ovarian endometriosis and in some deep infiltrating endometriosis involving the rectum.

- MRI of the pelvis

MRI imaging better define endometriosis in the deeper rectum, the bladder and other indeterminate pelvic mass. It gives a global survey of the disease extent, which is helpful in planning the surgical approach.

- Biochemical markers of disease

Much effort is spend to identify markers in the blood serum and the peritoneal fluid that may be useful to diagnose endometriosis and to chart that progress of the condition. The candidates include the cytokines, matrix metalloproteinases, adhesion molecules and angiogenesis factors. Unfortunately, most of these inflammatory factors are not unique to endometriosis and not helpful. The search continues.

Invasive Testing

- Laparoscopy

Laparoscopy remains the “gold standard” in diagnosing endometriosis. At laparoscopy, the types and extent of endometriosis can be determined and recorded. Furthermore, taking samples of the affected tissue clinched the diagnosis histologically, when two or more of the following features are needed: endometrial epithelium, endometrial glands, endometrial stroma and hemosiderin laden macrophages. Nevertheless, the visual diagnosis of endometriosis may be unreliable in 40% of the times. These false positive pick-ups may actually be inflammatory changes, hemangiomas, foreign body reaction, mesothelial hyperplasia or hemosiderin deposits.


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