Abnormal growth of the womb lining outside of the uterus

Endometriosis is a non-cancerous condition where the endometrial tissue or womb lining which normally grows only in the uterus is found in other parts of your pelvis, for example the ovaries, fallopian tubes, rectum, bladder, appendix and pelvic walls. This womb lining that grows outside the uterus responds also to hormones but at the time of your periods it can not be expelled (as the womb lining) and causes pain, cysts in the ovaries (called chocolate cysts), inflammation in your pelvis, scar tissue, pain with sexual intercourse, chronic pelvic pain, pain when passing bowel motions, lower backache, symptoms similar to urinary tract infections, premenstrual discomfort, etc.

The cause of endometriosis is not known. The old theory of the blood from your periods going backwards through your tubes and into your pelvis is now very much in disrepute. It seems more likely that the lining of your pelvis that has the potential to change, it does so into endometrial tissue or womb lining.

Endometriosis is a very common condition affecting 15-20% of menstruating women between the ages of 20 and 50. However, teenagers can present with endometriosis as well. It seldom occurs before menstruation starts, or after menopause. Endometriosis however, tends to get worse with time and if not treated may seriously impair quality of life and fertility.

If the mother or sister had endometriosis then a patient is at high risk of endometriosis herself.

Diagnosis of endometriosis can only be done with certainty through a laparoscopy. Although this means surgery, a patient can also be treated at the same time, saving an extra procedure and the associated risks.

A normal pelvic ultrasound will not exclude endometriosis and it would only reveal ovarian cysts.

Laparoscopy is an operation (keyhole surgery) conducted under general anaesthesia. A telescope is introduced into a small incision in your navel, other small incisions are made for using special laparoscopic instruments and all the pelvic organs are examined with magnification (Video-laparoscopy) ; then the endometriosis is treated. Video Laparoscopy allows conservative surgery (hysterectomy is NOT the usual treatment for endometriosis) which means laparoscopic excision of the endometriotic implants, with restoration of the normal anatomy and preservation of the uterus, tubes and ovaries.

There is plenty of evidence that laparoscopic excisional treatment improves fertility, even in mild cases of endometriosis.

Endometriosis-associated Infertility

There are a number of ways as endometriosis may cause infertility. Although women with mild endometriosis may get pregnant, endometriosis is usually a progressive disease, as it gets worse with time. So early diagnosis and treatment is important. Women with advanced disease have low chance of achieving a spontaneous pregnancy. There is plenty of evidence based medicine showing that laparoscopic treatment of endometriosis does improve fertility. When a patient has an ovarian endometriotic cyst associated with infertility, laparoscopic surgery is the first line of treatment. The average pregnancy rate reported after surgery in these cases is 35-50%. So laparoscopic surgery provides a woman with good chances of becoming pregnant spontaneously.

There are a number of medications for treating endometriosis. Many of them may cause side effects. They are only advisable therefore in certain cases and only after the diagnosis of endometriosis have been made with no doubt. However, as laparoscopic surgery becomes more and more available, the need for medication has been reduced.

Pregnancy and Endometriosis

There is no evidence that pregnancy cures endometriosis. If a woman has endometriosis and she gets pregnant, the disease would go dormant or the progression of the disease will be stopped during the pregnancy but it will continue after the pregnancy is over.

Laparoscopic view of a normal uterus, tubes and ovaries

Endometriosis of the anterior part of the uterus, a uterine ligament and the lining covering the bladder. This patient was complaining of painful periods and "symptoms" of urinary infections with normal urinary tests.

Endometriosis of the lower part of the posterior uterine wall and its posterior ligaments. This lady was suffering with severe painful periods and pain on sexual intercourse.

Severe endometriosis. The Bowel and the right ovary is adhered to the lower aspect of the uterus. This is only the "tip of the iceberg". Most of the endometriotic implants are covering the rectum and the upper part of the vagina. This young lady used to have painfuls periods, pain at the time of sexual intercourse and pain when opening her bowels.

Big ovarian cyst with endometriosis. Note the size of the cyst in comparison with the size of the uterus which lies above the cyst. The tube is elongated around the ovarian cyst. This patient had a long history of infertility and painful periods.

It is important to assess the appendix in cases of endometriosis. This photo shows endometriosis of the appendix, which will be removed.

This is also endometriosis of the uterosacral ligaments (same area from a previous photo). However, in this case the endometriosis reveals as "white patches". Endometriotic lesions give different sort of appearances at laparoscopical view.

This lady was complaining from severe pain with periods and also pain on sexual intercourse. She had substantial endometriosis around the sacro-uterine ligaments.

Endometriosis may present with a variety of appearances in the pelvis. In this case a "pocket" of the lining covering the pelvis is shown. The "pocket" lining will be excised revealing endometriosis.

Endometriosis of the diaphragm (muscle between the abdomen and the chest). The "wine colour" structure below the nodule of endometriosis is the liver!

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