Endometriosis

Date of publication 31 August 2004

Endometriosis has a surprisingly low profile, given that it affects millions of women around the world - more than AIDS according to some authorities - and the symptoms can be severe. In order to appreciate how the various pelvic structures can be affected, it might be a good idea to start by revising the organs that make up the female reproductive system, and the precise relationships between them.

Basic facts about the condition can be gleaned from the Endometriosis Association or the US National Women's Health Information Center. They explain that endometriosis occurs when the tissue lining the uterus (the endometrium) is found elsewhere in the abdomen, usually on the ovaries, fallopian tubes, the ligaments that support the uterus, the area between vagina and rectum, and the lining of the pelvic cavity. This picture of characteristic 'powder burn' lesions on the uterosacral ligament shows how they appear as small bumps on the surface of an affected structure.

The ectopic tissue responds to the menstrual cycle in the same way as the uterine lining; each month it builds up and breaks down, but unlike the endometrium it has no way of leaving the body. An interactive tutorial on endometriosis at MedlinePlus, complete with questions and patronising voiceovers, has animations which illustrate this clearly. The internal bleeding and inflammation that result may lead to chronic pain, scarring, infertility, adhesions and bowel problems. The severity of symptoms is unrelated to the extent of the condition; some women have very few symptoms even though many pelvic organs are involved. Other interesting facts can be found in this health encyclopaedia. For example, a woman's risk is higher if she has relatives with the condition, and pregnancy slows its progress. Also, the length of the menstrual cycle is an important influencing factor; women whose periods last longer than a week with intervals of less than 27 days between seem to be more susceptible.

Although the precise cause is not known, two possible theories are outlined on the emedicine site. The first claims that endometrial tissue is carried from the uterus by retrograde menstruation or by the vascular or lymphatic circulations. Analysis of peritoneal fluid supports this hypothesis; as many as 90% of women have blood in the fluid around the time of menstruation and endometrial cells have also been found. The pattern of endometriosis suggests retrograde menstruation, being most common in the ovary, followed by the dependent areas of the pelvis. When the ovary is affected, an endometrioma or 'chocolate cyst' is formed which is filled with a dark, viscous fluid - for a colour photograph, click here. However, distant sites such as the lungs and CNS are occasionally involved, indicating that blood or lymphatic spread may also be a factor.

Alternatively, the epithelium of the peritoneum could undergo metaplastic change into endometrial-like tissue. This theory is supported by the fact that both endometrial and peritoneal cells are derived from the same embryonic tissue, and that the condition can develop in women who lack a normal endometrium.

Diagnosis involves a physical examination and tests such as ultrasound, MRI or laparoscopy (the insertion of a very small telescope through an incision in the navel). A simple patient-orientated explanation can be found at this site. Most specialists regard laparoscopy as the most useful procedure because it is the only one capable of identifying superficial peritoneal lesions, but ultrasound also has its advocates, such as the writer of this comparison of the two techniques. When he talks about smearing gel over the traducer before the procedure, I do hope he means transducer - or could this be a medical procedure for exacting revenge?

As we have seen from some of the preceding sites, medical treatment may consist of analgesics in mild cases or hormone treatment to suppress the menstrual cycle. Surgical approaches involve the ablation of endometrial implants, lysis of adhesions and the removal of endometriomas, via laparoscopy or laparotomy (i.e. conventional rather than minimally invasive surgery). A hysterectomy and removal of the ovaries may be indicated in severe cases. Techniques for the ablation and excision of endometrial tissue are described at some length here, but if you have a fast connection you might also like to visit IVF.com, where there is a 5.6 megabyte Quicktime video of an actual operation.

Endometriosis is still poorly understood, but research has unearthed some encouraging results. Firstly, women who are infertile as a result of endometriosis have very low levels of an enzyme involved in the synthesis of L-selectin, a molecule that must be present on the uterine wall before an embryo can attach itself. This study also discovered that a number of genes present in the uteri of endometriosis patients appear to function inappropriately. These findings may lead to the development of a less invasive screening test, based on the detection of abnormal gene activity.

The condition is also linked to an increased risk of other ailments, including rheumatoid arthritis, lupus, chronic fatigue syndrome, fibromyalgia and allergies. Chronic fatigue syndrome, in particular, is 100 times more common in endometriosis sufferers than among the general population. A common link between all these conditions may be the malfunctioning of cytokines.

Exposure to complex organic chemicals is a possible aetiological factor. There is evidence to suggest that dioxins and related chemicals (polyhalogenated aromatic hydrocarbons) have a causative role, although the mechanisms are not yet clear. There also appears to be a higher incidence of endometriosis in the daughters of women who took diethylstilboestrol during pregnancy to prevent miscarriage.

Perhaps the most unexpected discovery, however, is that women who engage in sexual activity and experience orgasms during menstruation (and use tampons) are less likely to be sufferers, and may have a degree of protection as a result. If this is the case, then perhaps a dedicated preventative programme is not too much of a hardship...!

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A Tour around Endometriosis

A Tour around Endometriosis