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Endometriosis

HCA Healthcare UK Endometriosis Centre

We provide treatment for women with symptoms suggesting the presence endometriosis, and those confirmed with endometriosis. The centre consists of a multidisciplinary team of specialists managing women with all grades of endometriosis (from mild, severe, and complex cases), consultant gynaecologists specialising in complex minimal access surgery, an Endometriosis Clinical Nurse Specialist, colorectal surgeon, a urologist and a pain management specialist. The Endometriosis Centre is an aspiring British Society of Gynaecological Endoscopy (BSGE) provisional centre, and aims to achieve accreditation in 2018.

What is Endometriosis?

Endometriosis is a chronic condition which is found in 1 in 10 women of reproductive age in the UK. It occurs when tissue, similar to the lining of the womb (endometrium), is located elsewhere in the body (usually in the pelvic area) leading to the formation of lesions found on the ovaries, fallopian tubes, bladder, bowel, surface of the uterus and on the peritoneal lining throughout the pelvis. In rare cases it may be found in other parts of the body such as in the chest cavity (on the diaphragm and lungs).

If endometriosis is present on the ovaries it can lead to the formation of a cyst (Endometrioma) which is filled with old blood and as this is brown in colour is known as a ‘chocolate cyst’. Endometriosis can also occur within the uterus itself where it is known as adenomyosis.

Endometriosis acts in a similar way to the bleeding that occurs during menstruation, and can induce a chronic, inflammatory reaction and cause the structures close by to become stuck together, distorting the pelvic anatomy and could result in a ‘frozen pelvis’.

How will Endometriosis affect me?

The effect Endometriosis has on everyday life will vary between women, couples and their families but can sometimes include:

  • Impact on physical functioning
  • Inability to continue work
  • Emotional impact on relationships

Causes of Endometriosis

Though the cause of Endometriosis is unknown, some factors can include:

  • Retrograde menstruation - where the menstrual flow, during a period, travels backwards up the fallopian tubes and into the pelvic area instead of flowing out through the vagina, causing a change in cells called metaplasia
  • Lymphatic transportation – where endometrial cells enter the lymphatic system (blood stream) which could cause symptoms occurring in other parts of the body
  • Genetic – where Endometriosis is thought to be genetic and passed down through families and generations
  • Environmental factors - including toxins affecting the immune and reproductive systems

Symptoms of Endometriosis

Symptoms vary in severity and type from one woman to another and some women experience no symptoms at all.

Symptoms include:

  • Painful periods, with the pain often radiating to hips and down legs
  • Deep pain during sex
  • Pain on having an internal examination and/or when passing a speculum for a smear test
  • Chronic pelvic pain
  • Painful bowel movements (dyschezia) with or without the presence of blood
  • Pain when passing urine with or without blood in the urine (haematuria)
  • Chronic fatigue
  • Depression
  • Infertility
  • Painful caesarean section scar or lump at scar during period

Diagnosing Endometriosis

A diagnosis of Endometriosis can be presumed based on symptoms, so it is essential that a thorough and detailed history is given.

Other investigations which may be carried out to provide more information are:

  • Vaginal examination  - to determine if the pelvic organs are ‘fixed’ or nodules of Endometriosis are present
  • Transvaginal ultrasound - to identify areas of Endometriosis and/or an endometrioma (chocolate cyst) seen on one or both ovaries. One or both of the ovaries may be fixed rather than mobile and may be seen stuck together underneath the uterus (kissing ovaries)
  • MRI  - to show areas of Endometriosis
  • Laparoscopy – considered the gold standard for diagnosing Endometriosis

Endometriosis and fertility

The majority of women with Endometriosis do become pregnant but in some circumstances having the condition leads to a delay in conceiving or infertility.

If infertility does occur, then it is thought to be due to a chemical substance being released from the Endometriosis tissue which affects the normal reproductive process. Chances of conception may be increased if the Endometriosis tissue is removed.

Having a ‘chocolate cyst’ on the ovary may interfere with the normal functioning of the ovary which may prevent ovulation therefore surgical treatment to the cyst may be offered.

In cases where the tubes are known to be damaged due to Endometriosis or, where the anatomy of the pelvis has become distorted, the movement of the egg from the ovaries down the fallopian tubes may not occur at all or result in ectopic pregnancy. In some women the specialist may recommend removing the tubes in which case subsequent fertility treatment such as IVF would be required. Management may be decided in conjunction with or on the advice of the fertility team.

Treatments for Endometriosis

A woman’s decision to undergo treatment is dependent on many factors including: symptoms, age, previous treatment and the desire to become pregnant. The choice and decisions made regarding management can change and a woman may undergo various treatments over the course of her lifetime.

A confirmed diagnosis is not essential prior to the commencement of treatment as the aim of any management is to control the symptoms being experienced.

Expectant Management - In the absence of symptoms a ‘watch and wait’ approach may be chosen. Some women may develop symptoms at a later stage, affecting their quality of life, leading them to choose active treatment, however, in some women treatment will never be needed.

Medical Management - Medical Management may consist of analgesics (painkillers) and/or hormones treatment.

Painkillers (analgesics) - The main symptom of Endometriosis is pelvic pain so women may choose over-the-counter painkillers. If these are not effective then prescription painkillers may be used with the advice of the pain management team.

Hormone Treatment - As endometriosis symptoms tend to be cyclical (worse around the time of menstruation), hormones to reduce or stop periods may be offered, depending on choice, medical history, age and side effects experienced.

Combined Oral Contraceptive Pill -The Combined Oral Contraceptive pill (COC) contains both oestrogen and progesteroneand is taken for three weeks with the aim of the resulting ‘withdrawal’ bleed in the fourth week being much lighter and less painful than the usual period. The COC may also be prescribed continuously without a monthly break to avoid bleeding.

 

Progesterone/Progestogens - There are different ways of administering progesteroneincluding the progesterone only pill, Mirena Intra Uterine System (IUS), Depo Provera Injection and Nexplanon Implant.

Common side effects of using hormones include:

  • Acne
  • Depression
  • Bloating
  • Irregular vaginal bleeding
  • Breast discomfort
  • Fluid retention
  • Headaches
  • Changes in mood
  • Nausea
  • Vomiting
  • Weight gain

Side effects generally decrease within a few weeks of stopping the treatment although in some long acting hormones such as depo provera, they may last for a longer period.

Gonadotrophin Releasing Hormone Analogues (GnRHA) - switch off the ovaries and result in a temporary menopause by stopping oestrogen production. Side effects include hot flushes/night sweats, decreased libido (sex drive), insomnia, change in mood and aching joints. They are not recommended for long term use due to the risk of osteoporosis.

In cases where side effects are not tolerated a small amount of oestrogen (addback therapy, for example, tibolone) may be prescribed.

Surgical Treatment - Surgical treatment is carried out laparoscopically (keyhole surgery) and the aim of surgery is to eliminate Endometriosis by (excising) or ablating (destroying) it. In addition any adhesions formed by scar tissue will be divided or removed and endometrioma(s) can be treated.

The surgery offered will depend on the extent and location of the Endometriosis and the procedure can vary from minor surgery to a complex operation involving bowel and bladder specialists.

 

Further Advice and Support

For further information or advice or to request an appointment at the HCA Healthcare UK Endometriosis Centre, contact Cathy Dean the Endometriosis Clinical Nurse Specialist (CNS) on 02073908350 or email  phendonurse@hcahealthcare.co.uk

Endometriosis UK www.endometriosis-uk.orgoffers help through an informative website, support groups, a helpline and online community.

The guideline of the European Society of Human Reproduction and Embryology, ESHRE Endometriosis Guideline Development Group

Dunselman GA, Vermeulen N, Becker C, Calhaz-Jorge C, D'Hooghe T, De Bie B, Heikinheimo O, Horne AW, Kiesel L, Nap A, Prentice A, Saridogan E, Soriano D, Nelen W. ESHRE guideline: management of women with endometriosis. Hum Reprod. 2014 Mar;29(3):400-12. doi: 10.1093/humrep/det457. September 2013

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