Many of my patients present in their teens with period problems. On several occasions, I have lectured groups of GPs encouraging them to send patients early for laparoscopic assessment to diagnose endometriosis and adenomyosis. I am still concerned when a GP asks “isn’t she too young to have a laparoscopy?” (NO!) Or “can’t we just see how she goes on the pill?” (NO!). Failure to diagnose endometriosis or adenomyosis may mean we are failing to assist not only a future fertility problem, but we are also failing to help the patient with the pain both of these conditions cause.
With this in mind, excessive period pain, heavy periods, back pain or painful intercourse are not normal and must be investigated. Excessive pain means time off school, time off work and needing more than an anti-inflammatory to treat it.
Too many women tend to believe that pain is part and parcel of having periods, but the truth is, it is often the warning sign that something is not right, and this is commonly a condition called endometriosis. Unfortunately, GPs tend to have limited experience with the diagnosis of endometriosis and adenomyosis.
Living with untreated endometriosis can be very stressful for a woman both physically and emotionally, and the reality is that if it is diagnosed early (even before children are contemplated) and treated, the symptoms can be reduced or even eliminated.
What is endometriosis?
In simple terms it is when the inside lining of the uterus (womb) called the endometrium, is also growing in other places outside the womb. Adenomyosis is when the lining of the womb begins to grow into the muscle of the uterus and was previously thought to only occur in older women.
What causes endometriosis?
Unfortunately, there is no one definitive answer at this stage. However, there are many theories that try to explain the origin of endometriosis. One of them explains it via a process known as “retrograde menstruation” or the backward flow of menstrual bleeding. Another says it is likely that there is some genetic component to endometriosis as sometimes females in the same family are affected; however, genetics is likely to be only part of the reason that a woman gets endometriosis.
Why is it important to diagnose and treat endometriosis?
It is important for the reasons of improving quality of life and fertility outcomes whether now or in the future.
Why does endometriosis cause pain?
It is thought that endometriosis causes pain because the misplaced endometrium causes inflammation, eventually causing scarring and at times adhesions. Similar to the lining of the uterus, these implants respond to female hormones such as estrogen. It is not fully understood why it can cause so much pain in some women; however, it is thought that sometimes the implants bleed and the blood cannot escape from the body during the period, so it bleeds directly onto the surface of the surrounding organs and tissues.
How does endometriosis impact fertility?
It can sometimes hinder pregnancy success due to the altered womb lining, impact on the quality of eggs produced, and by even obstructing or blocking the fallopian tubes.
How is it diagnosed?
A laparoscopy is always needed to diagnose endometriosis. The best practice to diagnose adenomyosis is an MRI. Excisional surgery at the time of the first laparoscopy is the best practice of treatment. Besides surgical treatment, hormone medications that suppress or stop the periods can be effective to suppress endometriosis. As these hormones usually also act as contraception, they are only suitable for women not currently wanting to fall pregnant.
If a laparoscopy and removal of the endometriosis has not achieved a pregnancy if that is desired, or is unlikely to, then fertility treatments such as Intra-Uterine Insemination (IUI) or IVF can be considered. IVF treatment can bypass damaged or blocked tubes, which is often helpful in these cases.
Great care must be undertaken to exclude adenomyosis, especially if pain continues after laparoscopic excision of endometriosis.
If you are experiencing any symptoms of endometriosis, it is important that you seek professional help from your GP as a starting point, then consult a gynaecologist or specialist in the area of fertility medicine.
For more information on endometriosis or other common female fertility issues and treatment options visit our page on causes of female infertility.
Watch Dr Graham Tronc’s video for further advice.
Please note: This video may not be copied or used, in whole or in part, without the prior written permission of City Fertility Centre © 2017.
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