ENDOMETRIOSIS IS the presence of endometrial glands and stroma in sites outside of the uterus. Its clinical manifestations may vary sometimes with poor correlation.

Endometriosis affects 6–10 percent of women of reproductive age and may be as high as 35–50 percent in women experiencing pain or infertility.

There are three recognised forms of endometriosis:

1. Peritoneal endometriosis which is usually minimal or mild endometriosis

2. Ovarian endometriosis where endometriosis is found on the ovaries or form cysts.

3. Deep infiltrating endometriosis (DIE) involving the bowel, bladder and rectum.

Symptoms and Diagnosis Endometriosis is frequently associated with painful menses, chronic pelvic pain, painful intercourse, painful or difficult defecation and bleeding around menses and infertility.

Diagnosis is first suspected based on the history, examination and imaging and is confirmed by visual inspection and histological examination of tissue excised during laparoscopy.

Laparoscopy is vital in diagnosis as physical examination or ultrasound is insufficient to make a diagnosis of endometriosis.

Medical Treatment 1. Analgesics Nonsteroidal anti- inflammatory drugs (NSAIDs) are widely used as a first-line treatment of endometriosis-associated pain.

Hormonal therapies Combined oral contraceptives (COCPs), progestogens, anti-progestogens, gonadotrophin- releasing hormone (GnRH) agonists are used.

Medroxyprogesterone acetate is significantly more effective in reducing all symptoms, but is associated with side effects like acne and oedema and weight gain.

The levonorgestrel-releasing intrauterine system (Mirena) renders the endometrium atrophic and inactive.

A response to hormonal therapy does not always predict the presence or absence of endometriosis, as some options include a trial of hormonal treatment before a definitive diagnosis is made.

Hormonal treatment is used to prevent secondary reoccurrence of endometriosis after surgical treatment. Surgical Treatment Treatment ideally performed at the first diagnostic laparoscopy is recommended, however unexpected severe disease may be discovered at the initial laparoscopy and this may require further counselling and subsequent surgical treatment. In counselling one should include the woman’s choice to have a definitive diagnosis and any infertility investigations.

A minimally invasive approach is associated with less pain, shorter hospital stays, quicker recovery and better cosmesis.

Surgical procedures range from excision/ablation of peritoneal endometriotic deposits and resection of rectovaginal nodules and removing scar tissue. Conservative surgery aims to treat all visible endometriotic lesions and restore normal pelvic anatomy.

Laparoscopic excision of ovarian endometriotic cyst walls (≥3 cm) is superior to drainage and coagulation for treating the recurrence of dysmenorrhoea, dyspareunia and non-menstrual pain and reduces the rates of repeat surgery.

Deep infiltrating endometriotic (DIE) may involve all the pelvic organs and requires surgical treatment which involves resection of nodules done with a colorectal surgeon.

This is associated with an improvement in pain outcome and quality of life.

Hysterectomy and removal of ovaries for endometriosis is generally reserved for women with debilitating symptoms due to endometriosis, and who have completed their family benefit as the disease is removed in bulk.

Ovarian conservation at hysterectomy presents a six-fold greater risk for the development of recurrent pain and a significant risk of risk of reoperation.

In conclusion Endometriosis can be a complex disease and require Multidisclipinary input for best outcome.