What is endometriosis?
Endometriosis is a condition in which endometrium (the lining of the uterus) grows in locations outside the uterus. These may be the ovaries, Fallopean tubes, ligaments supporting the uterus, or less commonly the appendix, bowel, bladder, ureter, or outside the pelvis.

How common is endometriosis?
Endometriosis may affect women anytime during their menstruating years. Up to 20% of women may have this condition.

What happens in endometriosis?
Like endometrium inside the uterus, the endometriotic implants swell and bleed in response to the cyclical ovarian hormones each month. This results in inflammation, adhesions, cyst and scar tissues, which can damage or destroy the affected organs.

What are the consequences of having endometriosis?
Endometriosis is one of the most common causes of severe period pain, pelvic pain and abnormal bleeding in women. Untreated, it may result in long-term complications such as pelvic adhesions, blood-filled ovarian cysts and infertility. At times, bowels, bladder and ureter may also be damaged.

What causes endometriosis?
Although endometriosis may run in families, there is no clear genetic predisposition and the cause remains unclear.

What are the symptoms of endometriosis?
The symptoms of endometriosis are variable and do not usually correspond to the severity of the disease. You could have severe endometriosis and be completely asymptomatic. However, most women with endometriosis have symptoms which may include any of the following:
• Pain: with periods, ovulation, and intercourse
• Low back pain
• Pain when passing urine or opening bowels
• Abnormal bleeding: irregular menstrual cycles, premenstrual
• Spotting, heavy periods
• Infertility

How is endometriosis diagnosed?
If you suffer from many of the above symptoms and have signs such as retroverted uterus or tender scars on pelvic examination, you may require further tests such as pelvic ultrasound and a referral to a gynaecologist. At the present time, there is no simple screening (X-ray or blood test) for endometriosis and the only way to tell with certainty is by laparoscopy. This is a day-only examination in hospital, under general anaesthesia, in which a small telescope is introduced through a skin incision at the umbilicus. This allows the doctor to see and to biopsy the endometriosis.

How can endometriosis be treated?
Endometriosis may be treated by:
• Medications
• Surgery
• Combination of medical and surgical treatment

To help you choose the most suitable treatment, your doctor will consider such factors as your age, your plan to have children, the severity of your symptoms, the extent of endometriosis at laparoscopy and your response or side effects from previous endometriosis or fertility treatment. 'Wait and see' option may be appropriate if you have minimal endometriosis with no symptoms and have not started trying for pregnancy. Medications such as Ponstan, Naprogesic may be used for relief of symptoms such as period and pelvic pain. These do not treat the endometriosis.

Hormones are used to suppress the menstrual cycles and thereby preventing the growth and development of the endometriotic implants. In general, hormonal treatments usually take six to nine months to complete. Up to 80% of women experience total or partial pain relief while on therapy. Some 40-80% of women who wish to conceive become pregnant following treatment.

There are four main groups of hormones:
• Progestogen
• Combined oral contraceptive pill
• Danazol and Gestrinone
• GnRH agonists (Synarel, Zoladex)

All the hormonal treatments carry a wide variety of side effects and should only be taken under the guidance of your gynaecologist and family doctor.

When is surgery needed?
Laparoscopy is needed to confirm the diagnosis. With appropriated instrumentation and surgical experience, laparoscopic surgery can also be used to treat the disease by removing the endometriotic implants, ovarian cysts and repairing tubal damage. Occasionally, laparotomy (open surgery) may be required to deal with very extensive disease. In general, adequate surgical treatment of endometriosis produces more immediate results in terms of pain relief and pregnancy as compared to prolonged hormonal therapy.

When might hysterectomy be required for the treatment of endometriosis?
Hysterectomy is a last resort and is only indicated when the disease is severe, childbearing has been completed and other conservative treatments have been tried and failed.

Can endometriosis come back after treatment?
Despite effective treatments, there is no magical or permanent cure for endometriosis. Regardless of the type of treatment used, it is estimated that 20% of women may have recurrence of symptoms within 12 months to five years. Pregnancy, breastfeeding and the oral contraceptive pill may help reduce the likelihood of recurrence. Despite increasing awareness of endometriosis, research has shown that it still takes a woman, on average, six years from the onset of her symptoms to the time a diagnosis of endometriosis is confirmed. As endometriosis is thought to be a progressive condition with possible long-term complications of infertility, adhesions and chronic pain from delayed treatment, it is important to seek medical attention if you suffer from symptoms that may suggest the presence of this common gynaecological disease.

Early diagnosis and individualised management is the key to prevention of long term complications and successful treatment of endometriosis.