Endometriosis is an extremely common condition that affects about 30% of women of childbearing
years between the ages of about 15 and 45. What we think happens is that during menstruation
some of the blood flows back into the pelvis, taking with it live endometrial cells. Cells
like those that line the womb. These cells are able to attach themselves to the peritoneal
surfaces inside the abdominal cavity and grow new blood flow to themselves, so they can
continue to proliferate. In the normal situation, the immune system will deal with these abnormal
endometrial cells and they will be eliminated, but for some reason, in some women this doesn't
happen. Every month, as a result, these endometrial cells like those lining the womb are stimulated
by the normal hormone cycle and ovulation and they proliferate. When they proliferate
they may also bleed, they cause irritation. This irritation can cause fibrosis. It could
cause adhesions to form. And these then in turn can cause pain. Particularly if the endometriosis
is associated with the nerve supply in the pelvis. Typically, this will be if the uterus
sacral ligaments are involved as there are many nerves in that place. Endometriosis can
also occur elsewhere in the body when we think it might need you to blood-borne spread. So,
it's not unusual for us to find endometriosis in relation to episiotomy scars that are from
around the time of childbirth, maybe even in caesarean section scars, and sometimes
people who even have endometriosis in the lung. Although, of course this is quite a
rare situation.
It's difficult to know how we should define the word serious in this context. Endometriosis
isn't cancer. It's not going to kill you. But it is serious in the sense that it can
give rise to really unpleasant symptoms. The typical scenario is a woman who's trying to
get pregnant and she's having difficulty getting pregnant. And at the same time, she's having
pain having sex, and at the same time her periods are very painful and difficult too.
So, you could imagine the situation: every month she's failing to get pregnant, every
month is very painful, and every time she tries to have sex it doesn't really work.
Not surprisingly, this can mean that it has a really big impact on women's lives. So,
it's definitely serious in that regard. And the women who have this condition, can find
it extremely frustrating. To add to the frustration, it's difficult to treat. And we often find
ourselves in a situation where women and coming back again and again with endometriosis symptoms.
This is probably because they're not being sent to the right specialist, they're not
being treated properly, and the condition is never properly diagnosed or properly treated.
And this is what makes it such a frustrating condition. So, whilst it's not serious in
the true sense of the word, it's certainly a serious problem for those women who have it.
That's an interesting question. I think the main problem with endometriosis is that you
don't know that you've got it. We know this because when we look at women coming in to
see endometriosis specialists, it normally takes about four and a half years for them
to get there. So, women have pain, but they get pain with their periods anyway. They go
and see their doctor and their doctor says, "Ah, there's nothing very much wrong with
you. Perhaps take the oral contraceptive pill. Go away and you'll be fine." They go away,
things don't get better, they go back, maybe the GP suggests some other form of hormone
treatment. Often basic tests aren't done, so the women don't know that they have endometriosis.
If they don't have an ultrasound that sees endometriosis, if they're not examined to
find out if they've got it, and certainly if they haven't had a laparoscopy to really
check to see if they've got it, they don't know. And this could be the biggest problem
that we have-- that we face. Now, the commonest symptoms to look out for are pain particularly
associated with the periods that perhaps comes on a few days before and goes on a few days
afterwards, pain during intercourse because the endometriosis can be at the top of the
vagina inside and as a result, woman will feel pain particularly in particular positions
and always in the same spot, and the other thing to watch out for of course is if there's
fertility issues associated with this. The pain that women get can also radiate down
the legs because nerves are involved and it can radiate round into the back as well and
up into the loins.
Having made a good diagnosis of endometriosis we then have a number of treatment options
at our disposal. If the condition is minor and isn't causing too much in the way of any
problems, then probably we don't want to treat aggressively and hormonal treatment then is
the right answer. The simplest hormonal treatment would be to try cycle the oral contraceptive
pill. That way, diminishing the number of periods that you have, diminishing the amount
of blood that gets deposited in the pelvis, and also diminishing the hormonal stimulation
of the endometriosis that's already present. If we want to step up to a next phase of treatment,
we might want to use some Depo-Progesterone. This can either be given as the contraceptive
injection or implant, or it can be given as a coil that's put inside the womb which has
progesterone within it: the Mirena coil. The key, of course, is accurate diagnosis. And
to do this we might well perform a laparoscopy to see exactly where the endometriosis is.
And this gives us a unique opportunity to also excise it. And this is what we would
typically do: try to excise the endometriosis and then start with hormonal treatment in
those women where the condition is serious enough. But, if the condition isn't quite
so serious, it won't be necessary to excise it. If it's really bad, maybe more than one
operation will be required with hormonal treatment in between. So, the treatment that's required
is really very different from one person to another. And we also need to take into account
what the patient wants to try and achieve. If pregnancy is the main thing or if pain
reduction is the primary thing that needs to be considered.
There are a number of different treatments available. And the key thing when we treat
endometriosis is that we look at the whole person. This really does need to be something
where we are holistic in our approach. It's absolutely crucial that we listen to women
and work out exactly what the goals of their treatment are. We know that this is a quality
of life issue, and we know that fertility and pain are issues for all women. But what
is their primary goal? Are we trying to cure the pain, are we trying to improve fertility?
If we're trying to improve pain, we may want to try and cut out all the endometriosis.
And this may not be the smartest thing to do from a fertility perspective. If we're
going for fertility, then perhaps what we need to do is to optimise our surgery to improve
fertility. So, I think the key to treating you as an individual with endometriosis is
to listen and to set goals together so we can get the best possible outcome.