diseases

ENDOMETRIOSIS


Introduction:
'Endometrium' is the lining of the uterus. It is the functional part of the uterus. It undergoes several changes during the monthly menstrual cycle due to the change sin the hormonal levels.

Endometriosis is a disease occurring due to growth of the endometrium in sites other than the uterus. It is estimated to affect 10-15% of the females in the reproductive age group; especially between 25-44 years of age.

Also, it affects 25-50% of infertile women. The disease is more common in the females belonging to the higher socio economic class. Incidence in India is relatively less, but incidences due to endometriosis after hysterectomy or tubectomy have increased in India.


Definition:
Endometriosis means the presence and functioning of the ectopic areas of endometrium like tissue at various sites.

The growth of this endometrium like tissue may occur at various sites around the uterus. Ovaries, fallopian tubes, umbilicus, urinary bladder, the pouch between the uterus and the urinary bladder, the small intestines, the pouch between the uterus and the small intestine.

Other sites uncommonly involved are the ligamental supports of the uterus, the scar remaining after any abdominal surgery, appendix etc.

Causes and risk factors:

The exact cause of developing such an ectopic functioning endometrium is unknown, though, following causes are predicted:
. During menstruation, along with the menstrual discharge, the endometrial cells which are shed get implanted into the pelvic peritoneum. (The membrane lining the abdominal cavity and most of the organs of the abdomen).This may result in pelvic endometriosis.
. Right during the fetal development, migration of the cells from the endometrium to any of the above sites may take place.
. The disease may spread from the uterus through the pelvic lymph nodes, thus affecting the lymph nodes.

Risk factors:
. If any of the family members are also suffering from this disease, then there are chances of the individual also developing the disease.
. Late marriage is also a risk factor.
. In fertility is the risk factor as well as a complication of the disease.
. Any previous abdominal surgeries may increase the risk of scar endometriosis.
. Repeated tubal insufflations (where air is pushed through the fallopian tubes to check its patency) may lead to implantation of the cells into the fallopian tubes, thus increasing the risk of endometriosis in the tubes.

Findings and diagnosis:
. No single symptom is diagnostic.
. 30% of the females are asymptomatic.
. Remaining 60% of the patients may present with a variety of symptoms ranging from painful menstruation to infertility.
. These complaints occur cyclically during every menstrual cycle.
. Pain is felt in the lower abdomen, in the vagina, back.
. It begins 5-7 days before the menses, reaches a peak and then lasts for 2-3 days.
. Pain may also be felt during sexual contact.
. Rarely, there may be rectal pain and bleeding, which is indicative of the lower bowel involvement.
. If there is painful urination, it indicates the involvement of the urinary bladder.
. The patient may complain of a painful nodule at various sites every time during menses.
. Some females may complain of fever during menses.
. The severity of the pain is not proportional to the extent of involvement.

Diagnosis:

The history and the clinical findings may only help in diagnosing 20% of the cases. Though, the history and the clinical findings point towards endometriosis, we can confirm the diagnosis only by:
. Pelvic ultrasonography (we can know about the extent of the lesion);
. Laparoscopy (where with the help of some instruments we can visualize the endometriotic lesions);
. Laparotomy (where a small portion of the lesion may be collected for biopsy);
. Biopsy will confirm the type of cells present in the lesion, thus supporting the diagnosis

Complications:
. Infertility is the most common complication which we come across. This may occur as a result of tubal distortion. Due to the presence of functioning endometrial tissue in the fallopian tubes, recurrent inflammation takes place, which may lead to adhesions and loss of tubal patency.
. Rupture of the endometrial cyst may result in peritonitis due to the contents of the cyst.
. In a very few number of cases, this may transform into a malignancy.
. Obstruction of the small intestines is a also one of the complication

Treatment:
Treatment aims at preserving the fertility of the patient and increasing the woman's potential for achieving pregnancy.

Hormonal therapy: If the patient having mild to moderate endometriosis presents with severe pain during menses and infertility; or in females having recurrence of symptoms even after conservative therapy, are advised hormonal therapy.

Steroids like: Medroxyprogesterone, Danazol, GnRH analogues, Methyl testosterone are used; which through different mechanisms, induce regression of the endometrium in the uterus as well as the ectopic sites, and thus produce relief of symptoms.

Conservative surgery: It is indicated as a primary procedure even before starting the hormonal therapy, or in cases of recurrence of symptoms. Dilatation and curettage of the uterine cavity is done to prevent the retrograde menstruation.

Ovarian cysts, if any, are removed along with the lesions in the pelvis; thus sparing the uterus, the ovaries and the fallopian tubes.
This is indicated in infertile females of less than 35 years of age, having cysts of 6-8 cm or more.

Laparoscopic removal of the endometriotic lesions, the adhesions and the ovarian cysts may also be indicated.

In females of more than 35 years of age or those with completed families can be advised total hysterectomy (removal of the uterus, the fallopian tubes and the ovaries), bilateral salphingo oophrectomy (removal of the fallopian tubes and the ovaries on both the sides).These are most effective surgery for a permanent cure.

Homoeopathic treatment:
In homoeopathy, the disease is treated from its roots. It's not done just by suppressing the symptoms. We will ask you very finer details about your disease, its onset, its progress, the nature of the symptoms. If there is any trigger factor which you feel is responsible for the onset of endometriosis in you, then it becomes very useful in the selection of a perfect remedy.

While acting at a very deeper level, it relieves your symptoms of pain, cramps in the abdominal muscles and makes you feel much better. Thus, homoeopathy helps in regression of your complaints without suppressing them. As the disease is removed from the roots, recurrence is very rare.

Patient care:
. The patient should be made to understand that her symptoms will regress after her menopause. . The female should be provided emotional support. She should be encouraged to express her feelings and speak about the effects of endometriosis on her interpersonal relationships, if any. . Any misconceptions about the disease, its diagnostic or therapeutic procedures should be cleared. She should be explained about all the possible options for treatment. . A young patient, who wants children, should be advised not to delay pregnancy, as infertility is a common complication of this. . Getting regular exercise has been shown to reduce the severity of menstrual cramps as well as help improve circulation. This is especially important for women with endometriosis as better circulation means that your blood is receiving more oxygen, which helps to relax the uterus thereby easing cramps. . Aim to exercise daily at a moderate level for at least 30 minutes. Even just a daily walk after dinner can make a big difference to your endometriosis symptoms.

References:
. Dawn's textbook of gynecology
. Taber's cyclopedic medical dictionary