Dr Sherene Kalloo

March is recog­nised world­wide as En­dometrio­sis Aware­ness Month. The yel­low rib­bon—sym­bol­is­ing sun­shine, hope, and re­silience—rep­re­sents mil­lions of women liv­ing with this chron­ic and of­ten de­bil­i­tat­ing con­di­tion.

En­dometrio­sis af­fects an es­ti­mat­ed 10% of women of re­pro­duc­tive age world­wide, maybe more un­di­ag­nosed, ap­prox­i­mate­ly 190 mil­lion.

En­dometrio­sis oc­curs when tis­sue sim­i­lar to the en­dometri­um, the lin­ing of the uterus, grows out­side the uterus. This mis­placed tis­sue be­haves much like the uter­ine lin­ing: it thick­ens, breaks down, and bleeds dur­ing the men­stru­al cy­cle. How­ev­er, be­cause it is lo­cat­ed out­side the uterus, the blood and tis­sue have no easy way to ex­it the body. This leads to in­flam­ma­tion, scar tis­sue for­ma­tion, and some­times the de­vel­op­ment of ad­he­sions—bands of fi­brous tis­sue that can cause or­gans to stick to­geth­er.

The con­di­tion most com­mon­ly oc­curs with­in the pelvis, af­fect­ing the ovaries, seen as en­dometri­omas, fal­lop­i­an tubes, ade­no­myosis (in the uter­ine mus­cle, sis­ter con­di­tion) and in the tis­sues lin­ing the pelvis. In some women, how­ev­er, en­dometrio­sis can ap­pear in oth­er ar­eas of the body, in­clud­ing the ab­domen and, rarely, the chest.

One of the most com­mon signs is se­vere pain dur­ing men­stru­a­tion, of­ten far more in­tense than typ­i­cal men­stru­al cramps. Oth­er symp­toms may in­clude heavy men­stru­al bleed­ing, chron­ic pelvic pain that per­sists even af­ter the men­stru­al pe­ri­od ends, painful sex­u­al in­ter­course, painful bow­el move­ments or uri­na­tion dur­ing men­stru­a­tion, ab­dom­i­nal bloat­ing, nau­sea, and in­fer­til­i­ty.

Many pa­tients de­scribe liv­ing with con­stant anx­i­ety as their pe­ri­od ap­proach­es, an­tic­i­pat­ing the in­tense pain that may fol­low.

Over time, the chron­ic na­ture of the con­di­tion can con­tribute to de­pres­sion .

Glob­al­ly, stud­ies sug­gest that 25–50% of women ex­pe­ri­enc­ing in­fer­til­i­ty may have en­dometrio­sis. The con­di­tion can dis­tort pelvic anato­my, dam­age re­pro­duc­tive or­gans, and cre­ate an in­flam­ma­to­ry en­vi­ron­ment that in­ter­feres with con­cep­tion.

Di­ag­nos­ing en­dometrio­sis has his­tor­i­cal­ly been chal­leng­ing. For decades, the gold stan­dard for di­ag­no­sis has been la­paroscopy, a min­i­mal­ly in­va­sive sur­gi­cal pro­ce­dure that al­lows doc­tors to di­rect­ly view biop­sy le­sions. Be­cause surgery is in­va­sive and cost­ly, many women ex­pe­ri­ence symp­toms for sev­en to ten years be­fore re­ceiv­ing a di­ag­no­sis. But a com­bi­na­tion of de­tailed symp­tom as­sess­ment, phys­i­cal ex­am­i­na­tion, and imag­ing stud­ies can as­sist. We can now treat and di­ag­nose ear­li­er to help ease the suf­fer­ing.

In re­cent years, re­searchers and clin­i­cians have been ex­plor­ing less in­va­sive ways to as­sist with ear­li­er de­tec­tion. These in­clude struc­tured symp­tom as­sess­ment check­lists de­signed to iden­ti­fy women at high­er risk, lab­o­ra­to­ry tests that analyse blood, sali­va, or men­stru­al flu­id for spe­cif­ic bi­o­log­i­cal mark­ers such as mi­croR­NA .

Cur­rent­ly, there is no cure for en­dometrio­sis, and treat­ment fo­cus­es on man­ag­ing symp­toms and re­duc­ing long-term com­pli­ca­tions. Man­age­ment strate­gies de­pend on the sever­i­ty of symp­toms and whether a woman wish­es to be­come preg­nant.

Pain re­lief is of­ten the first step in treat­ment. Anal­gesics such as ibupro­fen and naprox­en are com­mon­ly used. Hor­mon­al treat­ments al­so re­duce symp­toms by sup­press­ing the hor­mon­al stim­u­la­tion that caus­es en­dometrio­sis tis­sue to grow. These in­clude com­bined hor­mon­al con­tra­cep­tives such as the pill, patch, or ring; prog­estin-based treat­ments like the hor­mon­al in­trauter­ine de­vice, tablets or in­jectable med­ica­tions; and GnRH ana­logues such as le­upro­lide or gosere­lin, which sup­press the pro­duc­tion of sex hor­mones. Oth­er hor­mon­al med­ica­tions, in­clud­ing aro­matase in­hibitors, may al­so be used to re­duce es­tro­gen lev­els.

For women whose symp­toms do not re­spond to med­ica­tion, surgery can re­move the le­sions, scar tis­sue, and ad­he­sions, which can as­sist with fer­til­i­ty.

A hys­terec­to­my—the sur­gi­cal re­moval of the uterus, some­times along with the ovaries—may be a last re­sort con­sid­ered in se­vere cas­es when oth­er treat­ments have failed and when a woman does not plan to have chil­dren. How­ev­er, in rare cas­es, some symp­toms may per­sist or re­cur.

Re­search al­so sug­gests that en­dometrio­sis may be as­so­ci­at­ed with oth­er im­mune-me­di­at­ed con­di­tions, in­clud­ing lu­pus, mul­ti­ple scle­ro­sis, and in­flam­ma­to­ry bow­el dis­ease. A fam­i­ly his­to­ry of en­dometrio­sis may al­so in­crease a woman’s risk. Prop­er di­etary habits and lifestyle changes may al­so as­sist.

Be­yond the phys­i­cal ef­fects, the emo­tion­al bur­den of the dis­ease should not be over­looked. Sup­port groups can al­so pro­vide in­valu­able en­cour­age­ment and shared ex­pe­ri­ences.

The Trinidad and To­ba­go En­dometrio­sis As­so­ci­a­tion, found­ed by Abee­sha Tou­s­saint, and Sorop­ti­mist In­ter­na­tion­al San Fer­nan­do are play­ing an im­por­tant role in rais­ing aware­ness and of­fer­ing sup­port.

Al­though there is cur­rent­ly no known way to pre­vent en­dometrio­sis and no de­fin­i­tive cure, through ed­u­ca­tion, re­search, ear­ly in­ter­ven­tion and com­pas­sion, we can help en­sure that women liv­ing with en­dometrio­sis are heard, un­der­stood, and treat­ed with the care they de­serve.

Dr Sherene Kalloo

MDW, MBBS, DGO, DM, FACOG

Spe­cial­ist Ob­ste­tri­cian & Gy­nae­col­o­gist