Today’s Subject: Endometriosis

Nowadays, infertility and IVF are words which have become increasingly common in today’s society. Everybody seems to know someone who has been affected by infertility and recently I have been listening to a lot of people discuss this concept and find that there is a lot of misconception and stigma surrounding it. As a health advocate I find that this is a sensitive issue, I don’t want to be seen as interrupting or being a know it all,  so I will listen to all concerns and only offer my advice if I am addressed.

With that I thought today I would give you all some information on ONE of the possible causes of infertility in woman. Endometriosis.

Endometriosis is a female condition when the endometrial like tissue is found in sites outside the uterine cavity, particularly on the pelvic peritoneum and the ovaries. It is an oestrogen dependant inflammatory disease which affects 5 to 10% of the female population (Melmed et al 2011) of reproductive age. It is associated with chronic pelvic pain, pain with intercourse, and infertility.
Incidence of endometriosis is increased seven fold in females whom have a relative who also suffers from the condition.
As the pathophysiology of endometriosis is explored it is beginning to come to light that it is a systemic and chronic complex disease.

There are several different theories on the causative factor and the pathophysiological development of endometriosis.
One of these theories is known as the implantation theory also known as retrograde menstruation (Sourials et al 2014).
This theory proposes that endometriosis occurs due to the retrograde flow of endometrial cells and debris through the fallopian tubes into the pelvic cavity such as the ovaries, the bladder and portions of the large intestine, during menstruation. Once these cells have been deposited they are able to react to progesterone and oestrogen in the same way that the normal endometrial cells in the uterus do.
Endometrial lesions occur and this tissue can distort the structures of the abdomen and pelvis. Endometrial cells can be found on the outside of the uterus as well as the posterior cul-de-sac, or the area between the colon and the uterus, as well as other internal structures which inhibit their function as well as cause severe pain once progesterone levels drop and menstruation bleeding begins.
More research into this theory needs to be conducted. It is doubtful that renegade menstruation is responsible for endometriosis on its own.

Another possible causative factor is the coelomic metaplasia theory. It suggests that endometriosis originates from the metaplasia of specialised cells that are present in the mesothelial lining of the visceral and abdominal peritoneum. Hormone factors such as oestrogen, are believed to stimulate and transform the normal peritoneum tissue into endometrium like cells. It is not obvious what causes this to develop but suggestions that irritation by the retrograde menstruation, or infections may be the cause.

Other theories include the transfer of endometrial tissue from a surgical procedure such as cesarean or episiotomy, is proposed as a possible cause of endometriosis, as endometrial cells have been seen in surgical scars (Sourials et al 2014).
Suggestions that sufferers of endometriosis have abnormalities in the immune system, which plays a role in the development of the condition.
In rear cases when endometriosis develops in the brain or other organs can be due to the spread of the endometrial cells through the blood stream or the lymphatic system.

There are certain hormonal changes that occur in endometriosis but are not as well documented. Progesterone counteracts oestrogen and inhibits the growth of the endometrium. Progesterone resistance may play a role in endometriosis due to a diminished response in sufferers. Gene expression patterns in females with the disorder reflect a defective progesterone action and exaggerates the influence of oestrogen which leads to hyperproliferative and the anti-apoptotic changes. Endometrial lesions have fewer progesterone receptors (Melmed et al 2011) and results in an abnormal functioning of the existing progesterone receptors. This means that endometrial cell menstruation is more likely to occur, establish and be maintained.
Endometrial proliferation and endometrial lesions has oestrogen as a driving force and an increased response to oestrogen, which enhances the development of endometriosis.
There is also a higher bioavailability of the oestrogen, oestradiol in endometrial tissue because of the aromatisation of androgen to oestradiol by the endometriosis stromal cells.

Most cases of endometriosis will begin at menarche, but a great deal of females can develop the condition later in the reproductive years.
There are a handful of females who are asymptomatic when it comes to symptoms of the condition, however most will experience a constant aching pain which is felt deep within the pelvic region, including the glutes and lower abdomen. This pain is said to be worse prior to and during menstruation with relief at the end of menstrual bleeding.
Experiencing pain during intercourse is common. Infertility associated with the failure to ovulate effectively, endometrial scarring, hormone irregularities, or the blocking of the fallopian tubes can cause this, though not all sufferers experience infertility.
There is no correlation with the severity of the symptoms and the amount of the disease but there is a classification system based upon visual observation at laparoscopy of minimal, mild, moderate, and severe.
Minimal is when there are isolated implants but no significant adhesions. Mild is with superficial implants of less than 5 cm but without significant adhesions. Moderate has multiple implants and adhesions around the fallopian tubes and ovaries. Severe is with multiple implants, large ovarian endometriomas with thick adhesions.

This condition is usually a manifestation of other disorders such as hypothyroidism or and underactive thyroid, sjogren syndrome as well as autoimmune disorders like lupus, multiple sclerosis, and rheumatoid arthritis.
If the condition is not diagnosed and controlled then it can manifest into more severe and potentially life-threatening conditions such as infertility, ovarian scarring, ovarian cancers particularly the oestrogen dominant types, iron deficiency, chronic fatigue syndrome, and fibromyalgia.

Endometriosis is a complex condition where endometrial cells are located in areas of the body where they would otherwise not be found such as the intestines, fallopian tubes, ovaries, bladder as well as other more distant organs. It is a condition which can cause severe pain and infertility and should be diagnosed and treated as soon as possible to avoid scarring and permanent damage of the female reproductive system.
There are many theories on the pathogenesis of endometriosis but further work on this matter needs to be addressed.

Aly Curd



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