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Endometriosis and the common issue of fertility

My periods have become very painful in the past year. I went to my GP and she has referred me to a specialist as she thinks I may have endometriosis. I have heard of this condition but don't really understand it. Can it be cured and what treatment am I likely to need?

Endometrium refers to the tissue that normally makes up the lining of the womb. During each menstrual cycle this thickens over a number of weeks and is then shed from the body monthly during a menstrual period.

Endometriosis occurs when this tissue grows in parts of the body other than in the womb. This growth most commonly occurs on the ovaries, fallopian tubes, outside of the womb, and on the tissue lining the pelvis. Endometriosis can also be found in the cervix, vagina, bowel or bladder and it has even been found beyond the pelvis in the liver, surgical scars and lungs.

Endometrial tissue is activated by oestrogen. Through a normal menstrual cycle, as hormone levels increase, the tissue thickens and then as levels fall off, it starts to shed in the form of tissue and blood. In endometriosis this process still occurs but as the tissue cannot leave the body it breaks down and may collect and thicken, leading to cysts, inflammation and scar tissue. This tissue can ultimately end up blocking off the fallopian tubes, extending into the ovaries or making organs more sticky causing fibrous thickening referred to as adhesions.

The symptoms of endometriosis include menstrual pain which can be severe, pain during intercourse, pain with urination or bowel motions, that may be at its worst during your period, pain in the pelvis and back, and more vague symptoms such as fatigue, altered bowels bloating or nausea.

Endometriosis is thought to affect up to one in 10 women. It can occur in any menstruating female but is most common in those aged 30 to 40. You are more at risk if you have never been pregnant, have a family history of the condition, have frequent menstruation either due to prolonged periods or shorter menstrual cycles or have had previous pelvic infection or inflammation.

The cause of endometriosis is not fully understood. One of the simplest theories is referred to as retrograde menstruation. This implies that during menstruation the tissue flows backwards up the fallopian tubes towards the ovaries rather than downward and out of the body. These cells that flow back then attach to other areas of the pelvis and continue to grow causing the symptoms mentioned above.

Another theory suggests that some of these endometrial cells may be present in the pelvis since birth and become active with menstruation. More recently the immune system's role in endometriosis is being explored.

If your doctor suspects endometriosis, they are likely to refer you for further tests. A pelvis exam and ultrasound may show areas of tenderness or inflammation but the best way to diagnose is by laparoscopy.

This is a surgical procedure often referred to as key-hole surgery. It is usually performed as a day case but does require general anaesthetic. The gynaecologist makes a small incision in the abdomen usually around the umbilical area. A gynaecologist can then see endometriosis if it is present.

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These deposits of endometriosis can be burnt off during a laparoscopy so diagnosis and treatment often occur hand in hand. More radical surgery involving the removal of the womb, fallopian tubes and ovaries may be an option in severe and persistent cases.

Endometriosis is not curable but there are a number of treatments. The contraceptive pill can be used to control menstruation. Other hormone treatments switch off the normal menstrual cycle. The side effects of this medication are similar to severe menopause and debilitating hot flushes can occur. Lastly, a low dose of male hormone has been used but the side effects of this - which include acne, increased body hair and weight gain - make this a more unpopular choice. Endometriosis will improve during pregnancy and it no longer occurs once a woman is menopausal.

The most common complication of endometriosis is infertility.

It is thought that up to one half of those affected will have fertility problems. As some of the symptoms are vague or may not be severe, this condition may only be diagnosed at the time of fertility investigations. If the condition has been present for a long time and there is a lot of inflammation or scarring, treatment may not improve the chance of pregnancy. However, if milder deposits are present treating these can help improve fertility.

The psychological impact of endometriosis should not be underestimated. Chronic pain can result in low mood, anxiety and withdrawal from friends and social activities. Exercising regularly, maintaining a healthy weight and considering contraceptive options such as the pill may prevent higher levels of oestrogen and are worth considering.


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