Endometriosis is a common medical condition characterized by growth of endometrium (the tissue that normally lines the uterus) beyond or outside the uterus. It looks and acts like tissue in the uterus. It most often appears in places within the pelvis:

• Ovaries
• Fallopian tubes
• Surface of the uterus
• Cul-de-sac (the space behind the uterus)
• Bowel
• Bladder and ureters
• Rectum

Endometrial tissue may attach to organs in the pelvis or to the peritoneum, the tissue that lines the inside of pelvis and abdomen. In rare cases, it also may be found in other parts of the body. Endometrial tissue that grows in the ovaries may cause a cyst (endometriotic cyst) to form. Endometrial tissue outside the uterus responds to changes in hormones. It breaks down and bleeds like the lining of the uterus during the menstrual cycle. The breakdown and bleeding of this tissue each month can cause scar tissue, called adhesions. Adhesions can cause pain. Sometimes, adhesions bind organs together. The symptoms of endometriosis often worsen over time.

Women may complain of the following:

• Heavy and sometimes irregular menses
• Painful periods
• Pain during sex (this is a deep pain during penetration)
• Pain in the pelvis or lower abdomen in between periods
• It may be associated with infertility.

It is estimated that 30-40% of women with endometriosis may have difficulties in becoming pregnant i.e. unable to conceive after 1 year of regular intercourse. The age-dependent cycle fecundity (monthly) rates in healthy fertile women range between 15 and 25%. That chance is less than 1% for women with severe endometriotic disease.

Endometriosis pain can mimic the pain caused by appendicitis for example especially if it is on the right side (I had a patient that presented this way and also ended up needing an emergency operation and hormonal injections post op.) This can be distinguished by performing ultrasound scans and CT scans which will be able to see the enlarged endometriotic cyst or an inflamed appendix. The cyclical nature of the pain points towards endometriosis rather than other pathological causes of pelvic pain (ureteric colic, bladder stones, bowel disorders).

The causes of endometriosis are still unknown and its spread is related to female hormones so much so that endometriosis can affect any menstruating woman, from the time of her first period to menopause, regardless of her race or ethnicity, or her socio-economic status. It does not cause cancer. Surgery is advisable if the endometriotic symptoms like pain is severe, the endometriotic cyst is enlarged or for fertility investigation and treatment. The only instance in which surgery cannot be performed is if the patient is deemed to be unfit for surgery which is very rare.

Although the disease affects women of all races, there is some evidence to suggest that Asian and Caucasian women are at greater risk of developing endometriosis than other races. Because endometriosis is such a variable disease and because it is often misdiagnosed and under diagnosed, the true incidence is not known but it is estimated to occur in about 1 in 10 women of child-bearing age.

Besides a thorough history to determine if women have any characteristic symptoms to suggest the presence of endometriosis, the doctor can perform a pelvic exam. This is to try to localize the area of pelvic pain. Other causes of pelvic pain would have to be ruled out. A pelvic ultrasound scan can be used to detect endometriotic cysts and this is usually combined with blood Ca125 investigation (which can be raised in endometriosis).

Endometriosis can be mild, moderate, or severe. The extent of the disease can be confirmed by looking directly inside the pelvis using a laparoscope (key hole surgery) under general anaesthesia. The endometriotic lesions as well as endometriotic cysts and adhesions can also be removed during a laparoscopy.

When a type of progestogen (dienogest) is taken as prescribed, studies have shown that it can provide long-lasting pain relief associated with endometriosis and reduces endometriotic lesions.

If the surgery is performed laparoscopically, most patients are discharged after 1-2 days. For open surgery, the hospital stay is typically 2-3 days or more. Most women recover within 2 weeks for laparoscopy and up to 1 month for open surgery.