The endometrium (or uterine lining) grows in the uterine lining each month in preparation for a pregnancy and sheds each month when no pregnancy occurs. This shedding is known as menstruation, menses, or a period. Endometriosis is a disorder in which endometrial tissue is present outside of the uterus, in various areas of the pelvis or body. Endometriosis can damage the ovaries, fallopian tubes, cervix, bladder, colon, outer uterine wall, and peritoneum (the membrane that lines the abdominal and pelvic cavities). It can occasionally be spotted on distant structures.

Regardless of their location in the body, these endometrial cells all respond to monthly hormonal signals to prepare for a pregnancy and shed if one is not obtained. The shedding of endometriosis implants outside the uterus causes bleeding inside the pelvis, which can cause a chronic, inflammatory reaction in the affected tissues, potentially leading to scarring and adhesions that cause pelvic organ distortion as the body attempts to heal itself.

Endometriosis’s cause is unknown, but as we learn more about it and treat it, it is widely assumed that a variety of variables have a role. These include a hereditary predisposition, compromised immunity, altered cell function, abnormal hormone activity, and abnormal endometrial cell migration.

In Australia, one in every ten women suffers with endometriosis, which is often diagnosed between the ages of 25 and 35. Endometriosis is difficult to diagnose, and the average time between symptom start and diagnosis is 7 years. Approximately one-third of people with endometriosis are unaware of their condition until they are unable to conceive.

There are several potential symptoms, which vary depending on where the endometriosis implants are placed in the pelvic cavity. The severity of symptoms does not consistently predict the size, grade, or number of endometriosis implants. The most common presenting symptom of endometriosis is pain, which affects approximately 80% of those diagnosed, however for some, infertility may be the primary presenting issue.

Endometriosis is directly impacted by the menstrual cycle, thus it frequently causes cyclical pain in conjunction with period symptoms in the areas where the endometriosis implants have formed. Three out of four endometriosis patients report the most severe pain during their menstruation, although endometriosis can also cause discomfort during ovulation and sexual activity. Some persons with endometriosis may not have any symptoms at all. Unfortunately, endometriosis can worsen with time.

Endometriosis can make it difficult to conceive, with 30-50% of people affected experiencing infertility. This is assumed to be due to endometriosis-related inflammation, scarring, and adhesions.

Endometriosis implants can cause inflammation, scarring, and adhesions in the organs on which they have developed. On the ovaries, it can impede and/or negatively effect egg growth, development, release, and quality. It can obstruct the release and transit of an egg in the fallopian tubes, as well as interfere with fertilization by making sperm harder to reach. Severe endometriosis can harm the uterine outer wall or deform pelvic anatomy, preventing embryo implantation.

Some endometriosis patients may not require therapy from a fertility specialist and will be able to conceive spontaneously after surgery by a competent gynaecologist, however they may continue to experience subfertility and conception delays.

To conceive, around one-third of endometriosis patients will need to see a reproductive specialist.

If a couple has been trying unsuccessfully to conceive for more than a year (or more than 6 months if over 35 years old), it is recommended that they consult with a No.1 Fertility Specialist about their alternatives.

The majority of persons with endometriosis will experience a normal, uncomplicated pregnancy. Rarely, some women will suffer pain throughout their pregnancy. Extra monitoring is usually unnecessary, although it is crucial to consult with an obstetrician.

Endometriosis symptoms may be lessened or nonexistent during pregnancy as the hormonal communications that cause endometrial cell growth and shedding are replaced with hormones that communicate pregnancy.

If regular periods have not yet resumed, nursing may help to alleviate symptoms.

It is crucial to note that pregnancy does not heal endometriosis, and symptoms may reappear once the menstrual cycle and periods return after childbirth and/or nursing cessation. Endometriosis symptoms may improve or resolve during pregnancy, but they can sometimes worsen.

Pelvic ultrasonography is used to investigate pelvic pain in women (it is also included in baseline infertility exams).

Ultrasound imaging can detect some endometriosis abnormalities, such as endometriomas (endometriosis-related ovarian cysts), deep nodules in severe endometriosis, and adhesions where tissue has adhered together. Endometriosis cannot be detected with ultrasound if these characteristics are lacking. As a result, a normal baseline pelvic ultrasonography does not exclude endometriosis.

Magnetic resonance imaging (MRI) is also utilized to diagnose endometriosis, especially in cases where severe endometriosis (deep invasive endometriosis) is suspected. It is very beneficial for surgical planning in difficult situations. As with ultrasound examinations, MRI will not detect endometriosis in cases where severe symptoms are absent, therefore a normal MRI does not rule out endometriosis.

Laparoscopy is a procedure in which a surgical telescope and camera are inserted through small ‘keyhole’ incisions in the abdomen. These cuts are often performed at the belly button, with one or two more made on either side of the lower abdomen. These wounds are usually 5mm in size, however larger incisions are sometimes done. Carbon dioxide gas is used to gently inflate the abdomen, creating space for your surgeon to observe your pelvic organs on a screen and operate without causing damage to surrounding structures. The surgeon can then examine and operate on the pelvic and abdominal organs. Instruments are passed through the incisions during surgery, and tissue can be removed this way.

Endometriosis has no known cure and rarely resolves on its own. As such, the purpose of treatment is to control endometriosis symptoms rather than cure disease.

Endometriosis is often managed and treated using a multimodal approach. Depending on the severity, the treatment team may comprise a gynaecologist and fertility specialist, a pain specialist, pelvic floor physiotherapist, and a dietitian, among others.

Non-hormonal pain alleviation, as well as hormonal drugs like progestogens and laparoscopic surgery, are used in medical treatment. Specific case management is determined by the intensity and location of endometriosis implants, as well as each patient’s clinical circumstances.

Because endometriosis is directly impacted by the menstrual cycle, most suggested hormonal drugs for therapy will frequently inhibit pregnancy. Hormonal drugs may limit endometrial tissue growth and prevent the creation of new implants of endometrial cells, however they are not always curative and try to suppress the condition.

Endometriosis is surgically treated using operational laparoscopy; if the patient is not planning a pregnancy or is not actively attempting to conceive, hormone suppression is often used in conjunction with surgery. Endometriosis deposits can be excised (cut out) or ablated (burned) under laparoscopy. Excisional surgery is chosen over ablation due to its superior effectiveness. Surgical treatment for pain can be useful at all stages of endometriosis. Endometriosis frequently recurs, and some people may require repeated procedures throughout their lives to relieve symptoms.

Endometriosis patients with mild to moderate endometriosis may benefit from operational laparoscopy to improve fertility. However, this is not true for all cases.

• In patients with endometriomas (endometriosis-related ovarian cysts), there is limited evidence that removing the cyst may enhance natural conception rates. However, the possibility of losing healthy ovarian tissue after surgery must be addressed before proceeding with treatment.

In certain extreme circumstances, if patients have crippling symptoms and no longer intend to carry a pregnancy, more radical surgical procedures are contemplated. These involve removing the uterus (hysterectomy), fallopian tubes (salpingectomy), and sometimes the ovaries (oophorectomy). This procedure is more intrusive, with a higher surgical risk. It is not undertaken lightly since endometriosis symptoms may persist after surgery. There are other potential risks to consider, such as premature menopause.

Endometriosis should be managed and treated in consultation with your primary fertility specialist.