About Endometriosis
Endometriosis is a condition characterised by the presence of endometrial tissue, which is normally found lining the womb, at sites outside the womb. It is most commonly found in the pelvis but it has also been found at remote sites such as the lung and nose.
The prevalence of the condition is not completely clear but best estimates range from 2-10% of females of reproductive age. There is a genetic tendency in that the conditions can cluster in families; however, most sufferers do not have a family history of note.
Symptoms
Symptoms usually consist of pain and/or sub-fertility. Pain can occur with periods, intercourse and sometimes on passing stool or urine. It may also be a more constant pain throughout the menstrual cycle. The effect of endometriosis on quality of life can be enormous.
Diagnosis
The main technique for diagnosis is a laparoscopy, which involves a small camera being passed though the umbilicus (belly button) under anaesthetic to allow direct inspection of the organs of the pelvis. Because of this, and often a lack of awareness, there is frequently a delay in diagnosis, with the average delay from first presentation to diagnosis being 3-11 years.
Causes
The cause of endemetriosis is not clear. The original theory was that is was due to menstrual fluid spilling from the fallopian tubes during a period and the tissue ‘taking hold’. This, however, cannot be the whole answer as menstrual fluid is found in most women’s pelvises during a period, but less than 10% actually develop the disease. In addition this theory would not explain how endometriosis can be found in the lungs. Disorder of the immune system probably plays a part and studies have shown the immune system in ladies with and without endometriosis to be different. A further theory involves the ability of cells within the body to change from one cell type to another (metaplasia). In this situation a cell, anywhere in the body, may change into an endometrial cell and develop into endometriosis although the trigger for this has yet to be proven. The probable answer is that there are several factors that can lead to endometriosis and combinations of factors increase the chance of developing the disease.
Treatment
Broadly speaking, treatments of the condition bare are broken down into medical treatments (drugs) and surgical treatments.
Medical treatment
The aim of medical treatment is to improve symptoms by suppressing the endometriosis. Drugs used include the combined oral contraceptive pill, progestogens (eg norethisterone, provera), depo provera injection, danazol (rarely) and gonadotrophin releasing anologues (eg Zoladex, Prosap). Around 80-90% of patients will have improvement of their pain symptoms and all have similar efficacy. Relapse rates on stopping, however, are high, with up to 50% relapsing at one year and 33-74% relapse rate at 3-5 years. This is due to the fact that these treatments suppress disease rather than irradicate it. Side effects are relatively frequent and vary from treatment to treatment, and none of these treatments are suitable for patients trying to conceived as they are relatively contraceptive.
Surgical treatment
Surgical treatment is either conservative, aiming to treat the disease and leave the gynaecological organs (or as much of the gynaecological organs as possible), or radical, with hysterectomy and removal of the ovaries. However, this classification is often confusing, as most endometriosis experts will perform ‘radical’ excision of endometriosis, whereby all the disease is excised with electrosurgery or ablated / vapourised with the laser, rather than simply being superficially burnt with diathermy.
At present less than 20% of UK consultant gynaecologist perform excisional laparoscopic surgery for endometriosis and even fewer laser surgery. Conservative treatment is usually carried out by keyhole surgery and most often as a day case procedure. However, this does depend on the severity of the disease. Severe disease involving the bowel will usually require the gynaecologist to operate with a colorectal surgeon who specialises in keyhole surgery.
Overall symptomatic improvement following excisional / laser surgery occurs in 62-80%. Further laser surgery in those who relapsed or did not achieve significant benefit the first time gives similar results with nearly two thirds having symptomatic improvement. In patients with sub- fertility and endometriosis, laparoscopic surgery has been shown to increase fertility.
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