Sunday, February 3, 2013

What is Endometriosis? | ඔසප් වීම අධිකව වේදනාකාරීද? ඔබට ත් "එන්ඩොමෙට්‍රියෝසිස් " විය හැකියි


What is endometriosis?

Endometriosis is a common but poorly understood disease of women. The characteristic feature of endometriosis is the presence of endometrial cells (cells that line the inner wall of the womb) in other sites. The inner lining of the pelvis is by far the commonest site for deposits of endometriosis but the disease has been described rarely in distant sites such as the lungs and the eye. The other characteristic of the disease is the inflammation that occurs in relation to these tissues, which results in pain. Deposits also have nerve fibres that contribute to the pain.

The simplest way to explain endometriosis is that the cells that line the cavity of the womb (the endometrium) change during the menstrual cycle to break down at the end to result in menses. In women with endometriosis these cells become implanted outside the womb (‘the endometrial deposits). During the menstrual cycle, these also respond to the hormones and tend to bleed into the pelvic cavity. In addition to the blood the endometrial deposits also produce a variety of noxious chemicals that produce inflammation and pain. In addition, this process makes the structures in the pelvis stick together (‘adhesions’). For example, the ovaries, which are normally freely mobile may become adherent to the womb or the lateral walls of the pelvis. In other women, blood may collect over a period of time in relation to the one or both ovaries and form cysts, called endometriomas. Since blood has persisted in the over a long period of time, it changes to a chocolaty color and these cysts are therefore also known as endometriomas.
These form the basis for the pain and other problems of endometriosis.

How common is it?

Endometriosis affects up to 6-10% of women of childbearing age – therefore it is common. The disease tends to run in families. If you are a person who has pelvic pain or infertility, the likelihood of your having the disease goes up to 25-50%. The general impression is that there is a progressive increase in the prevalence of the disease in the world.

What are the features of the disease?

The preeminent features of endometriosis are pain and infertility.
Pain of endometriosis is typically felt during menstruation and/or sexual intercourse. Typically, menstrual pain due to endometriosis outlasts the bleeding, meaning it begins before, lasts throughout and ends after the bleeding. Many women have menstrual pain or cramping from time they begin to have menses. This is considered normal. Pain that signifies endometriosis usually begins later in life. Menstrual pain that begins afresh or keeps getting worse with time are highly suggestive of the disease. Endometriosis is also well known to produce pelvic pain that is continuous and continuous low backache.
A problem that is well recognized as a consequence of endometriosis is infertility. This could be due to many causes. The distortion of pelvic structures associated with the disease is an obvious reason. However, it is known that the mere presence of endometrial deposits in he pelvis even without distorting the structure of the pelvis could affect fertility. It is accepted that treatment of these deposits could improve fertility. Another reason that contributes to infertility is the inability to have intercourse effectively due to pain.
Deposits in the ovaries bleed cyclically to produce collections of blood which result in what are commonly called ‘chocolate cysts’ (endometriomas) with the blood changing its colour to brown with time.
Image from-Radiology Assistant.in

How does one develop it?

Despite extensive research, the exact cause of endometriosis remains unknown. Out of many theories, retrograde menstruation hypothesis is the most widely accepted. This theory, first proposed by John A. Sampson in 1927, suggests that during a woman's menstrual flow, some of the menstrual blood flows backwards through the fallopian tubes into the pelvis and attaches itself to the peritoneal surface (the lining of the abdominal cavity). It can then proceed to invade the tissue as endometriosis.  

Why is it that not all women develop endometriosis

This is one of the great mysteries about this disease. Almost all women have ‘retrograde menstruation’, but only a minority develops the disease. There has been evidence that environmental pollution and immunological factors may have a role in this. This is an area where lot of research is currently taking place. 

Is it a cancer?

Endometriosis itself is not a cancer, but some studies have shown a risk of progression to malignancy if it persisted for a long time.

Diagnosis

The gold standard for diagnosing endometriosis is a laparoscopy. However, the presence of endometriomas (chocolate cysts) and other signs will indicate the diagnosis on ultrasound scanning. the ‘transvaginal’ approach is the more accurate way to make diagnose. Chocolate cysts are typical of endometriosis and detection of them almost confirms the diagnosis. In addition, limited mobility of the ovaries is a pointer. 

Treatment

Not all endometriosis needs to be treated by surgery, however. Those who have lesser degrees of pain may benefit from simple analgesics. Pregnancy has long been recognized to have a positive effect on endometriosis, but one of the problems of the disease is difficulty in conceiving. The commonly used contraceptives, the ‘pill’ and medroxyprogesterone acetate (Depo Provera) injections are considered first-line treatments for the condition. Prolonged use of these mimics pregnancy and gives temporary relief.
There are other drugs also available for treatment, but the consensus among experts is that these do not confer additional advantages over the first-line drugs which are considerably cheaper. Taking the ‘pill’ in a way that brings on a withdrawal bleed once in three months will have particular advantages for women with menstrual pain. The newer hormone-releasing intrauterine devices are a useful addition since they suppress menses, thus reducing associated pain.
The main disadvantage of treating endometriosis with drugs is that they necessarily act against conception. Therefore, women with endometriosis-associated infertility will have to undergo surgery. Treatment with drugs is not suitable for them. 

Surgery will allow the separation of ‘adhesions’ and for normal relationships of the pelvic organs to be restored. The endometrial deposits could also be destroyed by cauterization during surgery. In fact, studies have shown that such destruction of the ‘deposits’ will improve fertility rates.
With more extensive disease, where more of the lining of the pelvis (the peritoneum) is affected, the lining needs to be stripped off to achieve a cure. These procedures are highly specialized, since some vital structures such as the tubes that take urine from the kidneys to the bladder (the ureters) need to be teased out from the lining to avoid damaging them. Only a surgeon who is experienced in such procedures should undertake them.  Another category of patients who will usually need surgery is those suffering pain during intercourse. Treatment with medicines is of little value to them. It is recommended that chocolate cysts of more than 3 cm diameter are treated surgically as well. Women who have failed to respond to treatment and continue to have disabling symptoms will require to be treated by removing the uterus and both ovaries. This will expose the sufferer to the effects of a premature menopause.

By Professor Hemantha Senanayake
uploaded by Dr.Wedisha Gankanda

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