This was the strong message delivered from the podium of the auditorium of the De Soysa Hospital for Women in Colombo by a powerful group of Gynaecologists & Obstetricians gathered there to launch a full-scale battle against endometriosis.

1 in 10 women is affected by endometriosis.

Loud and clear came this terrible statistic, as the doctors urged not only women but also society to talk about it openly. “Don’t ignore or hide menstrual pain, for disabling pain is the leading symptom of endometriosis,” they said in one voice.

“Endometriosis is a very common condition affecting women and it is typified by a delay in diagnosis and can cost the country substantial expenditure through loss of work and healthcare costs,” stressed Prof. Hemantha Senanayake.

How does endometriosis start?

Endometriosis begins when tissue similar to the inner lining of the womb (endometrium) is found where it should not be – that is outside the womb. These ‘endometrial cells’ then begin growing at these sites but act just like endometrial cells do – undergoing changes with the hormonal cycle and starting to bleed at the time of menstruation (period). Like the womb lining, they too break down when the woman gets her menses.

 

This causes blood to accumulate in the pelvis and form cysts and a tissue reaction that makes the tissues stick together (adhesions), MediScene learns.

The common symptoms of endometriosis are:

Painful menstruation, especially if the pain has come newly (eg. Having initially had painless periods)

Progressively increasing menstrual pain

Painful sex

Difficulty in conceiving

Symptoms related to bowel and bladder Prof. Senanayake says that the chances are “high” of developing endometriosis if:

Your mother or sister has had it

You have menstrual cycles that come every 27 days or less

Your menstrual loss (bleeding) lasts more than 7 days

You had your first period before the age of 12 years

Endometriosis is believed to be the result of a complex interplay between environmental and genetic causes.

Pointing out that endometriosis will “never leave” the patient, Dr. Dhammike Silva explains that there will be an increase in this condition during the reproductive age but a decrease thereafter.

A laparoscopic expert and part of the multi-disciplinary team which has taken gynaecological care in Sri Lanka to greater heights at the Kalubowila Teaching Hospital by setting up the South Asian Minimal Access Gynaecology & Endometriosis (SAMAGE) Centre with accreditation from the British Society for Gynaecological Endoscopy (BSGE), Dr. Silva says simply “apita keli ivath karanna puluwan” (we can remove pieces affected by this condition) but we can only control it, not cure it.

With clinical precision, he places those affected by endometriosis in three groups:

Those who need to have children but are also burdened by massive pain due to endometriosis – something needs to be done for them.

Those who are not looking to have children but are in massive pain due to endometriosis – for them too, something needs to be done.

Those who have endometriosis but do not know that they are having the condition – they can be left alone, without any treatment.

He says that excision (removal) of endometriosis as much as possible from the affected organs through laparoscopic (keyhole) surgery can turn the condition towards a better direction. Laparoscopy is good because “everything” within the pelvis can be seen clearly and sometimes endometriosis is everywhere.

It is not just the woman who is deeply affected but also her family. Her life gets disrupted – “ekathu wenna be” (she is unable to have sexual relations with her husband) as it is very painful. As she would be in pain throughout each month, she would not be able to attend to her usual work.

Through a powerful presentation, Dr. Silva shows MediScene how endometriosis goes to every mullak mullak assata (every little corner). Earlier, it was believed that a ‘frozen pelvis’ caused by severe endometriosis was inoperable as it involved not only a woman’s reproductive organs such as the ovaries, fallopian tubes, womb and vagina but also the bladder, the ureters (urinary tubes), the bowel (intestine) and the nerves in the area.

However, a skilled laparoscopic surgeon can negotiate and navigate the endometriosis-hit areas and resect or cut them out separately. What the surgeon will do is skeletonize and isolate the bowel, the ureters, the womb, the ovaries, the vagina and the nerves and clear all these of endometriotic deposits. The procedure may entail dissecting some parts of the affected ureters and re-implanting them or exposing and raising the nerve plexus (complex branching networks) for nerve-sparing.

Referring to the medical management of endometriosis, Dr. Chandana Jayasundara says that as the symptoms seriously affect the quality of life of women and their mental and emotional health, medical management targets pain control and suppression of the hormonally-active endometriotic tissue.

“The main components causing these symptoms are prostaglandins and other cytokines and oestrogen. As such, suppressing or inhibiting them will control the symptoms associated with endometriosis,” he says.

The medications used in endometriosis can be categorized into:

Non-hormonal – non-steroidal anti-inflammatory drugs (NSAIDs); aromatase inhibitors; and danazol

Hormonal – combined oral contraceptives; progesterone containing contraceptives (oral/injectable, implant or intrauterine system); selective progesterone receptor modulators; gonadotrophin-releasing hormone agonists; and gonadotrophin-releasing hormone antagonists

NSAIDs are the most commonly used first line agents in the management of endometriosis-related pain, says Dr. Jayasundara, adding, however, that they will prevent the pain but not the progression of the disease.

Picking up the hormonal medications, he says that the combined hormonal contraceptives will suppress the ovaries and disease activity. “This is the most commonly used first line hormonal therapy and is proposed to slow the progression of the disease. The low cost, ease of administration and tolerability of combined hormonal contraceptives have made them popular.”

Dr. Jayasundara, quoting many a study, says that there is a need for a paradigm shift from ‘short-term treatment with strong drugs’ to ‘long-term treatment with drugs with fewer adverse effects and higher compliance’.

Meanwhile, it is Dr. Mohamed Rishard who goes into history to pinpoint that endometriosis is not a new disease.

“Typically, endometriosis causes pain and infertility, although 20–25% of patients are asymptomatic. About 25-50% of infertile women have endometriosis and 30-50% of women with endometriosis are infertile,” he says.

Dr. Probho-dana Ranaweera Unbearable pain during menstruationThe reality of the suffering that women with endometriosis undergo is highlighted by Dr. Probhodana Ranaweera when he says that usually when there is menstruation a woman would have slight pain which can be dealt with effectively with paracetamol. However, in those hit by endometriosis, the body-wracking pain starts a few days to a few weeks before menstruation, becoming unbearable on the day of menstruation and usually outlasts the period once again from a few days to a few weeks. In severe form, it makes some women suffer the whole month, he says. Pointing out that there are two treatment options for endometriosis – medical and surgical – Dr. Ranaweera says diagnosis of endometriosis is made by taking a detailed history, followed by an examination of the patient and investigations. The examinations would be abdominal, pelvic and rectal and the investigations an ultrasound scan of the abdomen, an MRI or diagnostic laparoscopy. The gold standard for diagnosis is laparoscopy.

Birth of Lanka Endometriosis Association It affects so many women that medical professionals with an interest in this disease have come together to form the ‘Lanka Endometriosis Association’. The association has designated August as the Endometriosis Awareness Month to make people aware of this debilitating condition.

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