What do you know about endometriosis? Have you even heard of it?

Endometriosis is a chronic pain condition affecting about 1 in 10 females of reproductive age, so globally that’s about 190 million females!!! It has certainly earned itself quite high rankings in the league of chronic pain conditions in female health. Endometriosis can have negative impacts not just on one’s physical well-being, but emotional, and psychological wellbeing also. Let’s take a deeper dive into the condition….

What goes wrong in the body with endometriosis?

During a normal female menstrual cycle, under the influence of hormones, the inner lining of the uterus builds up and then breaks down. In endometriosis, tissue similar to the lining of the uterus grows outside the uterus as indicated here.  It can grow on the fallopian tubes (which connects the ovary to the uterus), it can grow on the ovary, and even the bladder and bowel. The problem with this is that the tissue on the outside of the uterus behaves in the same way as the tissue on the inside of the uterus. This means every month under the influence of hormones, the tissue outside the uterus builds up, breaks down and bleeds, but the blood has nowhere to leave the body so it bleeds into the pelvis.

Bleeding into the pelvis causes inflammation.  Inflammation is associated with pain which is one of the common symptoms of endometriosis.  Bleeding into the pelvis can also leads to scar tissue forming which can cause organs in the abdomen to stick together.

What are the symptoms?

A common symptom of endometriosis is pain. This can occur before, during or continue after a period. Pain can occur during or after sex (and is usually deep seated), during a bowel motion or even when passing urine. Other symptoms include heavy irregular vaginal bleeding. Some females may struggle to get pregnant, indeed endometriosis is a well-recognised cause of infertility in up to 30% of females.

Endometriosis can also cause gut-related symptoms such as bloating, nausea, constipation, diarrhoea. Other symptoms include back pain and fatigue

Making the diagnosis

Making the diagnosis of endometriosis can be tricky, as it has symptoms that are similar to other conditions, BUT… you can begin to suspect endometriosis based on symptoms and examination can sometimes be useful.

Ultrasound can pick up evidence of endometriosis if there are deposits on the ovary, called an endometrioma, BUT ultrasound can be normal.

The current well-recognised investigation is a laparoscopy.  This is key-hole surgery where small cuts are made around the navel and a thin tube with camera attached is passed into the abdomen and pelvis. The surgeon can see the areas of endometriosis. During laparoscopy, endometriosis lesions can be removed, tissue samples taken, and any scar tissue can be divided.

It’s very important to mention that the need to confirm the diagnosis with laparoscopy should not delay the commencement of treatment if you have convincing symptoms of endometriosis.

Approach to Management:

I like to approach treatment in the form of 3 main pillars:

(1) Medication/painkillers (2) Hormonal treatment and (3) Surgery

Medication includes painkillers such as simple paracetamol, anti-inflammatories such ibuprofen, Naproxen, Aspirin, and then weak opioids such as Co-Codamol, Co-Dydramol, and Tramadol. Most patients by the time they see a doctor would have tried at least one or two of the above and so ‘combination’ treatments should be considered.

Hormonal treatments such as progestogens can be taken orally, or delivered as an injection or Implant. Guidelines also recommend use of  the Combined Oral Contraceptive Pill 

Surgery involves laparoscopy which is considered a minimally invasive procedure, or ‘key-hole’ surgery where a surgeon makes small cuts around the navel and a thin tube with a camera attached is passed into the abdomen and pelvis.  The surgeon can see the areas of endometriosis. During laparoscopy, endometriosis lesions can be removed, tissue samples taken, and any scar tissue can be divided. Hormonal treatment can also be given after surgery to help prevent recurrence.

Treatment should always be in line with the patient’s symptoms, preferences and priorities, rather than just the disease extent, as well as adopting a holistic approach where possible.

Is lifestyle important?

Is there a role for lifestyle in the management of endometriosis?  Well, there isn’t much robust evidence.  The studies haven’t produced consistent results. There is emerging evidence for the role of Omega 3 and 6 fatty acids. These are polyunsaturated fatty acids found in fish, nuts, seaweed. They may have a role in reducing inflammation. That leaves us with the general recommendation about maintaining a healthy lifestyle:

We should have a balanced diet: 

  • High fibre:  fruits, vegetables, legumes, and whole grains
  • Iron-rich foods such as dark-leafy green vegetables, cruciferous vegetables (such as broccoli, cauliflower and kale), nuts, and seeds.
  • Foods rich in essential fatty acids such as oily fish (salmon, mackerel, herring), walnuts, chia, and flaxseeds
  • Antioxidant rich foods such as such as oranges, berries, dark chocolate, spinach, beetroot
  • Pre- and Probiotics are important in maintaining the microbiome of not just your gut but also your urinary system and vagina
  • Keep well hydrated. Majority of us don’t drink as much as we should, which ideally should be at least 2L a day.
  • Regular daily bowel movement
  • Cut down on red meat specially processed meat.  Go for lean meat options.
  • Reduce your intake of trans-fats found in fried, fast food.

Stop smoking, reduce your intake of alcohol to less than 2 units a day. Take a Vitamin D supplement particularly over the winter and autumn months. Stay as active as possible and avoid long periods of sitting. The recommendation regarding exercise is 75mins of high intensity or 150mins of moderate intensity exercise a week

Why the long delay to diagnosis?

Why is there this unusually long delay of 7-8 years to make a diagnosis? Let’s look at some of the reasons:

First, there may be no symptoms, and so the condition goes undetected for several years.

The pain associated with endometriosis is often put down to ‘normal period pain’ or ‘normal period cramps’.  Indeed, majority of females (as high as 80%) experience mild period cramps at some stage of their reproductive years…that’s quite normal. BUT! What needs to be addressed is pain that is severe enough to impact on your day-to-day activities and sex life.

It is not uncommon for us to see patients who have been told that they are unlikely to have endometriosis because they are too young! We’ve already mentioned that endometriosis is a condition associated with reproductive years.  This means that symptoms can start soon after the onset of your periods, which we all know can before your teenage years!  Let’s not get caught out!

Furthermore, symptoms of endometriosis can be similar to those of other conditions, for example Infections such as pelvic inflammatory disease, gut problems such as inflammatory bowel disease or irritable bowel syndrome, bladder problems such as chronic inflammation or infections, ovarian problems such as cysts or even a cancer and abnormal growths of the uterus.

It is very important that investigations are carried out to exclude these other conditions as we do not want to miss a potentially serious problem. Investigations to exclude other conditions, can lead to delays in diagnosis of endometriosis.

The Future of Endometriosis: How do we move forward?

Education

We believe there needs to be more education at every level of the patient journey. Endometriosis affects females as young as 7yrs. Many females do not talk openly about their health or seek support when required due to embarrassment, common stigmas, fear of pain, normalising symptoms, or lack of reliable information. Education about female health must start from a young age. There needs to be more resources available in educational settings as part of the curriculum, to raise awareness about the disorder so that all girls better understand their bodies, are informed of where and when to get help and feel confident to talk about any health issues.

Check out the Menstrual Health Project at www.menstrualhealthproject.org.uk, a charity that provides practical support for those suffering with menstrual health concerns and conditions through educational tools and resources that can be used as part of the teaching curriculum. Education for health-care professionals, incorporating female health as part of the

The Royal College of General Practitioners (RCGP), in partnership with Endometriosis UK, has developed a Menstrual Wellbeing Toolkit for GPs and healthcare professionals (HCPs) that is available on the RCGP’s website. The toolkit includes evidence-based resources for GPs and other primary care clinicians to help diagnose, support and manage problems caused by menstrual dysfunction. Endometriosis needs to be on the radar of the HCP…… if we’re not thinking about it, we won’t be diagnosing it!

Investment

Where is the money at? We need more training for doctors and HCPs in female health, either through integration into the core curriculum or incentivise postgraduate skills development or training in female health. We need Integration of female health care services for example through Female Health Hubs (FHHs) that provide access to the right compliment of trained female health specialists, allied health professionals, imaging services, to provide the highest standard of care that avoids fragmentation in service provision but provides also delivers care in a setting where clinicians have time and feel confident (particularly in the context of complex consultations) to explore and provide advice and support about women’s health. This should also includes dedicated Endometriosis clinics. In these settings, clinicians should have time to discuss the full range of evidence-based management whilst adopting a holistic patient-centred approach to enable patients to make informed choices.

Innovation

Laparoscopy still remains the current gold-standard technique for diagnosing endometriosis which is an invasive procedure. We need more non-invasive diagnostic tools. This includes innovations in diagnostic imaging techniques, and development of diagnostic biomarkers with high reliability.

References:

National Institute for Health and Care Excellence (NICE) Guidelines: October 2023: Endometriosis

This Independent Life: Future of Endometriosis March 2024

Better for Women: Improving the well-being of girls and women: Royal College of Obstetric and Gynaecology: December 2019

If you are concerned about Endometriosis, book a call to speak to one of our friendly doctors at 2meclinic.com

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