Endometrium is the hormone-sensitive lining of the uterus (womb). At the end of a monthly cycle the endometrium peels off and is shed, there is some bleeding from the raw surface. These are the constituents of the period (menstrual flow). It flows through the cervix and out of the body through the vagina.

Endometriosis is a medical condition where endometrium grows in other parts of the body. It too is hormone sensitive and thickens in response to the hormones of ovulation. When those hormones dictate a period, the endometriosis also sheds its surface skin. This results in bleeding at the site of the endometriosis. Endometriosis is not cancer; it is the right tissue in the wrong place. It has been said to be present in over 10% of women and is commoner in patients being investigated for infertility.

Whilst Endometriosis has been described in many parts of the body, the commonest sites are behind the uterus and on the ovaries. In those positions the tissue that is being shed cannot escape. It may collect and result in a cyst, which contains the blood stained material. This is the so-called "chocolate cyst"; more commonly doctors refer to this as an "endometrioma". If it doesn't collect like that, the blood dissipates in the abdomen. Scarring occurs as a result of the body fighting the endometriosis (inflammation) and, as a result, tissues can stick together (adhesions)

Symptoms
Endometriosis may produce no symptoms. It may be discovered incidentally during unrelated investigations. However Chronic Pelvic Pain is a common symptom. It is often described as pain that precedes the onset of your period, being relieved with the onset of the menstrual bleed. However it may continue through the period and may even be continuous. This is because the pain may not just be due to the bleed itself. It may also result from distension of an endometrioma, inflammatory response to the deposit of endometriosis or to adhesions pulling on healthy tissues. The paradox of Endometriosis is that, often, the patient with most disease has less pain than the patient with just a few deposits. Small lesions can cause a lot of pain in some people.

Because endometriosis can result in distortion of the pelvic organs, it may impair fertility. Conversely, pregnancy can lead to relief of symptoms, as can menopause.

Although aspects of the history and symptoms may suggest the diagnosis of endometriosis; and even scans may suggest a chocolate cyst, Endometriosis is actually diagnosed at laparoscopy, a minor operation to look at the pelvis directly.

Treatment
The first line of treatment, if the disease is painful, is analgesia. Ibuprofen is particularly helpful as it has an anti-inflammatory action as well as working as a painkiller.
More active treatments include drugs and surgery.

The medicines that are used are preparations that mimic the hormones of pregnancy (progestagens such as norethisterone) or suppress the sex hormones thereby mimicking menopause (GnRH analogues such as Prostap or Zoladex ). They are therefore inducing an unaccustomed hormonal state to the whole body in order to get the required effect on the endometriosis. The side effects of mimicking pregnancy include bloating and weight gain. Those of mimicking menopause include flushes, reduced libido and in the longer-term osteoporosis. Treatment therefore is usually limited to about six months or so. There may be ways to prolong treatment safely if it is relieving your pain. This should be discussed with Mr Shaw if the situation arises.

Surgical treatment may be conservative or radical.

For those who have completed their family it may be appropriate to discuss removing the ovaries, uterus and tubes in order to remove all sources of hormones and to clear the pelvis of potentially painful organs. However it is very uncommon for this to be required.

It is possible through the laparoscope (key-hole) for Mr Shaw to destroy the deposits of endometriosis. The diathermy is sometimes used for this but a safer, more effective way is with a laser, as endometriosis is specifically sensitive to the wavelength of the laser. The laser also enables adhesions to be freed and chocolate cysts to be dealt with. In this way laser treatment enables the pelvic organs to remain intact. Although keyhole surgery is usually undertaken as a day case, it, as with all surgery is not without risk. However improvement in the pain with laser surgery exceeds 60%.

It is the nature of endometriosis that further lesions may develop in future. As a result the pain may return some years later. Further laser treatment to the new deposits is usually feasible.

Useful Contact
The National Endometriosis Society
50 Westminster Palace Gardens
Artillery Row
London
SW1P 1RR

Web: http://www.endo.org.uk
Tel: 020 7222 2781
Fax: 020 7222 2786