22 Apr 2015

Head of obstetrics and gynecology department at Princess Marina Referral Hospital, Dr Ponatshego Gaolebale says although there are several theories about endometriosis, the precise cause of the disease is still unknown.

Responding to a BOPA questinnaire on April 21, Dr Gaolebale said none of the theories could explain different types of the endometriosis disease. He explained that genetic predisposition seemed likely as endometriosis occurred 6-9 times more commonly in relatives of affected first degree relatives than in controls.

Dr Gaolebale said the prevalence was estimated at between 8-10 per cent of women of reproductive age, although the precise rate is unknown as the pelvis has to be estimated at surgery to make a precise diagnosis.

The Doctor said endometriosis is defined as the presence of endometrial like tissue outside the uterus which induces a chronic, inflammatory reaction. It is a condition found in women of reproductive age from all ethnic and social groups. The associated symptoms can impact on general physical, mental and social wellbeing.

He said the uterus is made up of three layers; the inside lining called the endometrium, the muscle layer (myometrium) and the outer covering (serosa). In the absence of pregnancy, it is the inside lining (endometrium) that is shed every month as evidenced by the cyclical monthly vaginal bleeding that most women experience.

Dr Gaolebale said the most commonly affected sites are the pelvic organs. The disease varies from a few small lesions on normal pelvic organs to solid infiltrating masses and ovarian endometriotic cysts often with scar tissue formation causing marked pelvic anatomy distortion.

Regarding diagnosis, he said it is initially made on clinical symptoms. Empiric therapy is usually started based on clinical suspicion only. He said key hole surgery (laparoscopy) can be performed to confirm the diagnosis or to rule out a another cause for the patients symptoms.

Patients may present with one or all of the following symptoms: severe pain with menstruation, painful intercourse, chronic pelvic pain, ovulation pain, infertility, pain on defecation. He said it must be noted, however that the usefulness of any one symptom or set of symptoms in diagnosis endometriosis is uncertain.

Each of the above symptoms can have other causes and a significant number of women with endometriosis are completely without symptoms. Establishing a diagnosis on symptoms alone can be difficult because the presentation is quite variable and often there is a delay of many years between symptom onset and a definitive diagnosis.
He said as mentioned, diagnosis can be confirmed via keyhole surgery.

However in resource limited countries where access to key hole surgery is limited, open abdominal surgery can be performed to confirm the diagnosis. Open abdominal surgery is an option that is not acceptable to most women given that there is a high likelihood of a negative finding.

He further said ultrasound examination is useful to confirm or rule out ovarian endometrium (ovaries enlarged by endometrial blood). On treatment, Dr Gaolebale said it is tailored to the specific needs of the woman and mostly painkillers with non-steroidal anti-inflammatory drugs may be effective in managing pain caused by endometriosis.

He said endometriosis in estrogen dependent and thus suppression of ovarian function usually leads to symptom control. However symptom recurrence is common following cessation of treatment as adverse effects limits prolonged ovarian suppression.

Dr Gaolebale said ablation (application of heat to endometriotic lesions) and removal of infiltrating nodules reduces pain secondary to endometriosis, and said women with debilitating symptoms with no response to medical treatment may benefit from bilateral oophorectomy (removal of both ovaries). The implications for this should be comprehensively discussed with the patient. Ends