Endometriosis, the elephant in the womb

It is very rare that endometrial-like tissue may be found beyond the area where pelvic organs are located but such lesions outside the pelvic or lower abdominal cavity are generally classified as extra-pelvic endometriosis, writes Dr Anu Joseph

The endometrium is the tissue that forms the inner lining of the uterus. The presence and growth of these cells outside the uterine cavity causes endometriosis. The cause and reasons for its growth outside the uterine cavity are unknown. However, the disease per se is a common and painful one. It also has a moderate genetic predisposition. This means if your mother or sister has suffered from it, there is a likelihood that you would too.

Typically, endometriosis affects the ovaries and fallopian tubes and presents itself as chronic lower abdominal or back pain, painful cycles, infertility or as an incidentally detected ovarian cyst. This is theorised as caused by transplantation and implantation of endometrial cells which are shed during menstrual flow through the fallopian tubes into the abdominal cavity (Sampson’s Theory). However, it fails to completely explain the endometriosis found in other parts of the body. There are various other theories postulated. However, none of them to this date explains the cause of endometriosis completely, and hence endometriosis remains largely an enigmatic disease.

Extra-pelvic endometriosis: The rare occurrence of endometriotic lesions outside the pelvic or lower abdominal cavity is generally classified as extra-pelvic endometriosis. Though not in huge numbers, endometriosis has been found in every organ system of the women’s body: gastrointestinal (stomach and intestines), nervous system (brain and spine), pulmonary (lungs), urinary tract (bladder), extremities (limbs) and skin. One of the commonest extra-pelvic locations of endometriosis is on the skin, especially on the healing scars of previous pelvic or laparoscopic surgeries. It is called scar endometriosis. Endometriosis is rarely detected in males as well.

The clinical symptoms of endometriosis vary with the organ affected by it. Ranging from cyclical mass/nodules on the skin which increases in size and is painful especially during the menstrual cycle to epileptic (Catamenial Epilepsy) episodes, if the endometriosis affects the brain. Endometriosis of the urinary bladder may present as cyclical hematuria (catamenial hematuria) or blood in urine and can be diagnosed and treated by cystoscopy. Similarly, it can present as blood in the sputum or lung cavity, blood in sputum/vomitus, blood in faecal matter, cyclical chest pains, cyclical nasal bleed etc.

The diagnosis is made by imaging especially ultrasound, MRI or CT scan and confirmed by biopsy.

Treatment

Once the diagnosis is made, treatment modality is decided based on factors like: location, symptoms, size of lesion etc.

Small asymptomatic incidentally detected endometriosis is left untreated and the patient is offered a follow-up.

Medical management: Various tablets and injections are available to counteract the oestrogen requirement of endometriosis.

Surgical management: Surgical excision, laser or electrical ablation of the lesion are also carried out.

Or even a combination of medical and surgical management.

In spite of multiple available modalities of treatment, endometriosis remains one of those disease conditions with very high recurrence risk.

Complementary therapies like vitamin supplementation, exercise, TENS, acupuncture etc., have given mild to moderate relief from symptoms to certain patients.

(The author is a senior consultant in obstetrics & gynaecology.)