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March is often a month where we look towards spring and new growth whilst enjoying the increase in daylight hours. However for a large proportion of the world’s population, March takes on an entirely different role, one concerning increasing awareness of the condition endometriosis.

Key Stats

  • 1 in 10 women suffer from endometriosis
  • Current estimates say 176 million women have the condition
  • It can affect girls and women from as young as 15
  • Infertility is present in 30-50% of patients
  • The cause is currently unknown

What actually is endometriosis and why should we care?

Endometriosis is simply where cells/tissue that resembles the lining of the womb is found in locations outside of the womb. This tissue is registered by immune cells of the body which negatively react to it leading to inflammation and pain. This pain and inflammation is compounded by the foreign tissue growing and responding to the female hormones, even bleeding at the time of menstruation. This tissue can be found throughout the body but it 60% of cases, it is found in the ovaries.

It has been estimated that 1 in every 10 women of reproductive age (i.e. between 15 and 49) suffer from this condition. To put that into context, endometriosis affects approximately 176 million women in the world, or nearly 3 times the population of the UK. In addition to this, endometriosis is a long term disease with a significant impact on a patient’s life and wellbeing.

Despite this, research from Endometriosis UK states that 54% of people don’t even know what this condition is.

History

The history of this condition is interesting as no one can actually decide who first ‘discovered’ it. There are references to endometriosis-like symptoms in texts recovered from the Ancient Egyptians however the first detailed description came in 1690 by Daniel Shroen.

It wasn’t until Carl von Rokitansky in 1860 produced his observation that we got a full identification and description with a likely cause.

Following this date, there have been numerous observations, studies and publications exploring endometriosis, however little progress and understanding has been gained. This is due to the variety of ways and locations this condition can present itself in patients.

What’s the normal physiology and what goes wrong?

The major organs of the female reproductive system include the ovaries, uterine tubes, uterus and vagina (figure 1). The ovaries are small, almond shaped organs which produce eggs. Eggs are released during the monthly ovarian cycle and travel down the uterine tubes. The ovary and uterine tubes are not actually connected and as such the egg must bridge a gap before entering the tubes. If this egg is fertilised, it should implant into the uterus wall and will develop into a fetus. If the egg isn’t fertilised, or is fertilised but doesn't implant successfully, the uterine wall will shed during menstruation.

Figure 1.jpeg

Figure 1

The current most widely accepted theory as to why endometriosis occurs is related to this shedding of the uterine wall. Backflow of shed material from the uterus through the uterine tubes occurs in 90% of women at some extent. This is called retrograde flow. The idea is that material can leave the uterine tubes via the small gap between ovary and tubes and move around the body, settling down in different regions.

This explains why the ovary is the most likely place for endometriosis to occur. Other common locations include uterine ligaments and pelvic linings. Endometriosis is also rarely seen in the bowel, kidneys and lungs. However, the cells found at sites of endometriosis are not the same as those from the uterine wall putting doubt on this theory and causing further confusion as to the real cause.

Regardless of the route, once this 'foreign' tissue has settled, the body attempts to remove it and through this process, irritates and aggravates the surrounding area leading to pain and swelling. This tissue will also grow and develop in response to the normal female hormones and will also bleed in sync with hormonal changes during the menstrual cycle. This blood and cell growth also leads to further pain and inflammation, eventually changing the surrounding tissue permanently.

Most patients report some pain but symptoms can range widely from patient to patient and also vary depending on the time of the month. What is more significant to women suffering with this condition however, is that in a third of cases infertility is reported. Infertility in anyone obviously has huge physical and emotional effects. The fact that girls as young as 15 can develop endometriosis has further implications when considering infertility.

In all cases, it is a chronic, debilitating disease which is extremely painful, leads to lack of energy and depressive feelings and has an impact on both work and social activities.

What’s changing?

The effects of endometriosis expand way and above the actual mechanism of the disease. It currently takes on average 7.5 years from first symptoms to formal diagnosis. This is due to the symptoms replicating many other diseases and women considering symptoms as heavy menstrual flow and pain as not serious. Additionally, there are thousands of studies indicating that women worldwide are not being listened to by professional bodies or their condition is being down played, especially in the cases of female reproductive issues. Many centres globally are looking at new ways to diagnose endometriosis rapidly and effectively although this is currently some way off but will undoubtedly improve the current time to diagnosis.

There is currently no cure for endometriosis even when diagnosed. Most treatment options involve basic pain relief although changing the bodies hormones through medication or surgery to remove the affected part are also options. Both of these treatment options carry their own pros and cons however.

A recent BBC article summed the current feeling on endometriosis up nicely – ‘women with endometriosis are finally being believed’. Participants in the BBC research found that half the women asked had suicidal thoughts, were reliant on additive painkillers and that the condition had even forced women to change careers.

Thankfully through hard work and awareness, more people are starting to understand this condition. Endometriosis Awareness Month has been a major contributing factor and there are many events seen all around the world in support of this campaign. Ultimately though, society and people in power must understand what a life changing disorder endometriosis really is before we see tangible change.

At Chester Medical School, we put the study of reproduction, pregnancy and reproduction complications throughout our core modules at every level of study on every course. We realise that some of the biggest diseases and problems the world currently faces start before we are even born during the critical nine months of pregnancy. In addition, we have already seen the amount of people suffering with hidden diseases such as endometriosis. As a department, we believe the key battle for the next generation of biomedical scientists and medical professionals will be overcoming diseases such as this one so that everyone can live their life pain free.

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