Insight on Endometriosis – by Dr Gerhard Hanekom and Prof Igno Siebert

March is endometriosis awareness month. Marie Hudson from RSG spoke to Aevitas’ Fertility- and Endometriosis Specialists, Dr Gerhard Hanekom and Prof Igno Siebert. Having pelvic pain associated with menstruation can be a symptom of endometriosis. To learn more about endometriosis and available treatment options, listen to the interview in Afrikaans, by downloading the podcast ‘Gesondheid 27 Maart 2019’. Alternative, a summary follows below.

What is endometriosis?

The endometrium is the inner lining of the uterus. Each month the endometrium thickens and if a pregnancy does not occur, the lining is shed through monthly menstruation. Endometriosis can be defined as the endometrial tissue which form on the outside of the uterus, on the ovaries, Fallopian tubes and other organs. It can cause tremendous pelvic pain and infertility.

What is the cause of endometriosis?

There are numerous theories about how endometriosis forms:

  1. Retrograde menstruation. Endometrial cells/debris flow back via the Fallopian tubes into the pelvic area, where it manifests.
  2. Metaplasia theory. When cells outside of the uterus, abnormally transform into endometrial cells.
  3. Other theories. Endometrial cells are spread through blood or lymphatic pathways into the pelvic area.

Are some women more prone to developing endometriosis?

These days, compared to 20 – 30 years ago, most women tend to have fewer children and at a later stage of their life. Therefore, more women are exposed to longer time frames of back-to-back menstrual cycles. This increases the chance of endometrial cells spreading/developing outside of the uterus.

What is the prevalence of endometriosis in women?

In the general population 10% of females in their reproductive years suffer from endometriosis. Furthermore, endometriosis is found in 50% of women suffering from pelvic pain associated with menstruation, as well as infertility. If a woman has pelvic pain associated with menstruation, there is a big chance that she has endometriosis.

What is the average age and youngest age of women suffering from endometriosis?

Women of any age can have endometriosis. We’ve had a patient eight years of age, suffering from endometriosis.

Why do women with endometriosis have infertility problems?

This question brings us to the different types of endometriosis. Every type affects fertility in a different way.

  1. Peritoneal endometriosis. This endometriosis causes an inflammatory environment which can cause fibrosis of the Fallopian tube. Therefore, functions such as the pickup of the egg, transport of the sperm and egg, as well as fertilisation of the egg by the sperm can be affected.
  2. Ovarian endometriosis. When endometriosis form on the ovaries it can negatively affect the quality and quantity of the eggs and therefore cause infertility.

How is endometriosis diagnosed?

Firstly, endometriosis can be diagnosed through a thorough medical history. Secondly, through laparoscopic procedure, allowing the surgeon to view the pelvic area by means of a small camera.  During the laparoscopic procedure, a biopsy can then be taken to confirm the endometriosis.

What does endometriosis look like?

There are different types of lesions. The cause of the pain associated with endometriosis is in fact caused by the inflammation. If endometriosis has been present for a long time and it is deep infiltrating endometriosis it can affect other nerve endings, the bladder and the colon. This could lead to additional sources of pain.

Endometriosis can appear as follows:

  • Black lesions
  • White fibrotic lesions
  • Nodular type lesions
  • A-typical subtle lesions, such as small pockets in the peritoneum (lining of the abdominal cavity), small changes in blood vessels etc.

An expert eye is required to identify and treat the endometriosis, which is why it’s so important to seek assistance from an Endometriosis Specialist.

Image result for endometriosis image

via JuJu

Can Endometriosis be treated with medication alone?

The cornerstone of medical treatment for endometriosis is hormonal suppression. It is a very effective form of treatment, but during this treatment pregnancy is not an option. If a woman wants to become pregnant, it is advised that the endometriosis is removed through surgery, to increase the chances of spontaneous pregnancy. Endometriosis plays a big role in fertility and therefore it’s important that women with endometriosis, who are planning for a future pregnancy, seeks advice from a Fertility Specialist.

If endometriosis is removed through surgery – how many surgeries are needed?

Firstly, surgery for endometriosis is usually performed through laparoscopy. Therefore, instead of using a large abdominal incision, the surgeon inserts a lighted viewing instrument called a laparoscope through a small incision.  This allows for enhanced vision of the pelvic cavity and improved surgery outcome.

Prior to surgery, examinations are performed as extensively as possible. Examinations could include ultra-sound imaging and scans to determine the extent of the endometriosis. In-depth surgical planning is then performed, with the needed experts. For instance, if the colon is affected, a colorectal surgeon will form part of the surgical team. Through a team effort, surgery is performed as conservatively as possible. Endometriosis is not treated as if it’s cancer. Instead the surgeons only remove what is necessary, to decrease the risk of damage to organs, while at the same time relieving symptoms. Therefore, it’s possible for traces of endometriosis to remain after surgery.

Endometriosis is a chronic condition, which cannot be completely cured by medical treatment or surgery. Therefore, treating the condition often requires a combination of both surgery and medical treatment. Endometriosis needs to be addressed holistically by a team of Infertility Specialists, Endometriosis Specialists and Colorectal Surgeons. Furthermore, the team needs to consider the patient’s age, family planning and effects of the disease. Through this approach, the amount of surgeries required are decreased, as a result of better planning of the surgery and the timing thereof. Surgery can be followed up with hormonal suppression and fertility treatment if needed.

What percentage of women with endometriosis can fall pregnant after surgery?

This is difficult to answer as fertility is a complex topic. One needs to consider age, Fallopian tube factors and male fertility factors. If there are no other contributing factors, chances of spontaneous pregnancy after surgery for endometriosis, is approximately 50%.

Key message

Endometriosis is a chronic condition, which can influence quality of life, as well as fertility. It is therefore important to seek advice from an Endometriosis Specialist, who can correctly diagnose the extent of the endometriosis and the potential effects thereof. Unnecessary surgery needs to be prevented. Furthermore, the patient’s treatment plan needs to include the correct short-term and long-term treatment to improve quality of life and preserve fertility (if desired).