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What Is Endometriosis

Tissue that forms the lining of the uterus (endometrium) is sometimes present in other places in some women. These sites can be ovaries, fallopian tubes, cul-de-sac (behind uterus), intestines, rectum, urinary bladder. Endometrial tissue outside the uterus also responds to changes in hormones. It also breaks down and bleeds like the lining of the uterus during the menstrual cycle every month. However the bleeding inside the uterus has a passage to come out as menstrual bleeding through vagina, the bleeding in endometriotic site accumulates and forms cysts (chocolate cysts) or adhesions. This can cause pain, especially before and during period. One third of cases of infertility is due to endometriosis.

Who Is Commonly Affected

  1. Young women in the reproductive age group (20-40years)
  2. Endometriosis commonly presents as infertility
  3. Women with uterine defects like septum or bicornuate uterus(double uterus)
  4. It can run in the family

What Are the Symptoms

  • Pelvic pain (pain in lower abdomen and back). Such pain may occur with sex, during bowel movements or urination, or just before or during menstrual cycle.
  • Heavy Bleeding during menstrual cycle.
  • Pain during sex.
  • Feeling of bloating & Fullness in abdomen around the periods.
  • Some women with endometriosis may have no symptoms.

How Do We Diagnose

  • Pelvic examination
  • Ultrasonography
  • LAPAROSCOPY- is the gold standard in diagnosing endometriosis

What are the treatment options?

Treatment for endometriosis depends on the extent of the disease, presenting symptoms, and whether one wants to have children. It may be treated with medication, surgery, or both. Although treatments may relieve pain and infertility temporarily, it is a = problem and conservative treatment (medical or surgical) cannot provide permanent cure.

Medications– is used both to relieve pain and to keep the disease under control. Painkillers like paracetamol or mefenemic acid relieves the pain up to great extent. Hormones like progesterones or combined pills not only relieve the pain but also help to control the disease process. Hormonal injections or Mirena (a intrauterine contraceptive device with progesterone) are also used in some situations. These medications cannot be used for long as women are not able to tolerate the side effects that these medications. Medications do not provide permanent cure.

Surgery – is done to remove endometriosis and the scarred tissue around it. In severe cases surgery is the best choice for treatment. Surgery is done almost always by LAPAROSCOPY. During laparoscopy, endometriosis can be removed or burned away. Extent of surgery depends on the patient’s needs. If infertility is the issue then conservative approach and trying to save the normal tissues is attempted followed by active treatment for infertility. If the woman does not desire any more children the complete removal of uterus along with both ovaries and all endometriotic tissue is done. Sometimes severe endometriosis cannot be handled with laparoscopy and a procedure called laparotomy may be needed.

Robotic surgery is the latest addition in approach to management of endometriosis. Da Vinci ® surgical intervention is a new category of minimally invasive surgery that combines the best of open and laparoscopic surgery. With the assistance of Robotic ARMS (controlled by the surgeon of course!), we can perform surgeries through small incisions with unmatched precision and control. Robot-assisted surgery allows superior 3D visualization of the surgical field with 10 times magnification with human wrist like manueuverability. Advantages of Robotic surgeries are-

Minimal scarring. Due to precise movement, tissue trauma is less.

Less blood loss. Better dissection in the right planes and the ability to suture more quickly, there is significantly less intra-operative blood loss

Less post-operative pain.

Faster recovery. Most patients are able to resume normal activities within 2 weeks, compared to 6 weeks for open surgery. Additionally, patients can go home the same day of the procedure

Excellent suturing The excellent precision and visualization offered by the da Vinci Si system enhances the surgeon’s ability to suture the uterus appropriately.

Endometriosis is a progressive disease. The source of the problem is the hormonal changes associated with menstrual cycles and presence of endometrial tissue at abnormal places. After conservative surgery the disease can recur. Patients who are treated with both surgery and medications have extended symptom-free period.

Endometriosis- time to end the silent suffering Your questions answered

1.How do I know if I have endometriosis?
One can know that they have endometriosis if they have symptoms like pain in periods, heavy bleeding, difficulty in getting pregnant or simply altered bowel habits with gaseous distension around the time of their periods. A definitive diagnosis usually requires visual inspection by laparoscopy. Ultrasonography can also pick up the disease if ovarian cysts have already developed.
2. My sister was diagnosed with endometriosis. Does that mean I have it too?
Not necessarily. If one has family history of endometriosis then there is increased chance of developing endometriosis. But does not necessarily mean that all family members will have it.
3. I have been diagnosed with endometriosis. Will I have difficulty in getting pregnant?
30% of women who have endometriosis can have difficulty in conceiving. But difficult to say if you will particularly have difficulty as every case is different and we don’t know for sure until you try to conceive. However laparoscopic surgery increases the chance of conception by 30-40% in early stage disease (stage 1 & 2). Another fact to understand is that pregnancy in a way also treats the endometriosis due to continuous high dose progesterone secretion that takes place during the nine months of pregnancy. Advanced reproductive technology also is helpful in women with endometriosis.

4. I was treated for endometriosis two years ago by laparoscopic surgery. Now I seem to have the same symptoms again.
Endometriosis is a chronic disease and recurrences are therefore common. The usual reasons for recurrence are inadequate resection during the first laparoscopic surgery or conditions that predisposed its appearance in the first place are usually still present. On average, one in three patients who had a laparoscopy for endometriosis will require a repeat procedure within five years. Complete removal of all implants during the first surgery is therefore important. Robotic assisted laparoscopic surgery these days gives the advantage of precise and complete removal of all endometriosis with preservation of ovarian tissues for future child bearing.

5. Is there a permanent cure for endometriosis?
There is no definitive cure for endometriosis, but there is treatment. Surgical treatment aims at removing all the endometriosis, which would mean removing uterus, both ovaries and all the endometriotic implants in the pelvic cavity. Medical treatment aims at alleviating the symptoms and can provide relief to an extent. Different women may require different treatments or a combination of treatments. Surgical treatment is at times difficult due to adhesive nature of the disease and here also robotic assistance helps to complete laparoscopic removal with negligible chance of conversion to open surgery.

6. Is endometriosis cancer?
No. Usually endometriosis is a benign (non cancerous) disease but can behave and affect areas around the uterus like a cancer. Some research shows that women with endometriosis have a slightly higher risk of developing a particular type of ovarian cancer, but it is still not confirmed by hard scientific facts. There are also some reports where endometriotic ovarian cysts have become cancerous.

7. Whom should I consult if I think I have endometriosis?
A gynecologist should be the person to consult. However, many, both patients and doctors often ignore dysmenorrhea as an inconvenience of having menstrual cycles. A gynecologist can help you assess your symptoms initially. Treatment of endometriosis often requires a specialist care and experience. If one needs surgical correction it is better one at center with gynecological surgeon having extensive experience in managing endometriosis by laparoscopy or robotic assisted surgery. Depending on the level of endometriosis the operation can be quite complex and not everyone is trained or have the experience to do it. The first surgery gives the best chance of controlling the disease. Surgery is often a delicate balance between what to remove and what to preserve so as to give best outcome in terms of pain relief and pregnancy outcome.