Up to 5–10% of women have endometriosis during their fertile years, often without knowing. Endometriosis may be associated with variable pelvic pain and dysfunction; patients with endometriosis need more often than others help to become pregnant. Effective and timely drug treatment can maintain fertility and reduce the need for repeated surgery. It is also vital that patients with endometriosis get individualized fertility guidance after the diagnosis has been set and also later during various phases of life.
What is endometriosis?
Endometriosis is a common chronic illness of unknown cause that affects women of childbearing age. The disease is characterized by focuses of tissue similar to the tissue of the endometrium, but these focuses are located in the abdominal cavity. The focuses may be situated on the surface of the peritoneum, ovaries, uterine suspensory ligaments and on the walls of the urinary bladder, gut or vagina. Based on their location and type, endometrial focuses are divided into superficial peritoneal focuses, endometriosis cysts of the ovaries and deep focuses. Endometriosis causes a strong local inflammation which, in turn, causes pain and may affect fertility. The hormonal activity of the endometriosis tissue is also disturbed. The tissue focuses produce locally estrogen, and this maintains their growth and amplifies the inflammation.
What are the symptoms of endometriosis?
Severe menstrual pain is the typical symptom. The pain may begin several days before the menstrual bleeding and may last for up to a week. Many patients experience pain in their lower abdomen and loins, painful intercourse and pain and functional problems of defecation and urination.
How is endometriosis diagnosed?
The diagnosis of endometriosis rests on the symptoms experienced by the patient, a gynecological examination and a vaginal ultrasound. Superficial endometrial focuses on the peritoneum are not visible on ultrasound, but ovarian cysts and, in the hands of experienced investigators, also deep focuses are usually seen. Laparoscopy is not necessary for the diagnosis; treatment may be started based on typical symptoms, a gynecological exam and other examinations, like ultrasound.
How is endometriosis treated?
Endometriosis is treated with non-steroidal anti-inflammatory drugs (NSAIDs), hormones and, if needed, surgically. Drug treatment is the usual primary therapy, and if endometriosis is chronic, medication will be needed for a prolonged time, often until menopause. Usually, hormonal contraceptive drugs are used, e.g., combined oral contraceptive pills, minipills or a hormonal IUD. If endometriosis is severe, the goal of treatment is to have menstrual bleedings stop completely, i.e., to discontinue menstruation for the duration of drug treatment. This eliminates pain and reduces the inflammation associated with endometriosis most effectively.
Surgery is considered if drug treatment does not provide sufficient symptom relief or if hormonal treatments cannot be used, e.g., if the patient desires pregnancy. Surgery must always be individualized and decided by a gynecologist who is familiar with the treatment of endometriosis, taking into consideration the patient’s life situation, the severity of endometriosis and the type of endometriosis focuses.
Does endometriosis cause infertility?
Endometriosis may affect fertility in many ways, but for at least for half of all endometriosis patients fertility is not affected. Of all women who consult a physician for infertility, about 20–50% have endometriosis, and of these women some 80% have a baby following infertility treatment. In addition to endometriosis, the age of the woman is the most important fertility-affecting factor. Fertility tends to decrease from age 30. Women with ovarian endometriosis may sometimes benefit form fertility-improving measures, like freezing of ovarian tissue or ova (egg cells), if endometriosis and age pose threats to fertility and the woman does not desire pregnancy immediately.
Infertility and symptomatic endometriosis are mental burdens to the patient and her relationship. Patients in this situation should actively be encouraged to visit a psychologist and to seek relationship and sexual counseling.