Menstruation is not a breeze for everyone. In fact, many women just endure menstrual pain in silence assuming it is normal. To top it, conditions/ symptoms related to period pain are often misunderstood for other conditions and even misdiagnosed by medical professionals.
One such condition is endometriosis, which seems to be extremely common and affects 1 in 10 women. Many of us might have heard the term, but do we really know what it is?
Let’s understand this troublemaker better!
What is endometriosis?
‘Endometrio-sis’ refers to a condition of the ’endometrium’, which is the tissue that lines the uterus. This tissue is required to house and nourish a baby, if and when it is formed. This lining is shed (what we see as menstrual blood) during menstruation and re-built in the next round.
In women with endometriosis, a tissue similar to the endometrium develops outside of the uterus, usually on the other reproductive organs in the pelvis or even in the abdominal cavity in some cases. It becomes troublesome because this tissue is also under the hormonal influence just like the endometrium. That is, it ruptures and re-forms every menstrual cycle! Now, you can imagine the chaos this can trigger.
Since there is no channel (like the vagina) for it to leave the body, internal bleeding can happen in the pelvis and abdomen, many a time leading to inflammation and scarring of the normal tissues around it, all of which lead to period pain and irregular periods.
If it is attached to other organs, their functions may also get disrupted, making the diagnosis a messy affair. Moreover, regular excessive bleeding (as these tissues are hormone-responsive as the uterus) can lead to anemia and can make things complicated when invisible (internal bleeding in the abdominal or pelvic cavity).
OMG! Why does this even happen?
Although the exact cause of endometriosis is unknown, some theories on the probable causes have been proposed, as listed below.
• Genetic- Though it is believed that certain ethnic groups are more prone to this condition than others, there are not enough data to support this claim.
- Recent research suggests chemical changes in the DNA of women with
endometriosis, hindering normal gene expression in response to hormones.
However, further research is necessary to ascertain this correlation.
- In some cases, there is growing evidence that proteins under the control of certain
nucleic acid regulators are altered in endometriosis, leading to abnormal
• Immune disorder/ dysfunction- A weak immune system may fail to recognize misplaced endometrial tissues.
• Displacement of endometrial cells/tissues to other parts of the body- during menstruation, parts of the endometrial lining flow through the fallopian tubes (retrograde flow) or the circulatory system and settle down elsewhere.
Important note: The above points are yet to be proven conclusively.
Nevertheless, the commonly observed risk factors include:
· Family history (first-degree relative)
· High frequency of exposure to menstruation: Short menstrual cycles or early menarche (reaching puberty below age 12)
· Hormonal or structural abnormality in the uterus (e.g.: uterine growths, such as fibroids or polyps) and other reproductive organs that lead to menstrual disruption
· Surgery, such as cesarean section, may sometimes cause the misplacement of the endometrial tissue outside of the uterus.
· Interestingly, a recent study suggests high-intensity sun exposure as a probable risk factor of endometriosis though further verification is awaited.
OK now, what should one be watchful about?
The most common symptoms based on uterine contraction/ function are:
· Heavy menstrual flow
· Excessive menstrual or period cramps in the abdomen or lower back
· Pain during intercourse
· Difficulty getting pregnant
In the case of pelvic congestion/ involvement of other pelvic organs, one may also suffer from:
· Painful bowel movements and excretion during the period
· Pain while urinating during the period
Hmm, these symptoms can be caused by other problems also, right? How do doctors confirm endometriosis?
Endometriosis is diagnosed mostly in women of age 20-30 when they try to conceive, as the condition can interfere with fertility in multiple ways.
· Pelvic examination by a physician to check for cysts or scars behind the uterus
· Imaging. MRI or ultrasound are commonly required for visual confirmation.
· Laparoscopy. In some cases, a tiny incision is made near the navel to look for signs of endometrial tissue outside the uterus in the abdomen. The surgeon might also collect tissue samples (biopsy) from the area for further testing.
· Biomarker analysis. Start-ups, such as Nextgen Jane and MDNA Life Sciences, have come up with tools for easy diagnosis of endometriosis. The company mails a test kit with a smart tampon to be worn during period. The kit can preserve the cells, and blood squeezed from the tampon is used in the lab for early endometriosis biomarker detection.
The bitter truth is, there is not a simple yet conclusive test for diagnosing this condition. Moreover, the symptoms may mimic other conditions, leading to misdiagnosis. These, along with the normalisation of menstrual pain and lack of recognition at the GP level, contribute to years of delay in getting a diagnosis (the average time in the UK is 7.5 years).
Recent research proposes that a comprehensive approach, including the implementation of the correct clinical diagnostic tools, equipping medical professionals and raising public awareness, can help quicken the process since the anxiety caused by the uncertainty and prolonged diagnosis can have a psychological impact on the affected women and their families.
That sounds gloomy. Is it possible to lead a normal life?
Unfortunately, there is no permanent cure for endometriosis yet. However, fret not! Various medical and surgical treatment options are available to manage the symptoms and maintain excellent quality of life.
· Medications to relieve period pain
· Hormonal therapy to prevent ovulation and reduce menstrual flow
· Stopping ovarian hormone production, which sort of creates “medical menopause”
· Laparoscopic surgery to remove the endometrial implants
· As a last resort, removal of the uterus and cervix
· A study in 2018 at Yale University has demonstrated the possibility of gene therapy to suppress the genes causing endometriosis in mice.
Nevertheless, latest research on endometriosis has given us some good news …
Researchers have observed promising symptomatic relief in mice by blocking a genetic drug target. They are hopeful that this will turn out to be true in humans too.
Special note for women trying to conceive
Endometriosis is listed as one of the common causes of infertility. The endometrial scar tissue can hinder the release of the egg from the ovary. Further, the altered pelvic environment can lead to impaired implantation of the fertilized egg. In mild cases, surgery to remove the cysts, adhesions, and scar tissue can restore fertility. However, in severe cases, natural conception may not be feasible and in-vitro fertilization is advised.
This too shall pass
Though endometriosis is a chronic condition without a cure, appropriate therapeutic strategies can eliminate its impact on daily life and even manage fertility issues. The good news is, endometriosis usually improves after menopause.
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About the author
Niranjana S. Rajalakshmi is a veterinary microbiologist turned science journalist. After her under graduation in Veterinary Medicine, she was curious to study diseases at a molecular level which led her to pursue a Master’s in Veterinary Microbiology. When the pandemic struck, she being a microbiologist felt the need to communicate about the hitherto unknown virus and its possible implications to a large audience. Subsequently, she produced several pieces on COVID-19 and other topics related to health, which are being published in leading news outlets in India.
This article was edited by Dr. Ayshwarya Ravichandran.