What is Endometriosis? Women should know!

Contributed by Dr Christopher Ng





1. Endometriosis is a common medical condition characterized by growth beyond or outside the uterus of endometrium, the tissue xxthat normally lines the uterus.

It affects an estimated 89 million women (usually around 30 to 40 years of age who have never been pregnant before) of reproductive age around the world. Current estimates place the number of women with endometriosis at between 5% and 20% of women of reproductive age. In endometriosis, the endometrium is found to be growing outside the uterus, on or in other areas of the body. Normally, the endometrium is shed each month during the menstrual cycle; however, in endometriosis, the misplaced endometrium is usually unable to exit the body. The endometriotic tissues still detach and bleed, but the result is far different: internal bleeding, degenerated blood and tissue shedding, inflammation of the surrounding areas, pain, and formation of scar tissue may result. In addition, depending on the location of the growths, interference with the normal function of the bowel, bladder, small intestines and other organs within the pelvic cavity can occur. In very rare cases, endometriosis has also been found in the skin, the lungs, the eye, the diaphragm, and the brain.
The prevalence of endometriosis in Singapore is unclear as we do not have this data available but should be around 20% of women of reproductive age. About 30% to 40% of women with endometriosis are infertile.

2. The literature seems to indicate that Caucasian women are at greater risk of developing endometriosis than blacks. Reports on xxthe prevalence of the disease in Asian women are lacking. One report (Miyazawa K. Incidence of endometriosis among Japanese xxwomen. Obstet Gynecol 1976) showed that Japanese women had a higher incidence when compared to whites or blacks; 9.2% xxin Japanese women, 2.8% in whites and 1.9% in blacks. Another paper by Kulenthran Arumugam and A. A. Templeton xx(Endometriosis and Race. The Australian and New Zealand Journal of Obstetrics and Gynaecology 1992) showed that Asian xxwomen have a significantly greater risk of developing endometriosis than Caucasian women. The authors gave no reason as to xxwhy this is so but is could be related to the risk factors which includes many years of spontaneous menstrual cycles, longer xxduration of menstrual flow, defects in the outflow tract and hereditary factors. For instance, a woman with a first-degree relative xxhaving the disease has a risk approximately seven times the normal risk of developing the disease.

In another article published in the American Journal of Epidemiology 2004, Incidence of Laparoscopically Confirmed Endometriosis by Demographic, Anthropometric, and Lifestyle Factors by Stacey A. Missmer, showed that the rate of endometriosis diagnosis among African Americans or Hispanics was 40 percent lower than compared to Caucasian women. The difference in risk between Asians and Caucasians was however not shown to be significant. The authors in this study did acknowledged that 3 other studies have also suggested that Asian women are at higher risk of endometriosis compared with women of other races (Sangi-Haghpeykar H, Poindexter AN. Epidemiology of endometriosis among parous women. Obstetric & Gynecology 1995 / Eskenazi B, Warner ML. Epidemiology of endometriosis. Obstet Gynecol Clin North Am 1997/ Houston DE. Evidence for the risk of pelvic endometriosis by age, race, and socioeconomic status. Epidemiol Rev 1984)

3. There is no permanent cure for endometriosis short of natural menopause or surgical menopause (by removing the ovaries) but xxeven then there are reports of endometriosis found in menopausal women although rare. There are however treatments to help xxwomen manage and deal with their symptoms. For some women pregnancy can lessen the symptoms and effects of xxendometriosis. The reality is that pregnancy, like hormonal drug treatments, usually suppresses the symptoms of endometriosis xxbut does not eradicate the disease itself. Symptoms may or may not recur after the birth of the child. Most women can delay the xxreturn of symptoms by breastfeeding, but only while the breastfeeding is frequent enough and intense enough to suppress the xxmenstrual cycle. Doctors sometimes advise women with endometriosis not to delay having children because endometriosis xxtends to worsen with time. The longer you have endometriosis, the greater your chance of becoming infertile.

4. There is an association between the presence of endometriosis and subfertility. It is estimated that 30-40% of women with xxendometriosis may have difficulties in becoming pregnant (but this means that 60-70% will have no problems!). This is two to xxthree times the rate of infertility in the general population. When endometriosis is moderate or severe, it can cause pelvic xxscarring. The scar tissue formed around endometriosis implants can change the shape or location of the ovaries, fallopian tubes, xxor uterus. This tissue can block the fallopian tubes, preventing or slowing the movement of eggs from the ovaries to the uterus or xxsurround the ovaries, preventing eggs from moving to the fallopian tubes. The ovaries often contain endometriotic cysts and xxmay become adherent to the uterus, bowel or pelvic side wall.

In some cases the eggs in the ovaries can be damaged, resulting in decreased ovarian reserve and reduced egg quantity and quality. In this situation, there is likely to be a causal relationship between endometriosis and subfertility. When endometriosis is minimal to mild, a causal relationship is controversial. Endometriosis is more common in subfertile women when compared to the women of proven fertility.

5. As it is estimated that 30-40% of women with endometriosis may have difficulties in becoming pregnant i.e. unable to conceive xxafter 1 year of regular intercourse (but this means that 60-70% will have no problems!).There is no question that chances for xxpregnancy in endometriosis are significantly decreased. Without treatment, women with mild endometriosis have an xxapproximately 2% chance for conceiving in any given menstrual cycle (cycle fecundity rate). That chance is less than 1% for xxwomen with severe disease. By comparison, age-dependent cycle fecundity (monthly) rates in healthy fertile women range xxbetween 15 and 25%.

Laparoscopic surgery can almost double the chance of pregnancy and a live birth for women with mild endometriosis compared with not having the surgery. Following surgery, rates of pregnancy for women with mild endometriosis as their only fertility problem range from 81% to 84%. Those with moderate or severe endometriosis, including damage to the ovaries, have a 36% to 66% chance of conceiving after surgery. Pregnancy rates are highest within a year of surgery, since endometriosis commonly recurs in spite of the operation.

6. Not true. Based on controlled prospective studies, there is no evidence that endometriosis is associated with (recurrent) xxpregnancy loss (Vercammen and D'Hooghe, 2000) or that medical or surgical treatment of endometriosis reduces the xxspontaneous miscarriage rate (Marcoux et al., 1997; Parazzini, 1999). This conclusion is derived from the guideline published by xxThe Diagnosis and Treatment of Endometriosis (European Society for Human Reproduction and Embryology (ESHRE) Special xxInterest Group for Endometriosis) and the Endometrium Guideline Development Group in 2005.

7 + 8. Pregnancy often causes a remission of endometriosis and therefore their symptoms, as ovulation ceases causing the xxxxxxendometriotic growths to shrink. But it is not always the case as some women report relief from pain during pregnancy, xxxxxxwhile others report no relief at all. Discomfort during pregnancy is common as a result of the physical changes during xxxxxxpregnancy and this may sometime be confused with endometriotic pain.

9. Treatment is directed at either relief of pain or infertility. The treatment options for pain range from the analgesics, combined oral xxxcontraceptive pill, danazol, oral or depot progesterone injections (medroxyprogesterone acetate) to GnRH agonists. They are xxxequally effective but their side-effect and cost profiles differ. Suppression of ovarian function with any of these medications for 6 xxxmonths reduces endometriosis-associated pain.

Surgery may be advisable for some women in whom medical treatment has failed to relieve their pain or infertility. The goal of surgery is to remove or coagulate all visible endometriotic peritoneal lesions, endometriotic ovarian cysts, deep rectovaginal endometriosis and associated adhesions, and to restore normal anatomy. Ablation of endometriotic lesions plus removal of endometriotic adhesions to improve fertility in minimal-mild endometriosis is effective. Pregnancy rates are highest within a year of surgery, since endometriosis commonly recurs in spite of the operation.

In addition, IUI (intra-uterine insemination) or IVF (in vitro fertilisation) may be required in women who fail to conceive following surgery. Treatment with IUI improves fertility in minimal to mild endometriosis. IVF is appropriate treatment, especially if tubal function is compromised, if there is also male factor infertility, and/or other treatments have failed.

10. Suppression of ovarian function with hormones to improve fertility in endometriosis is not effective and should not be offered xxxfor this indication alone. Pregnancy rates are highest within a year of surgery so more harm than good may result from xxxhormonal ovarian suppression treatment, because of adverse effects and the lost opportunity to conceive.

11. Refer to answer to question 9.
xxxIn addition to surgery, IUI or IVF, it's important to maintain a healthy lifestyle prior to embarking on and during the pregnancy. xxxWomen should also take folic acid and vitamin supplements, avoid smoking and alcohol and reduce stress.

12. There is no cure for endometriosis, but there is treatment to help women manage and deal with their symptoms. There is also no xxxknown prevention at this time. Researchers have not discovered a conclusive reason why women get endometriosis, therefore xxxthey do not have a way to prevent it from occurring.

13. Radical procedures such as oophorectomy (removal of the ovaries) or total hysterectomy (removal of the womb) are indicated xxxonly in severe cases. If a hysterectomy is performed, the cervix should be removed as persistent pain in a remaining cervix is xxxcommon due to endometriosis in the cervix. However, it is important to note that women younger than 30 years at the time of xxxhysterectomy for endometriosis-associated pain are more likely than older women to have residual symptoms, to report a sense xxxof loss, and to report more disruption from pain in different aspects of their lives. Although radical resection is an effective xxxtreatment for rectovaginal endometriosis, a hysterectomy and/or removal of the ovaries will not guarantee that the xxxendometriosis areas and/or the symptoms of endometriosis will not come back. Currently, there is no known cure for xxxendometriosis, though in some patients menopause (natural or surgical) will abate the process.

14 + 15. Several scientific studies suggest that other treatment methods which may be helpful in relieving endometriotic pain xxxxxxxxinclude thiamine (vitamin B1), vitamin E, high frequency transcutaneous nerve stimulation, topical heat and herbal remedy xxxxxxxxtoki-shakuyaku-san (tang-gui-shao-yao-san).

Many women with endometriosis report that nutritional and complementary therapies such as vitamin B12, fish oil, magnesium, acupuncture, other herbal remedies and behavioural interventions and spinal manipulation do improve pain symptoms. Whilst there is no evidence from scientific studies in endometriosis to support the use of these treatments, they should not be ruled out if the woman feels that they could be beneficial to her overall pain management and/or quality of life, or work in conjunction with more traditional therapies.

Patient self-help groups can provide invaluable counselling, support and advice. The website www.endometriosis.org/support.html provides a comprehensive list of all the self-help groups in the world. Self-management programmes may be beneficial in providing the woman with tools to enable her to live with a chronic disease.

16. The treatment options for pain if allergic to painkillers range from the combined oral contraceptive pill, danazol, oral or depot xxxprogesterone injections (medroxyprogesterone acetate) to GnRH agonists.

17. The cause of endometriosis is still unknown. One theory is that endometriosis is an autoimmune condition (Immune dysfunction xxx- a potential target for treatment in endometriosis by N. GLEICHER published in BJOG: An International Journal of Obstetrics xxxand Gynaecology, 1995) and women with endometriosis are more likely than women without the condition to suffer from xxxvarious autoimmune diseases. Women with one autoimmune condition have a higher risk of also having endometriosis than a xxxwoman who does not have autoimmune disease.

Women with endometriosis are also more likely to have abnormally low thyroid function (hypothyroidism), chronic fatigue syndrome, fibromyalgia, lupus, multiple sclerosis, asthma and

Disease xxxxxxxxxxxxxxxxxxxxxxxxxxWomen With Endometriosis xxxxxxxxxxxxxxxxxxxxxxGeneral Population
HYPOTHYROIDISMxxxxxxxxxxxxxxxxxxxxxx 7% xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx2%
HYPERTHYROIDISM xxxxxxxxxxxxxxxxxxxx1.5%xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx 1%
HASHIMOTO'Sxxxxxxxxxxxxxxxxxxxxxxxzxx 2% xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx0.01%
RHEUMATOID ARTHRITIS xxxxxxxxxxxxxzxx2% xxxxxxxxxxccccccxxxxxxxxxxxxxxxxxxxxxxxxxxxx0.8%
LUPUSxxxxxxxxxxxxxxxxxxxxzzzzzzzzzxx 0.8% xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx0.05%
MULTIPLE SCLEROSISxxxxxxxxxxxxxxxxx 0.6%xxxxxxxxxxxccccccxxxxxxxxxxxxxxxxxxxxxxxxxxx 0.1%
MENIERE'S DISEASExxxxxxxxxxxxxxxxxxx 0.9% xxxxxxxxxxccccxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx0.2%

These findings are not surprising. There has been a large body of evidence accumulated over the last 10 to 15 years that endometriosis is, in large part, an autoimmune disease although the consensus on this has not been finalised. A research team in 2002 from the Endometriosis Association in Milwaukee; the National Institute of Child Health and Human Development, Bethesda Maryland; and the School of Public Health and Health Services at George Washington University in Washington D.C. carried out and analyzed a survey of 3,680 members of the Endometriosis Association who had endometriosis. They found that among these women:

- x20% had more than one other disease
- Up to 31% of those with co-existing diseases had also been diagnosed with either fibromyalgia or chronic fatigue xxsyndrome and some of these had other autoimmune or endocrine disease
- xChronic fatigue syndrome was more than a hundred times more common than in the female U.S. population generally
- xHypothyroidism was 7 times more common
- xFibromyalgia was twice as common
- xThe autoimmune inflammatory diseases, systemic lupus erythematosus, Sjögren's Syndrome, rheumatoid arthritis, and xxalso multiple sclerosis occurred more frequently
- xAllergic and atopic conditions such as asthma and eczema were higher. 61% of the endometriosis sufferers had allergies xxcompared to 18% of the U.S. general population, and 12% had asthma compared to 5%. If a woman had endometriosis xxplus an endocrine disease the figure for allergies rose to 72% and to 88% if she had endometriosis plus fibromyalgia or xxchronic fatigue syndrome.
- xTwo thirds reported that they had family members with diagnosed or suspected endometriosis, confirming research that xxsuggested there is a familial tendency.

Article contributed by

Dr Christopher Ng
GynaeMD Women's & Rejuvenation Clinic
#04-03A Camden Medical Centre
1 Orchard Boulevard
Singapore 248649
tel: 67338810
email: gynaemd@singnet.com.sg
website: www.gynaemd.com.sg

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