About Endometriosis

Endometriosis affects an estimated 1 in 10 women of reproductive age worldwide, totaling around 190 million individuals, though actual numbers may be higher due to underdiagnosis and delayed recognition. It is particularly prevalent among women with chronic pelvic pain or infertility, with up to 50% of infertile women and 70% of those with persistent pelvic pain found to have the condition. While most commonly diagnosed between ages 25 and 40, symptoms often begin in the teenage years and may go unrecognized for years, leading to an average diagnostic delay of 6 to 10 years.

What is Endometriosis?

Endometriosis is a chronic condition where tissue similar to the lining of the uterus (endometrium) grows outside the uterus, commonly on the ovaries, fallopian tubes, pelvic lining, or even the intestines and bladder. During each menstrual cycle, this tissue responds to hormonal changes by thickening, breaking down, and bleeding just like the normal uterine lining. However, because it’s outside the uterus, the blood has nowhere to go, leading to inflammation, pain, scar tissue (adhesions), and sometimes cysts (endometriomas). 

The most common symptoms include severe pelvic pain, especially during periods, pain during intercourse, infertility, heavy periods, and digestive issues. The exact cause isn’t fully known, but it may involve genetics, immune system issues, or menstrual flow problems. Diagnosis is often confirmed through laparoscopy, and treatment may include pain management, hormonal therapy, or surgery especially laparoscopic excision to remove endometrial growths and relieve symptoms, particularly when fertility preservation is a goal.

Some of the most common places you can develop endometriosis include the:

• Space behind your uterus.
• Myometrium (a layer of your uterine wall).
• Ovaries.
• Peritoneum.
• Fallopian tubes.

Less common places include your:

• Rectum.
• Bladder.
• Intestines.
• Diaphragm.
• Vagina.
• Lung.

Signs and Symptoms of Endometriosis

The most common signs of endometriosis are pain and infertility. Endometriosis pain typically presents as:

• Painful menstrual cramps that may go into the abdomen (stomach) or lower back
• Pain during or after sex

Other symptoms may include:

• Diarrhea or constipation during a menstrual period
• Fatigue or low energy
• Heavy or irregular periods
• Pain with urination or bowel movements during a menstrual period
• Spotting or bleeding between menstrual periods

Each person’s experience with endometriosis is different. Women with endometriosis may have some of these symptoms, all of these symptoms or none of them. Having severe pain or other symptoms is not necessarily a sign of more severe endometriosis.

Endometriosis Causes

Doctors do not know exactly what causes endometriosis, but there are a few theories of what might cause it:

• Blood or lymph system transport: Endometrial tissues are transported to other areas of the body through the blood or lymphatic systems, similar to the way cancer cells can spread through the body.
• Direct transplantation: Endometrial cells may attach to the walls of the abdomen or other areas of the body after a surgery, such as a C-section or hysterectomy.
• Genetics: Endometriosis seems to affect some families more often than others, so there may be a genetic link to the condition.
• Reverse menstruation: Endometrial tissue goes into the fallopian tubes and the abdomen instead of exiting the body during a woman’s period.
• Transformation: Other cells in the body may become endometrial cells and start growing outside the endometrium.

Endometriosis Risk Factors

Research shows that there are some things that put a person at higher risk of developing endometriosis, including having:

• A mother, sister or daughter who has endometriosis
• An abnormal uterus, which is diagnosed by a doctor
• Early menstruation (before age 11)
• Shorter menstrual periods (less than 27 days on average)
• Heavy menstrual periods lasting more than seven days

Some things that can lower the risk of endometriosis include:

• Pregnancy and breastfeeding
• Having your first period after age 14
• Eating fruits, especially citrus fruits

Endometriosis Complications

• Infertility: Scarring and adhesions impair egg release or fertilization.
• Ovarian cysts: Endometriosis may rupture or require surgery.
• Bowel/bladder dysfunction: Deep infiltrating lesions affect organ function.
• Mental health impact: Chronic pain linked to depression/anxiety.

Endometriosis Diagnosis

1. Pelvic Exam

• Manual examination by a healthcare provider.
• May detect:
  
  • Tender nodules behind the uterus or along pelvic ligaments.
  • Restricted mobility of pelvic organs due to adhesions.
  • Uterus may feel fixed or tilted.
• Not always conclusive but may raise suspicion.

2. Ultrasound

• Transvaginal or transabdominal ultrasound.
• Useful for identifying:
  
  • Ovarian endometriomas (chocolate cysts).
  • Deep infiltrating lesions affecting nearby structures.
• Cannot detect all forms, especially superficial peritoneal endometriosis.

3. MRI (Magnetic Resonance Imaging)

• Offers detailed imaging of pelvic organs and soft tissues.
• Helps map the extent and depth of deep infiltrating endometriosis.
• Useful for pre-surgical planning, especially if organs like the bowel or bladder are involved.

4. Laparoscopy (Gold Standard)

• A minimally invasive surgical procedure.
• A camera is inserted through a small abdominal incision to visualize endometriotic lesions.
• Allows biopsy confirmation, which is essential for a definitive diagnosis.
• Can be both diagnostic and therapeutic, as lesions may be removed during the same procedure.

Non surgical treatment:

• Pain management: NSAIDs (e.g., ibuprofen) for mild symptoms.
• Hormonal therapy:
  • Combined oral contraceptives to suppress ovulation.
  • Progestins (pills/IUDs) or GnRH agonists to shrink lesions.

Note: Medications are taken only under doctor consideration.

Laparoscopy for Endometriosis:

Laparoscopic Removal of Endometriotic Cyst.

• Purpose: Removal of ovarian endometriomas (endometriotic cysts) using laparoscopy.
• Technology: High-definition 2D imaging enhances surgical precision and depth perception.
• Procedure:
  
  • Small incisions are made in the abdomen. 
  • The cyst is carefully excised from the ovary, preserving healthy ovarian tissue.

Laparoscopic TLH + Cyst Excision + Peritonectomy

• TLH (Total Laparoscopic Hysterectomy): Complete removal of the uterus using laparoscopic technique.
• Cyst Excision: Surgical removal of endometriotic ovarian cysts (endometriomas).
• Peritonectomy: Excision of affected peritoneal tissue infiltrated by endometriosis.