The facts aboutEndometriosis

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A specialist team of health professionals with the

expertise to provide personalised and up to date

treatment for women with endometriosis.

Nurse Co ordinator - Katrina DowlingGynaecologists - Dr Russell Dalton

- Dr Judith FlemingColorectal Surgeon - Mr Bruce StewartUrologist - Mr Lachlan DoddsPsychologist - Sandra LorensiniPain Specialist - Dr Neil ShorneyAcupuncture - Dr Rimas Liubinas

- Dr Paul GhaieHerbalist - Greg HorganHerbalist/Natural fertility& Bowen therapy - Wendy DumaresqMasseur - Lauren Halliburton

Appointments: Initial appointments may be made with either Katrina Dowling or a gynaecologist. A referral from your GP is required if the appointment

is with a gynaecologist or surgeon.

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Contents

What is endometriosis? 4

What is endometrial tissue? 4

Endometriosis – FACTS AND FICTION 5

What are the symptoms? 6

How is it diagnosed? 6

How is it treated? 6

Surgical options 7

Drug therapy 7

Cure rates 8

Endometriosis and infertility 9

Hysterectomy 10

Summary 10

location 11

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Fallopian Tube

Ovary

Uterus

Bladder Rectum

Cervix

Pouch ofDouglas

Anus

Vagina

Hymen

Vulva

Pelvic Side View

What is endometriosis?

Endometriosis is a condition where endometrial cells and tissue (like thelining of the uterus) is found in the pelvis and occasionally in other placesin a woman's body. Endometriosis may cause pain or infertility by causingscarring and adhesions which may damage a woman’s pelvic organs.

What is endometrial tissue?

Endometrial tissue is the normally placed lining of the uterus, which fallsaway from the inside of the uterus when a period occurs.

Endometriosison Bladder

Endometriosisin Pouch of Douglas

Endometriosis(chocolate cyst)of Ovary

Endometriosison UterosacralLigaments

Pelvic Side Overview

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FACT: Endometriosis can be found in10% of women.

FACT: 40% of women with infertility haveendometriosis.

FACT: Surgical removal of even mildendometriosis has been shown toimprove the chances of gettingpregnant.

FACT: Women with untreatedendometriosis are more likely to suffermiscarriage.

FACT: Endometriosis is often present formany years before the diagnosis is made.

FACT: When women are cared for byexpert surgeons, repeated operations areseldom required.

FACT: Women who have experttreatment for endometriosis are able tolead healthy and normal lives.

FICTION: Endometriosis is cured bypregnancy.

FICTION: All women with endometriosishave pain.

FICTION: Laparoscopic surgery isrequired every six months “just in case”the condition has recurred.

FICTION: Ovaries which containendometriosis should be removed.

FICTION: Drug treatment forendometriosis does not work.

FICTION: Hysterectomy is the besttreatment for endometriosis.

Endometriosis – FACTS AND FICTION

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What are the symptoms?

Not everyone has all the symptomslisted, but any of them may be present

Pain• Painful periods. The pain may occur

either before, during or after the period• Pain with intercourse, especially with

deep penetration

Period problems• Heavy bleeding• Bleeding between periods• Irregular cycles

Bowel problems• Bleeding from the bowel especially

with periods

• Pain in the lower bowel during periods

• Constipation, incomplete emptying of the bowel

Bladder problems• Pain with full bladder• Needing to pass urine more frequently

Sexual discomfort

Infertility• Delay in getting pregnant

Other symptoms• Lethargy• Irritability depression• Absenteeism from work or school

How is it diagnosed?The discovery of endometriosis is oftendelayed because the diagnosis is notconsidered. Pain, bleeding or bowelproblems which interfere with a woman’slife are not normal, and may be due toendometriosis.

Abnormal areas of tenderness may benoted when a woman undergoes agynaecological examination. An ultrasoundperformed at the time of examination mayreveal endometrioma’s or“chocolate cysts”.

The only way to definitely diagnoseendometriosis is by laparoscopy.Biopsy samples should be taken at the timeof surgery to prove the diagnosis.

How is it treated?Treatment of endometriosis must beplanned to meet the needs of each woman.Factors which need to be considered are thetype of problems which the disease iscausing in the individual, her age, whetherfertility is an issue, and of course her choiceregarding the treatment options.

To view laproscopic images of endometriosis visit our website, www.ballaratendoclinic.com.au

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Surgical options

Laparoscopy

Laparoscopy is a minor, relatively safeprocedure performed under anaesthesia in ahospital. It has been shown clearly innumerous studies that laparoscopic surgeryis the best way to treat endometriosis.

Laparoscopic Surgery benefits are:

• Higher cure rates

• Small incisions with less pain and scarring

• Less time off work

• Most can be performed as

“day case surgery”

Laparoscopic surgery allows a skilledsurgeon to carefully check all of the pelvicorgans for any sign of disease and to gentlyremove it.All Gynaecologists perform laparoscopy, butnot all are trained to diagnose and treat alltypes of endometriosis by laparoscopy.

Laparoscopic surgery for severeendometriosis may take several hours.In some cases it may be necessary toundertake a second operation after drugtreatment is used to reduce the size andactivity of the areas of endometriosis.

The vast majority of surgery undertaken atthe Ballarat Endometriosis Clinic isperformed by the laparoscopic approach.

Drug therapy

Drug therapy can be used to manage thesymptoms of endometriosis.

Endometriosis is influenced by oestrogenlevels. Constant, or low oestrogen levels limitendometriosis activity. Varying oestrogenlevels cause endometriosis to grow.

Superficial endometriosis can be treatedsuccessfully with drugs, but more extensivedisease, or disease which causes adhesionsbetween pelvic organs can only be treated with surgery.

Hormonal Options

GnRH analogues (Zoladex, Synarel)These types of drugs reduce the production ofoestrogen by “turning off” the ovaries. Theseagents are highly effective in improving thesymptoms of endometriosis whilst a woman isusing them, but symptoms often return whenthe medication is ceased. Side effects are thesame as those of the menopause (hot flushes,dry vagina, irritability, headaches).

Thinning of the bones (osteoporosis) alsooccurs whilst using these drugs, so treatmenttime is limited to a maximum of six monthsBone loss is reversible once the drug is ceased.

At Ballarat Endometriosis Clinic GnRHanalogues are often used to reduce the activity of severe endometriosis prior toplanned surgery.

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Danazol/Dimetriose

Androgenic steroids cause cessation of thenormal hormonal cycle, in this way oestrogenlevels are stabilized and this causesendometriosis to become inactive.

Androgenic steroids are effective inmanaging endometriosis but there aresignificant “male hormone” side effects ofweight gain, facial hair growth, oily skin, acneand occasionally voice changes.

Because of their common and significant sideeffect profile, androgenic steroids are NOT thefirst choice of drug treatment used forwomen attending Ballarat EndometriosisClinic. When considered, all benefits and risksare discussed with the individual.

Progestagens (Provera,Duphaston, Primolut N)

These are progesterone like medicationswhich oppose the effects of oestrogen but donot usually stop the menstrual cycle. They areoften effective in controlling symptoms butside effects such as bloating, tiredness anddepression can occur.

Depo Provera

This is a three monthly injection of Proverawhich stops the hormonal cycle and lowersoestrogen levels, but not to the extent thatGnRH analogues do. Because of these effects,

Depo Provera can be very useful as a longterm therapy to control endometriosissymptoms after surgery. The main concern, inaddition to those mentioned above is ofirregular bleeding.

Oral Contraceptives (“the pill”)

Many women commence using the pill intheir teens to control painful periods. Many ofthese women have minor endometriosiscausing their symptoms. This may be all thetreatment which these women need.

Concern regarding the possibility ofendometriosis is often raised if the pill fails tocontrol period pain, or if pain returns after thepill has been effective.

After Laparoscopic removal of endometriosisat Ballarat Endometriosis Clinic, many womenwho are not actively trying to conceive usethe pill in a “continuous regimen”. This meansthat only active or hormone containing pillsare taken.

This keeps oestrogen levels constant andavoids periods, which may be the only timewhen women experience endometriosissymptoms.

Some women, for example, those who aresmokers, overweight or have a family orpersonal history of thrombosis (clots) orbreast cancer should not take the pill.

Cure rates

Surgical treatment 70%

Drug treatment 30 – 40% (if superficial disease)

No treatment 20% (if superficial)

Endometriosis and infertility

40% of infertile couples have endometriosispresent in the woman.In situations where the disease processcauses distortion and damage to thefallopian tubes and ovaries, the role whichendometriosis plays is obvious.

When damaged, the reproductive organs areunable to function normally.Mild endometriosis is also associated with inability to conceive.

Endometriosis related infertility can bemanaged by laparoscopic surgery,superovulation, intrauterine insemination, orin vitro fertilization.

For more information about infertility andendometriosis visit ballarativf.com.au

Endometriosis and HormoneReplacement Therapy (HRT)

Many women who have had endometriosischoose to use hormone replacement therapy.This may be required when a woman becomesmenopausal naturally or as a result of surgerywhen the ovaries are removed.

There is often concern that oestrogen whichis used as HRT may stimulate any residualdisease.

There can be some situations where pain andendometriosis symptoms do increase whenHRT is used.

To deal with this problem there are a numberof options:

1. The dose of oestrogen can be reduced to the absolute minimum required

2. Progestagens can be added to the existing treatment to reduce the activity of any residual endometriosis

3. A new drug, tibolone, can be used instead of oestrogen as HRT.

Tibolone has no activity in endometrial tissueand hence does not stimulate endometriosistissue.

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Hysterectomy

For some women, undergoinghysterectomy may be the best option totreat endometriosis. This option is oftenchosen when women have undergone anumber of previous procedures and haveadditional abnormalities present such asfibroids, troublesome heavy bleeding oradenomyosis.

Hysterectomy is only considered whenfertility is no longer an issue for thewoman.

Every effort is made to preserve theovaries when hysterectomy is performedfor women before the menopause. It isimportant to bear in mind that 10% ofwomen will require further surgery toremove one or both ovaries at a later time.

Most women who request hysterectomyare able to have the procedure performedby laparoscopy, which minimises time inhospital and off work.

SummaryEndometriosis is a common andserious condition which deservesproper diagnosis and expert treatmentthat is tailored to the individualwoman’s needs.

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Location

1107 Howitt St. WendoureePhone: 03 5339 8200Fax: 03 5339 8300Email: nurse@ballaratendoclinic.com.au