Endometriosis is a common condition affecting one in 10 women in the UK. It can occur at any age, with increasing risk as you go through your reproductive years and low risk after menopause. It refers to tissue that lines your womb (endometrium) growing elsewhere and attaching to other organs.
The growth of endometrium is highly dependent on the hormone oestrogen, which is why symptoms often change in severity according to your menstrual cycle. Flare-ups can occur at any time during your menstrual cycle but most often occur just before your period starts or around the time of ovulation (when an egg is released from an ovary). They can last for several days or until your period is over.
To reduce the incidence of flare-ups and symptoms overall, endometriosis is often treated using hormones, specifically progestogen and oestrogen. It helps to understand how these different hormones work.
Oestrogen is one of the two main female sex hormones and is produced by your ovaries. During your menstrual cycle, your oestrogen levels rise and reach a peak just before ovulation. This rise in oestrogen levels causes your endometrium to thicken, in preparation for the potential implantation of a fertilised egg.
In endometriosis, oestrogen not only causes endometrium lining your womb to grow but also endometrium that has spread elsewhere. This can cause symptoms of pain and discomfort to worsen as oestrogen levels rise.
Progesterone is the other main female sex hormone and is produced by the corpus luteum — the tissue (follicle) leftover after an egg is released during ovulation. It helps maintain the thickened endometrium and gets it ready for the potential implantation of a fertilised egg. Progesterone levels peak at around a week after ovulation.
This hormone prevents the endometrium from continuing to grow by changing the nature of the endometrium cells.
Progestogen is an artificial version of natural progesterone often used to treat endometriosis, in the form of the progestogen-only contraceptive pill, injection or implant, or as a progestogen-releasing intrauterine contraceptive device. It prevents growth of the endometrium, which reduces pain and prevents the condition from getting worse.
If you can’t tolerate these side effects, your doctor may recommend taking the combined oral contraceptive pill. This contains progestogen and oestrogen, and helps reduce the side effects of progestogen-only treatment.
If these treatments aren’t effective, medical menopause may be considered. This involves stopping your ovaries from producing oestrogen via a monthly injection or tablet. This will cause menopause symptoms but these side effects can be reduced by taking the drug tibolone.
A healthy lifestyle, with a good diet and regular exercise, can improve your endometriosis symptoms.
Warm baths and warm ‘hot water’ bottles can help relieve abdominal pain — avoid applying excessive heat as this can cause changes in your skin pigmentation.
You can also take over-the-counter painkillers, such as paracetamol, and anti-inflammatory drugs, such as ibuprofen. If these aren’t enough to manage your pain, see your doctor for alternative treatments.
As many of the symptoms of endometriosis overlap with other conditions, it takes, on average, eight years from symptoms occurring to receiving a diagnosis.
The journey towards diagnosis usually starts with an assessment by your GP. They will ask you about your symptoms and medical history, and may carry out a pelvic examination. They may also arrange for blood tests, infection screening and a pelvic ultrasound scan to rule out other conditions.
Based on these results and the severity of your symptoms, your GP may refer you to a gynaecologist (a consultant specialising in the female reproductive system). They will also assess you and, if they suspect you have endometriosis, may recommend a keyhole procedure called a laparoscopy to collect a sample of endometrium — this is the only way to receive a definitive diagnosis.
A laparoscopy involves passing a thin, telescope-like tube, with a camera and a light on the end, into your pelvic area via small cuts in your abdomen. This will allow your doctor to look for signs of endometriosis and collect tissue samples.
Once you have received a diagnosis, it is important to start treatment as left untreated, more patches of endometrium can build up. This can cause ovarian cysts, scarred fallopian tubes, reduced egg quality, pelvic inflammation and distorted pelvic anatomy, which increase your risk of infertility.
Endometriosis can reduce your fertility for several different reasons.
It can cause pain during sex, reducing how often you have sex and consequently the chances of becoming pregnant. It is, therefore, important to experiment with different sexual positions to identify which are more comfortable for you so you can enjoy a healthy sex life and increase your chances of becoming pregnant.
Endometrium on your ovaries, fallopian tubes and other organs in your pelvic area and lower abdomen can interfere with the fertilisation of an egg (eg due to damaged fallopian tubes) and/or implantation of a fertilised egg (eg due to distortion in the shape of your womb).
Endometriosis can also cause a rise in prostaglandin hormone levels, which can reduce the quality of your eggs, cause inflammation and distort the shape of your pelvis, all of which reduce your fertility.
If you’re struggling with infertility due to endometriosis, your doctor may recommend surgery to remove endometrium growing outside your womb — this can improve your chances of becoming pregnant. However, endometriosis can still return in months or years if the endometrium tissue grows back.
Mr Francis Gardner is a Consultant Gynaecologist and Cancer Surgeon at Spire Portsmouth Hospital and Spire Southampton Hospital, specialising in menstrual disorders, laparoscopic surgery, gynaecological cancers and screening, postmenopausal bleeding and endometriosis. He is a former Clinical Director for Gynaecology at the Queen Alexandra Hospital, where he led the development of a single-visit endometrial cancer screening service, and has also promoted the use of Minimal Access Surgical (MAS) treatment to speed up patient recovery after surgery.
If you're concerned about symptoms you're experiencing or require further information on the subject, talk to a GP or see an expert consultant at your local Spire hospital.