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• What are the signs and symptoms of endometriosis?
• What are the causes of endometriosis?
• What are the risk factors for endometriosis?
• How does a doctor diagnose endometriosis?
• What are the treatments for endometriosis?

Endometriosis

Endometriosis is the condition where the mucous membrane, which is called the endometrium and is normally lining in a uterine cavity, grows outside your uterus. This condition may occur in your ovaries, fallopian tubes, and the tissue that is lining in your pelvis. However, the endometrial tissue may rarely expand beyond your pelvic organs.

In normal circumstance, the tissue becomes thicker, and then it breaks down, and eventually bleed during each menstrual cycle. In an irregular circumstance, the tissue escapes your uterus but still produces menstrual blood as normal. However, when it breaks down, the blood has no way out and it becomes trapped. When this condition occurs in the ovaries, it forms the cyst called an endometrioma.

Endometriosis causes pain, which sometimes can be severe during your menstrual periods in particular. With the condition, you may have problems with your fertility development. However, there are various effective treatments for this condition.

What are the signs and symptoms of endometriosis?

Pelvic pain is the primary symptom of endometriosis. It also occurs during your periods. Despite experiencing cramping during the periods, the pain with endometriosis can be far worse than you think. And over time, the pain can be elevating.

In addition to the pelvic pain, signs and symptoms of endometriosis also include:

• Having dysmenorrhea: These painful periods or menstrual cramps may occur before the day your periods come and may persist for several days. In some circumstances, you may also have pain in your lower back and abdominal area.
• Pain with sexual intercourse: You may also experience deep pain during or after sexual intercourse with endometriosis.
• Pain that comes along with bowel movements or when you urinate: These symptoms occur when you are having a menstrual period.
• Excessive bleeding: Heavy menstrual periods may occur occasionally. Bleeding between periods can also occur, which is called intermenstrual bleeding.
• Fertility problem: Endometriosis may sometimes diagnosed first, especially when most cases seek infertility treatments.
• Fatigue, diarrhea, constipation, bloating, or nausea during menstrual periods in particular.

However, the severity of your pain does not necessarily indicate the condition. You may have mild endometriosis although your pain is severe. Also, you may have advanced endometriosis although your pain is light.

Endometriosis can sometimes be mistaken for conditions such as pelvic inflammatory disease (PID) or ovarian cysts, which cause pelvic pain. It can be also mistaken with irritable bowel syndrome (IBS), which is a condition that causes bouts of diarrhoea, the difficult passage of stools, and muscle cramps of the stomach.

When do you need to see a doctor?

When signs and symptoms of endometriosis are shown, you are advised to see a doctor.

What are the causes of endometriosis?

The causes of endometriosis remain uncertain. However, they can be:

• Retrograde menstruation: In a normal condition, this menstrual blood with some endometrial cells flows out of the body. In an irregular condition, however, the blood travels back through fallopian tubes as well as going into the pelvic cavity. This causes endometriosis. The cells stick to the pelvic walls and the surface of its organs. Over time, they grow thicker and thicker and then bleed during each period.
• Peritoneal cell transformation: In the induction theory, it has been proposed that hormones or immune factors promote the peritoneal cell transformation into endometrial-like cells. These cells exist in the inner side of your abdomen.
• Transformation of embryonic cell: In this circumstance, the hormones such as estrogen might change embryonic cells into endometrial-like cell implants during puberty.
• Implantation of surgical scar: After some surgeries such as hysterectomy or Caesarian section, an incision from surgery may be attached with surgical scar implantation.
• Transport of endometrial cells to other parts of the body: Endometrial cells may be taken to other parts of the body through blood vessels and lymphatic.
• Disorder of the immune system: In some cases, the immune system creates mistakes, fails to recognize, and destroy endometrial-like tissues that expand outside the uterus.

What are the risk factors for endometriosis?

The risk factors for you to develop endometriosis can vary, including:

• You have never given birth to a child before.
• You started your period at an early age.
• You have menopause at an older age.
• Your menstrual cycles are shorter than most normal women, such as less than 27 days.
• You have heavy periods that last longer than seven days.
• You have a higher level of estrogen or receive the hormone for a very long time.
• You have a low body mass index (BMI).
• Your female relatives such as mother, aunt or sister have had endometriosis.
• You have some health problems that prevent you from having a normal passage of menstrual blood to flow out of your body.
• You have problems with your reproductive tract.

Endometriosis normally takes many years to develop following the onset of the first menstrual period. Its signs and symptoms may temporarily undetectable with pregnancy, and they disappear completely when your period stops.

How does a doctor diagnose endometriosis?

When seeing your doctor, you will be asked to explain your symptoms. Your doctor will also ask the location of your pain as well as when the pain occurs as part of the diagnosis of endometriosis.

Moreover, your doctor may run some tests to check for physical clues of endometriosis as follows:

• Pelvic exam: Your doctor manually examines areas in your pelvis to see if there are abnormalities. The doctor will be interested in knowing if you have cysts on your reproductive organs or scars behind your uterus. In most cases, small areas of endometriosis are not easy to detect unless these areas cause the formation of cysts.
• Ultrasound: Your doctor will use a device called a transducer to press against your abdomen or insert it into your vagina to get the best view of your reproductive organ. These two tests are standard tests to help with the diagnosis of endometriosis. However, they cannot detect endometriosis directly, but they help your doctor to identify cysts that are associated with endometriosis.
• Magnetic resonance imaging (MRI): Some cases may require an MRI, which is an exam that utilizes a magnetic field and radio waves to produce detailed images of organs and tissues inside your body. The exam helps your surgeon to identify the location and size of endometrial implants.
• Laparoscope: Some cases require a procedure called laparoscopy that gives your surgeon a better view of your abdomen. This procedure requires general anesthesia. Your surgeon needs to make a small incision near your navel, and then insert a tiny telescope into it to look for signs of endometrial tissue outside the uterus. With the laparoscopy, your surgeon can identify the location and size of the endometrial implants. Along with this method, some tissue samples may be taken for further testing. With a proper plan, your surgeon can treat endometriosis during the laparoscopy; in this connection, you need only one surgery.

What are the treatments for endometriosis?

Most cases of endometriosis require treatments in the form of medication and surgery. The methods for treatments will be selected, based on how severe your signs and symptoms are and if you would like to get pregnant.

Your doctor is likely to advise you to receive conservative treatments first. Surgery will be selected if the initial options of treatment fail. 

Pain medication: When it comes to the pain, your doctor may advise you to take an over-the-counter pain reliever to help alleviate pains from menstrual cramps. And if you are not attempting to get pregnant, you may be advised to opt for hormone therapy along with the use of pain relievers.

Hormone therapy: Some supplemental hormones can sometimes be effective to help ease or eliminate endometrial pain. The fluctuation of hormone levels during your periods can cause thickened endometrial implants, which later breaks down and bleeds. With hormone therapy, the growth of endometrial tissue slows down as well as helping with the prevention of endometrial tissue. However, hormone therapy is not a permanent method for endometriosis. If you stop the therapy, the symptoms will return.

Various therapies to treat endometriosis are as follows:

• Hormonal method of contraception: Each month, birth control pills, patches, and vaginal rings help control any hormones that are responsible for the formation of endometrial tissue. Most cases experience a shorter menstrual flow due to the use of hormonal contraceptives, which may also alleviate or eliminate pains.
• Gonadotropin-releasing hormone (GnRH) agonists and antagonists (ตัวantagonist ยังไม่มีในเมืองไทย): With these drugs, the production of ovarian-stimulating hormones will be stopped. Estrogen levels will be lower as well. In this connection, menstruation will be prevented. While using the medicines, endometrial tissue is shrunk. These medicines create artificial menopause. Moreover, taking a low dose of estrogen or progestin with GnRH agonists and antagonists may help reduce the side effects of menopause. The side effects include sudden feelings of warmth, a vagina that is not well-lubricated and healthy, and the loss of bone density. Once you stop the medication, you will have your menstrual periods and the ability to get pregnant back.
• Progestin therapy: Levonorgestrel intrauterine device (IUD) such as Mirena and Skyla (ยังไม่มีในเมืองไทย); a small flexible plastic rod or contraceptive implant, such as Nexplanon; contraceptive injection (Depo-Provera); and progestin-only birth control pills can stop your menstrual periods as well as the growth of endometrial implants that may alleviate signs and symptoms of endometriosis.
• Aromatase inhibitors: This class of drugs is used to help reduce estrogen. You may be suggested to take an aromatase inhibitor along with a progestin. In some cases may be recommended to take an aromatase inhibitor with a combination of hormonal contraceptives when treating endometriosis.

Conservative surgery

Removing endometriosis implants while preserving the uterus and ovaries is a conservative surgery. If you want to get pregnant while having endometriosis, you may be advised to opt for conservative surgery. And with the surgery, the chance of success is high. The surgery may also benefit patients with endometrial pain. Despite the surgery, endometriosis and pain are likely to return. In most cases, conservative surgery with laparoscopy is more common than those procedures through traditional abdominal surgery. 

Fertility treatment

Endometriosis causes fertility difficulty. In this circumstance, your doctor may advise you to receive fertility treatment which is supervised by a fertility specialist. The treatment includes ovary stimulation to produce more eggs and in vitro fertilization.

Hysterectomy with ovary removal: Menopause also occurs when your ovaries are removed. Endometriosis pain can be alleviated when hormones cannot be produced. Early menopause is not healthy as you also have risks of having heart disease and blood vessel problems. Certain metabolic conditions and early death are also linked with early menopause. Your doctor may sometimes use a hysterectomy to remove your uterus to treat signs and symptoms that are associated with endometriosis. For those who do not want to get pregnant, your doctor may recommend a hysterectomy for heavy menstrual bleeding as well as painful menses from uterine cramping.