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Endometriosis


The lining of the uterus is called the Endometrium. When endometrial tissue is found in places other than its normal location, it is called endometriosis. Normally, most of the uterine lining is shed with menstruation. The remaining part redevelops, grows and then sheds once again at the end of the menstrual cycle. The process typically repeats monthly in a cyclical manner until pregnancy supervenes or menopause arrives. Under normal circumstances, endometrial tissue should not be detectable outside the uterine cavity. However, in about 15% of women, endometrial deposits are indeed detected outside the uterus, in the abdominal cavity (usually within the pelvis), and rarely in other locations such as the lungs, joints and even in the brain.
Typically, upon exam, a patient is found to have Abdominal and pelvic tenderness, and Ovarian cysts filled with altered blood (endometriomas), often referred to as "chocolate cysts" and endometriotic lesions which presents as blue lesions that often coalesce.

The most common symptoms associated with endometriosis are pain, infertility and a disturbance in menstrual flow.

Pain:

The pain is typically with menstruation, or dysmenorrhoea. Here, the pain usually begins a few days before, or with the onset of menstruation. It usually continues for two or more days after menstruation starts. Pain can also occur during ovulation, or mittelshmertz. This type of pain comes on suddenly about 12 to 14 days before menstruation.

Pain during Intercourse:

Women with endometriosis also can experience pain during intercourse, called dyspareunia. This is especially true during deep penetration. Dyspareunia tends to be most severe around the time of menstruation.

Pain during Defecation and Urination:

This type of pain tends to be less frequent. It is also possible for endometriosis to cause blood in the urine and/or bowel movement, however this may not cause pain.

Disturbances of Menstrual Flow:

There may be heavy menstruation with the passage of the large and/or numerous blood clots. There may be mid cycle; pre menstrual spotting or it may be continuous throughout the month.

Symptoms of cyclic pain are suggestive of endometriosis, but are non-specific, as a majority of women report some pain with their periods. Ultrasonography can identify large ovarian cysts, called endometriomas, indicative of a more severe disease state, but cannot identify early stages of disease. The only way to truly diagnose endometriosis is surgically, usually by laparoscopy.

Endometriosis is found in about 10% of women seeking Infertility treatment. Patients with all stages of endometriosis have decreased fertility compared with age-matched controls. Even at mild stages, endometriosis causes an inflammatory reaction. The resulting activation of the immune system may lead to an abnormal immune response in the endometrium that could prevent implantation or lead to embryo destruction.
In the presence of severe disease, there is often scarring and pelvic adhesions that block the fallopian tubes, preventing the egg from reaching the sperm and the uterus. Adhesions can cover the ovary like plastic wrap and prevent the ovulated egg from escaping the ovary. Adhesions may also fix the fallopian tube in place, preventing it from capturing the egg, even though it is open. Large endometriomas can compress normal ovarian tissue, reducing the number of good quality eggs.

Treatment of Endometriosis depends upon the problem you present to us with. The pain in endometriosis can be dealt with over the counter painkillers or with progesterone or oral contraceptive pills. However when you present with Infertility, the treatment is entirely different and requires aggressive therapy. This is because Endometriosis is a progressive disease and the longer you wait the more severe it becomes. Laparoscopy is the first line of management as it helps in diagnosis as well as allows treatment in the same sitting. Thereafter depending on the stage of the disease, IUI (Intra Uterine Insemination) with processed semen or IVF will be required. Waiting for a spontaneous conception after laparoscopy amounts to loss of time as studies have shown that once treated an approximately 6 month "window period" is achieved in which the chances of pregnancy are maximum. Therefore, whatever you do, "waiting and hoping" is not an option.

Adenomyosis occurs when the lining of the uterus (endometrium) grows into the adjacent muscular tissue of the uterus (myometrium). It is usually associated with Endometriosis. It causes the same symptoms as endometriosis though the bleeding during periods may be more prolonged and heavy in this case. Chances of conception are lower as implantation of the fertlised egg is inadequate. Unlike endometriosis medical therapy has a role to play.

Fertility Guideline For Treatment of Infertile Women Suffering From Endometriosis.

National Collaborating Centre for Women's and Children's Health, August 2003

Medical management (ovarian suppression)

Recommendations:
Medical treatment of minimal and mild endometriosis does not enhance fertility in subfertile women and should not be offered. [Grade A Recommendation] Commonly used ovulation suppression agents have been known to cause significant side effects such as weight gain, hot flushes and bone loss.

Surgical Ablation

Recommendations:
Women with minimal and mild endometriosis who undergo laparoscopy should be offered surgical ablation or resection of endometriosis because this improves the chance of pregnancy. [Grade A Recommendation] Women with ovarian endometrioma should be offered laparoscopic cystectomy because this improves the chance of pregnancy. [Grade A Recommendation]

Post-Operative Medical Treatment

Recommendations:
Surgical treatment of moderate and severe endometriosis may improve fertility and should be offered. [Grade B Recommendation] Post-operative medical treatment does not improve pregnancy rates in women with moderate to severe endometriosis and is not recommended. [Grade A Recommendation]

Intra-uterine Insemination for the Management of Endometriosis

Recommendations:
Women with minimal and mild endometriosis should be offered three cycles of intra-uterine insemination with ovarian stimulation because this is more effective in increasing pregnancy rates than either no treatment or intra-uterine insemination alone in subfertile women. [Grade A Recommendation].

In Vitro Fertilisation for Fertility Problems Associated with Endometriosis

IVF treatment has become the final stage in the management of fertility problems associated with endometriosis. This is the case for all severities of endometriosis. Counselling is necessary that pregnancy rates in patients with endometriosis may be lower than the general population.




11th December, 2011
The Telegraph, Kolkata
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