Manipal Nurse Sunday Column: Endometriosis in Women

Endometriosis is a common and exceedingly troublesome condition occurring in among 12 per cent of the women population. Lower abdominal pain is the main complaint of the disease. Extensive disease may be without complaints, while the minimal disease is sometimes associated with severe pain and discomfort. The probable causative factor is retrograde menstruation with subsequent implantation and proliferation, ie increase in size of viable endometrial cells.

There are, however, other factors possibly immunological, which determine the site and severity of the disease, in addition, to the spread by lymph vessels and peritoneal wall, (inner covering of abdominal wall). The cells revert back to the primitive state and then change the endometrial cells under the influence of estrogen hormone stimulation. This explains the distant spread and recurrence after radical excision. Genetic and racial factors may also play an important role in the occurrence of this disease. The presence of severe pelvic pain should alert the doctor to the possibility of endometriosis, and he should refer the case to an expert gynecologist for further evaluation and treatment.

Ultrasound of the pelvic organs will give a fair idea about the existence of the disease and its spread. The direct visualization called laproscopy will confirm the diagnosis. In this process a pen-like instrument is passed in the abdomen, through which the doctor can have a direct view of the abdomen and its organs. The disease resembles the head of a burnt matchstick in size and colour in a typical case, but the early lesions may be seen as small red, pink or white swellings. The disease causes severe scarring and results in gross disorganization of pelvic organs, giving rise to infertility and severe lower abdominal pain. The details of surgical or medical treatment have to be discussed by the woman with the treating doctor in detail. The treatment depends on each individual case. The medical treatment is to bring about regression of the swellings, by relying on the inherent sensitivity of endometrial tissue to the absence of estrogen hormone, and presence of high tissue levels of progesterone hormone. The commonest medicines used are progesterone preparations for 6 to 9 months. Danazol was introduced in 1970, and is at the present the most widely used drug for the treatment of endometriosis. Gestrinone is another new drug used and is as effective as Danazol. Potent medical therapy is now available which can be used either alone or with surgery.

In this way most women with troublesome disease can be helped, and many cured of their symptoms. Nevertheless there remains a minority of women who will continue to experience pain until they reach menopause. The disease is a headache for both the patient and doctor. Conservative surgery, ie removal of uterus and both ovaries is often temporarily helpful. The decision to perform radical surgery on, for example a young woman, involving removal of both the uterus and ovaries, may sometimes present formidable difficulties. Medical treatment when used alone or with surgery has numerous unpleasant side effects. Some 20 per cent of women in fact are medically non-responding to treatment. The most severe forms of this disease are probably not curable during the woman’s reproductive years.

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