Endometriosis

Endometriosis is a chronic gynaecological condition in which tissue similar to the lining of the uterus (the endometrium) grows outside the uterine cavity, most commonly on the ovaries, fallopian tubes, and the tissue lining the pelvis. This displaced tissue responds to the menstrual cycle in the same way the uterine lining does, thickening and breaking down each month, but with no way to leave the body, leading to inflammation, scarring, and the formation of adhesions that bind pelvic organs together. It affects an estimated 1 in 10 women of reproductive age worldwide, yet diagnosis is frequently delayed by 7-10 years on average, partly because severe menstrual pain is often normalised rather than investigated. Endometriosis is a leading cause of chronic pelvic pain and infertility, but treatment can significantly improve both symptoms and fertility outcomes.

Symptoms vary widely and do not always correlate with the extent of disease seen at surgery: • Severe, often debilitating menstrual cramps that worsen over time and are not relieved by standard pain medication • Chronic pelvic pain that is not limited to menstruation • Pain during or after sexual intercourse • Pain with bowel movements or urination, particularly during periods • Heavy menstrual bleeding or bleeding between periods • Fatigue, bloating, and nausea, particularly around menstruation • Difficulty conceiving, sometimes the first sign a woman notices, in the absence of significant pain

The exact cause of endometriosis is not fully understood, and several theories likely act together: • Retrograde menstruation: menstrual blood containing endometrial cells flows backward through the fallopian tubes into the pelvic cavity instead of leaving the body, where the cells implant and grow • Genetic predisposition: endometriosis runs in families, and having a first-degree relative with the condition raises risk significantly • Immune system dysfunction: an impaired ability to recognise and clear displaced endometrial tissue may allow it to implant and grow • Hormonal factors: endometrial-like tissue is oestrogen-sensitive, which is why symptoms typically improve after menopause

• Family history of endometriosis, particularly in a mother or sister • Starting periods at an early age • Short menstrual cycles or heavy, prolonged periods • Never having given birth • Structural abnormalities of the uterus or reproductive tract that obstruct normal menstrual flow

• Chronic pelvic pain significantly affecting quality of life, work, and relationships • Infertility, affecting an estimated 30-50% of women with endometriosis, from scarring, adhesions, and inflammation affecting the ovaries and fallopian tubes • Ovarian cysts (endometriomas), which can be large and require surgical management • Adhesions binding pelvic organs together, sometimes requiring complex surgery to separate • Significant psychological impact from chronic pain and delayed diagnosis, including anxiety and depression

There is no known way to prevent endometriosis, given its genetic and hormonal basis. However, early diagnosis and treatment can slow disease progression and reduce the risk of complications such as infertility. Treatment: hormonal therapies (combined contraceptives, progestins, or GnRH agonists) suppress the hormonal stimulation of endometrial tissue and reduce pain; laparoscopic surgery can remove or destroy endometrial implants and adhesions, improving both pain and fertility; and for women trying to conceive, fertility treatment may be needed alongside surgical or medical management.