Endometriosis is a condition where the uterine lining, the endometrium, grows outside the uterus, commonly in the ovary and pelvis. This ‘ectopic’ endometrial tissue responds to hormonal changes, and causes local inflammation within the pelvis. This can lead to scar tissue formation inside the pelvis and the abdomen, and to pain.
The symptoms of pain, bloatedness and abnormal vaginal bleeding vary according to the severity of the endometriosis. Occasionally, there may also be pain during intercourse or blood in the stools or urine.
Ovarian endometriosis can lead to the formation of cysts, commonly called ‘chocolate cysts’. These need to be removed, and residual ovarian tissue and function preserved.
Endometriosis may be associated with infertility. In these cases, a laparoscopic surgery would allow assessment of the severity of the condition, removal of any endometriotic (chocolate) cysts, and ablation of any pelvic endometriosis. It may also be necessary to follow this surgery with specialized hormonal treatment, usually by monthly injections for six months.
2. Polycystic Ovarian Syndrome (PCOS)
In this condition, the ovaries are noted on ultrasound to have multiple small cysts, often on the circumference of the ovary giving the appearance of a ‘string of pearls’. There may also be problems with ovulation (occasional or no ovulation), and of signs of male hormone overactivity. Common features of PCOS include irregular periods, acne, weight gain, unusually excessive hair growth, and infertility. Not all signs and symptoms are present in every patient with PCOS.
In itself, PCOS is not harmful, and almost never requires surgery for treatment. On the other hand, its effects on fertility and on the uterus long-term may be cause for concern. The absence of ovulation can lead to a chronic unbalanced estrogen level in the blood, and could lead in the long term to cancer of the uterus.
In many, but not all, patients weight loss alone can reverse many of the ill effects of PCOS. It is important that this weight loss is achieved by a healthy balance of caloric restriction, exercise and adequate vitamin and mineral supplementation. Menstrual cycle and hair growth control may require medication. Many options are now available for helping patients with PCOS-related infertility.
3. Asherman’s Syndrome
Asherman’s Syndrome is a condition where scar tissue inside the uterus causes a woman’s periods to stop altogether. The condition usually arises from procedures such as dilation and curettage (D&C), and evacuation of the uterus of pregnancy contents.
Pregnancy is unlikely in this condition, but if it does occur, it could pose a risk to both mother and fetus.
Hysteroscopy – a procedure where a thin telescope is used to examine the inside of the uterus – helps specialists pick up the condition and define the extent of scarring.
Scar tissue varies in thickness, and extent. This type of tissue does not have blood supply, which makes treatment easier. Removing scar tissue can restore fertility. In some cases, the scar tissue tends to reform. To prevent this, hormone treatment with estrogen keeps the uterine walls from re-adhering. Regular follow-up is crucial in this condition to ensure that scar tissue does not reform, and that fertility can be restored.
4. Uterine Fibroids
Uterine fibroids are benign (non-cancerous) tumours within the uterus. They are the most common tumours in the human body, occurring in as many as 1 in 2 women. Some racial communities are at higher risk of developing uterine fibroids than others e.g. women of African descent.
The location and size of the fibroid usually determines its clinical effects. Fibroids can occur at the uterine surface (subserous), in the deep muscle layers of the uterus (intramural) and within the uterine cavity (submucous).
Uterine fibroids are often not felt and usually tend to go unnoticed and undetected. Size, clinical symptoms and detailed gynaecological examinations are the usual way fibroids are detected in women. The most common symptoms are heavy/prolonged menstrual bleeding, pain and frequent urination. A clinical pelvic examination and an ultrasound evaluation will confirm their presence, location and size.
Uterine fibroids are hormonal dependent: they grow in pregnancy and shrink in menopause. They may be associated with infertility or miscarriages, especially if they are located within the uterine cavity (submucous). More often though, they grow in pregnancy and cause pain at the site of the fibroid.
Some medications can reduce the size of the fibroid, but these usually induce a state of ‘artificial menopause’. This reduction is temporary, and the fibroids grow in size soon after the medication wears off. If fibroids need to be treated, surgery is a better option, and a myomectomy can be performed to treat the fibroid and save the uterus.