Endometriosis affects approximately 1 in 10 women of childbearing age. If your periods are causing debilitating pain or other symptoms, assessment and treatment with an experienced gynaecologist can get you back on track.
Around 176 million women worldwide suffer from endometriosis. Despite its prevalence, endometriosis is often underdiagnosed due to the normalisation of menstrual pain and variability of symptoms. In addition to being associated with severe discomfort for many women during each menstrual period, endometriosis can also interfere with your ability to fall pregnant.
Endometriosis is a common gynaecological problem found in women of reproductive age. It occurs when the glandular tissue of your uterus lining (the endometrium), is found outside the uterus elsewhere in the pelvis. These patches of abnormal tissue growth, commonly termed endometriotic implants or deposits, may develop on your ovaries, fallopian tubes, on the outer surface of the uterus, or elsewhere in the pelvis such as the bowel. Rarely, endometriotic implants may even be found outside the pelvis, such as around the lungs and diaphragm. It can also very rarely be found on previous surgical sites such as the scar left from a previous caesarean section.
As these endometriotic deposits are hormone-sensitive, just like the normal endometrial lining of your uterus, they respond to the rise and fall of your hormones throughout your menstrual cycle. Due to their location outside of the uterus, this cycle results in chronic inflammation and scarring.
Endometriosis is most commonly diagnosed in women aged in their 30s or 40s, but it can occur in any woman still experiencing menstruation.
Unfortunately, the average time from onset of symptoms to a definitive endometriosis diagnosis in Australia is around six years. This is mainly thought to be due to many women not seeking medical assessment as they believe that period pain is normal.
Investigations for endometriosis are typically prompted by the presence of symptoms, or during a fertility assessment. An estimated 20-25% of women with endometriosis are asymptomatic, a situation often called silent endometriosis.
Endometriosis symptoms can be extremely variable between individuals, and are non-specific, meaning that they are not unique to endometriosis and may be dismissed as something else or just normal menstruation discomfort. Endometriosis symptoms can include:
Recognising your symptoms and getting checked by a doctor experienced in women’s health can enable you to receive a proper diagnosis and treatment, reducing the impact of this condition on your life.
Because of the wide variability in presenting symptoms and their non-specific nature, diagnosing endometriosis can be challenging. Endometriosis may be suspected based on your clinical history, or if abnormalities are seen (often incidentally when investigating something else) on ultrasound, MRI, or CT imaging. Sometimes, raised levels of a specific biomarker called CA125 may also suggest endometriosis. However, definitive diagnosis can only be made through visualisation at time of surgery.
The gold standard for definitively diagnosing endometriosis is through a keyhole surgical procedure known as laparoscopy. This is a day procedure performed under general anaesthesia, involving a long, thin camera (laparoscopy) inserted through a keyhole incision in your abdomen to look for endometriotic deposits or scarring and adhesions caused by endometriosis.
A benefit of laparoscopy is that it can be both diagnostic and therapeutic – treatment of the deposits and adhesions can be performed at the same time as diagnosis. A biopsy of a deposit may also be taken for histopathological testing.
International expert guidelines now recommend having an internal ultrasound as the first-line test to assess your pelvic area for evidence of endometriosis. An internal pelvic ultrasound requires the ultrasound probe to be inserted via your vagina, as this provides a more detailed view. To be properly effective at diagnosing endometriosis, the scanning clinician should have expertise and experience in looking for endometriotic deposits, as these can often be missed by inexperienced practitioners.
While there is no cure for endometriosis, Dr Huang can recommend or offer a suitable treatment to help manage your symptoms and improve your quality of life. Treatment plans are highly individualised based on your symptom severity, extent of the disease, and your future family plans.
Over-the-counter pain relievers such as non-steroidal anti-inflammatory medications or paracetamol can be effective at managing mild pain. Occasionally, stronger analgesia may be required.
Hormone-based medications can suppress the activity of endometriosis or decrease recurrence after surgical treatment. These medications include the oral contraceptive pill, progestogen in the form of a pill, injection, or as an intrauterine device (IUD), or gonadotrophin-releasing hormone (GnRH) medications. As these medications are used as approved methods of birth control, hormone treatment for endometriosis is not suitable if you are trying to conceive.
Surgery is a good option for younger women wishing to improve their natural fertility, as well as those with severe pain from endometriosis. It is most often performed as a minimally invasive approach via laparoscopy, where visible endometriotic implants can be removed and adhesions separated. On occasion, open surgery (a laparotomy) may be more appropriate over the keyhole laparoscopic technique, where a long incision is made in your belly.
A hysterectomy refers to the surgical removal of your uterus, cervix, and usually with the fallopian tubes. It is usually considered as a last resort in women with severe symptoms that have not responded to other treatments, and do not intend to have any children in the future.
The scarring and distortion of your pelvic structures may interfere with successful conception and/or pregnancy. There is a clear association between endometriosis and infertility, though there is less clarity around the underlying mechanisms connecting the two conditions. Up to 50% of women with endometriosis will have difficulties falling pregnant.
The impact of endometriosis on both pain and fertility can vary significantly between women. For this reason, its effect on your fertility often cannot be fully assessed until you begin trying to conceive. If endometriosis is suspected when you start trying for pregnancy, Dr Huang recommends timely progression to further investigation or fertility treatment if pregnancy does not occur within a reasonable timeframe.
If you are having difficulty conceiving, treatment of endometriosis may form an important part of your fertility care. For some women, surgically removing endometriosis tissue and restoring pelvic anatomy affected by scarring and adhesions can improve the chance of natural conception. Evidence suggests this benefit is generally greater in younger women, and tends to be less pronounced with increasing age. For others, in vitro fertilisation (IVF) is the most effective treatment pathway to pregnancy.
