Endometriosis Is Way Beyond Just Period Pains, And It Is Not Cancer

What is Endometriosis? A few days back there was a post on social media by a TV actor speaking about her own Stage 4 endometriosis. Post that there has been a turmoil in many minds correlating endometriosis with cancer. It is important to understand the condition more clearly. Period pain may be the first pointer towards the condition but endometriosis is way beyond just period pains. And it is not cancer. It is important to understand the condition more clearly.

Endometriosis is the presence of tissue resembling the inner lining of the uterus (endometrium) outside the uterus causing a chronic inflammatory reaction. Endometriosis may grow anywhere in the body but is most commonly seen around the ovaries, peritoneum, ligaments of the uterus and gastrointestinal system.

It is a multisystemic disease and is not just limited to the genito-urinary system. (organs of the reproductive system and the urinary system) Estrogen hormones which are secreted when a woman starts menstruating cause the endometriosis to grow and invade body tissues resulting in painful adhesions, scarification and disruption of other organ systems. Tissue growing into the rectum and bowel produces constipation or diarrhoea, if it grows into the ovary or tubes it causes infertility, if it grows within the vagina and the back of the uterus it causes painful sexual intercourse and also produces inflammatory processes causing generalised abdominal pain and bloating. The disease grows locally and infiltrates deeper into the tissues and pulls everything toward it causing entrapment of nerves and produces new blood vessels. This causes sequelae depending on which nerves and vessels are impacted ranging anywhere from sexual function to altered urinary function and/or bowel functions.

It affects women during their premenstrual, reproductive, and postmenopausal hormonal stages. 25 to 40 percent of adolescents with severe period pain may have endometriosis.

Tissue growing into the rectum and bowel produces constipation or diarrhoea, if it grows into the ovary or tubes it causes infertility, if it grows within the vagina and the back of the uterus it causes painful sexual intercourse and also produces inflammatory processes causing generalised abdominal pain and bloating

The severity of the disease is classified as stages/ points/ categories (superficial peritoneal/ ovarian or Deep infiltrating endometriosis) depending upon the involvement of organs, the size of the implants, the spread and the depth of the involvement by the implant.

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This is a medical or clinical staging. This is does not always correlate with the symptoms that the woman has. She might have mild symptoms but an extensive disease inside or vice versa.

Common symptoms

a) painful periods (dysmenorrhoea) limiting daily activities and quality of life (painful periods)
b) cyclical or non-cyclical pelvic pain
c) deep pain during or after sexual intercourse ( dyspareunia )
d) abdominal bloating
e) unexplained gastrointestinal symptoms, particularly when cyclical in nature and pain related to bowel movements including pain while passing stools (dyschezia)
f) unexplained urinary symptoms, particularly when cyclical in nature
g) sub-fertility that is otherwise unexplained

How would one suspect?

Endometriosis is highly suspected if the patient complains of dysmenorrhoea (Painful periods), dyspareunia (Painful sexual intercourse), abnormal bleeding and subfertility.

Special attention must be paid to symptoms like nosebleeds, haematochezia (blood in stools) and blood in urine among others which would lead one to a suspicion of extra-genital endometriosis.

What tests can detect endometriosis?

Ultrasonography:
Transvaginal ultrasound is the best non-invasive method to diagnose endometriosis. It may reveal cysts, rectovaginal nodules and adherent ovaries. It may not reveal much superficial disease. In younger girls who are not sexually active a transrectal approach is much better for diagnosing endometriosis than a transabdominal one.

MRI:
Useful in detecting rectovaginal disease but not much better than a well-performed ultrasound.

Laparoscopy:
Laparoscopy is the gold standard for diagnosis of endometriosis. The advanced optics and modern imaging modalities with HD, 4K, 3D and Near-Infra Red Imaging systems improve visual acuity in identifying lesions as never before. The corollary to this is that the surgeon should know what to look for. Subtle endometriosis lesions may be missed if he/she hasn’t seen them before.

Treatment of endometriosis

Treatment of Endometriosis depends upon the clinical staging/ points assigned to the disease. Mild and moderate (stage 1 to stage 3;1-40 pts) can be managed by a good gynaecologist in a good clinical set-up/hospital.

More severe endometriosis (stage 4/ category 4 and 5; >40 points) needs specialist multidisciplinary approach with Gynaecologists trained in endometriosis management, pain physicians, nutritionists, pelvic floor physiotherapists, bowel specialists, clinical psychologists and fertility specialists. Few hospitals in India have such specialised Endometriosis centres/ clinics.

Dr Sudeshna Ray is a senior Gynecologist and Obstetrician attached to Jaslok and H N Reliance hospitals, Mumbai. The views expressed are the author’s own.