Endometriosis is a condition which the tissue which lines the uterus, the endometrium, develops in abnormal sites, typicaly on the bowel, the outside of the uterus, the ovaries and the peritoneum.  Rarely it can also develop in the lungs and pleura surrounding the lungs.  

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Like the endometrium, endometriosis tissue undergoes cyclical changes in response to the natural hormonal cycles, leading to loss of the glandular tissue and bleeding like menstruation from the sites of endometriosis implants.  This causes fibrosis and scarring leading to cyclical pain at the sites of the implants, heavy and painful periods and pain with sex (dyspareunia).  The image to the right shows some blue nodules of endometriosis in the posterior wall of the vagina, behind the cervix.

The curious thing about endometriosis is that the symptoms it causes are not related to the size or extent of the lesions.  Therefore some women can experience disabling pain with only a small isolated spot of endometriosis which may not cause any symptoms in another woman, whilst others can have very extensive endometriosis with adhesions and scarring affecting the bowel, ovaries and peritoneum and yet have very little in the way of symptoms.

For those who are affected, the  symptoms can be controlled to some extent with hormones and are often relieved by pregnancy, but endometriosis can cause delay in conception and the condition is found in up to 30% of women presenting with infertility.

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Medical treatment incudes the use of progesterone, either orally or from the Mirena intrauterine system, oral contraceptives, gonadotrophin releasing hormone analogues (GnRH-a) such as Zoladex which is given by monthly injection and causes temporary reduction of oestrogen levels and menopausal symptoms which also causes temporary shrinkage of the endometriosis lesions.

Surgery to ablate or excise the areas of endometriosis is very successfuland has been shown to improve the chance of spontaneous conception.  Up to 80% of women will remain asymptomatic for up to 5 years following such surgery and many will conceive during this window, not least because sex can be less painful.  

Laparoscopy with laser ablation is Mr Lower's treatment of choice for this condition, endometriotic cysts can also be treated in this way, but sometimes the disease is so extensive that a more difficult and demanding operation is required, with removal of affected segments of bowel in the worst cases.

© Adrian Lower 2014