Endometriosis, Chocolate Cyst and Subfertility

Do you suffer from painful periods, constant lower abdominal pain and pain in pelvic area, painful intercourse, reduced fertility and intermenstrual bleeding? Think again, you could be suffering from endometriosis. If you persistently suffer from these symptoms, you must get yourself evaluated by your gynaecologist.

Endometriosis is simply the presence of endometrium (the uterine lining) outside the uterus. The most common places where it grows are the structures that lie adjacent to the uterus, namely the fallopian tubes, ovaries, broad ligaments, and the peritoneum.

Facts about endometriosis that every woman should be aware of:

• Many endometriosis patients are never diagnosed or are under diagnosed due to mild symptoms or no symptoms reported by patient. It is just mistaken for a painful period or pre-menstrual syndrome. Prompt medical advice is not sought after until the symptoms become troublesome and debilitating.
• Estimates say that about 1 to 5 in every 10 women develop endometriosis at some point in their life. That is how common it is.
• It is an oestrogen-dependent disease and thus usually occurs in women of reproductive age.
• Symptoms often begin between the ages of 25 and 40. Women attaining puberty at an early age are more at risk of developing endometriosis.
• Women with short menstruation cycles and long duration of periods (for more than 7 days) fall in the high risk category.
• It is more common in women who have delayed childbearing. However, it is rare in women of the post-menopausal age group.
• Sometimes, it is hereditary. Therefore, if you have a sister or maternal cousin with similar problems, there are chances that you could be affected by it too.
• Use of oral contraceptive pills have shown to reduce the risk of endometriosis. If you are taking one, then you are protected against endometriosis.

Now that you know the facts, you must be wondering as to what causes endometriosis. Please read on.
As with many other medical conditions, the exact cause of what causes endometriosis in unknown. However, there are various theories for the same.

Retrograde menstruation is one of the oldest theories. Here, the cells flow backward through the fallopian tubes and deposit the endometrial cells in other pelvic organs. Research that is more recent indicates an increased humoral immune response to the displaced endometrial tissue as a pathological role. Genetic basis has also been cited in the recent times showing an aberrantly expressed gene factor SF-1 for the enzyme aromatase causing increased aromatase activity. Metaplasia and anatomic defects in the uterus and pelvic structures are additional causes for the same.

What does endometriosis do to the body? - The 'Chocolate Cyst' story
An acquaintance of mine rang me up in the middle of the night last month and she was freaking out. She said, ‘Doctor, I have been diagnosed with a strange and complicated disease – my gynaecologist says it’s a ‘Chocolate Cyst’. Hence, there was I explaining everything in an understandable manner to calm her down.

In simple terms, these new endometrial cells in different locations outside the uterus just continue to proliferate under the influence of the oestrogen hormone and continue shedding as usual during the normal menstrual cycle. However, since they have no space to be washed out or escape from the body, they accumulate in the local area and form cysts. When bleeding occurs inside these cysts, they grow larger, forming cysts and exhibit brownish colour due to clotted blood. This blood filled enlarged cyst is what comes to be known as a ‘Chocolate cyst’. Now you know how one gets chocolate cysts.

These patches of cells outside the uterus are sticky. They tend to stick adjacent structures together for instance, the walls of the fallopian tubes getting stuck to the uterus. Hence, around 30% of the women with endometriosis are subfertile, have difficulties in conception or experience pain during intercourse.

Let us look into how it is diagnosed.
The primary diagnosing modality for endometriosis is laparoscopy. This is an invasive procedure where a flexible scope is passed through the uterus and a search for sites of endometrial deposits is done. The suspected areas are excised and sent for histopathological examination (viewing under the microscope) to confirm the presence of endometrial cells and glands.

Imaging studies like ultrasonography and MRI can be used for its diagnosis as well, but are less specific.

How is endometriosis managed or treated?
Usually doctors use conservative or medical management in the initial stages. As many as 3 out of 10 women affected with endometriosis need no active medical management. The cells disappear on their own in 3 months.

Patients with troublesome symptoms, taking infertility treatment or with long standing problems require surgical management.

Medicines used are combined oral contraceptive pills, progestational agents, Danazol and GnRH analogues. Patients usually require continuous treatment for a minimum of 6 months to attain maximum recovery.

Surgical methods used include conservative surgeries like laparoscopic cystectomy, ablation and laparoscopic uterine nerve ablation (LUNA). Women who are not planning for future pregnancies can opt for hysterectomy and cytoreduction of the endometriosis.

Extreme cases require radical surgery that involves complete removal of the uterus along with the ovaries.
To conclude, if your friend or you have persistently moderate to severe pain while menstruating that does not respond to painkillers, that is lasting for more than 3 months, please consider endometriosis as a possibility.
Recent evidence suggests that early treatment of the disease can help prevent a woman from becoming subfertile or infertile in the future.