As part of our Lunch & Learn series we were joined by Dr Karen Morton of Dr Mortons – the medical helpline.
In this session we talked about endometriosis and the menopause. Endometriosis can be a debilitating condition for sufferers. But does it go away or does it get worse during the menopause transition?
Henpicked: First, can you tell us: what is endometriosis?
Dr Karen Morton: The lining of the uterus is called the endometrium. Endometriosis is a condition where there is endometrium (or cells incredibly similar to endometrial cells) in the wrong place; outside the uterus. There is also a condition where you can have endometrium in the wall of the uterus, called adenomyosis, which produces very similar symptoms.
Endometrium responds to the cyclical hormones from the ovaries. Oestrogen tells the endometrium to grow. Progesterone tells it to stop growing after ovulation and become nice and thick to prepare for a pregnancy. If a pregnancy doesn’t occur the progesterone level falls and the lining of the uterus falls away as a period.
The lining of the womb itself is flimsy. Most of the blood that you see is coming from the raw blood vessels in the wall of the uterus. So if this is happening in your uterus, these growth and bleeding cycles are happening everywhere else in the body where there is endometrium in the wrong place. Blood is a very irritant substance in the tummy, and causes inflammation, scarring and sticking. If you get endometriosis on an ovary, instead of dispersing, the blood collects together. Every time a period happens the area the ovary will grow and bleed, grow and bleed. Older blood is brown, so this produces what is called chocolate cysts on the ovary, which contain what looks like chocolate sauce. These can be huge.
Henpicked: Why do some people get endometriosis?
Dr Karen Morton: We don’t know why endometriosis happens. Was the woman born with these spots of endometrium in the wrong place? Or is it that there is some retrograde menstruation where during a period cells pass along the tubes and grip on and develop a life of their own? In likelihood it’s probably a combination of the two.
Henpicked: How do doctors diagnose endometriosis?
Dr Karen Morton: There are some classic features to the sort of pain that comes with endometriosis. A lot of women with heavy periods have pain when they’re bleeding. But that’s not the kind of pain women get with endometriosis. It’s not because of heavy bleeding. And often the pain will be at its worst in the few days leading up to a period.
It can commonly cause painful sex because the inflammation and scarring means that the uterus and ovaries are stuck and can’t move. Often you can get deposits of endometrium in the space between the vagina and the rectum, that can lead to terrible pain when you do a poo during a period. These are the distinguishing features.
Henpicked: Is it easy to diagnose – how is it done?
Dr Karen Morton: If you do have painful periods you should go to your doctor. They will probably suggest an ultrasound scan, which will only be abnormal if there are chocolate cysts on the ovaries. If the scan is normal you still might have spots of endometriosis. The only way of finding that is to have a telescope put into your tummy, a laparoscopy.
Henpicked: What is the treatment for endometriosis?
Dr Karen Morton: The best treatment is always to stop the period. They can be stopped with hormonal methods or anti hormonal methods which switch off the ovaries and make a woman menopausal temporarily. The simplest and most reliable method would be to take a combined oral contraceptive back to back, or to go onto a progesterone-only pill. On these, over 80% of women will have no periods after three months. While the Mirena coil is great as a treatment for heavy periods, it releases hormones straight into the uterus. It’s not designed as a hormonal treatment outside the uterus. It may stop visible bleeding but it might not stop cyclical pain. However, it can be a good treatment for adenomyosis.
Henpicked: Will endometriosis get better or worse as a result of menopause?
Dr Karen Morton: It usually gets better post menopause as long as you’re not taking HRT. If you’re taking a cyclical HRT your endometriosis is likely to remain troublesome. But once you move on to a no-bleed regime, after your periods finish, things should settle.
Some women with severe endometriosis may well have their uterus and ovaries removed, which will send them into surgical menopause. And surgery can never guarantee removing every single spot of endometrium. If you’ve had a surgical menopause say at 40, you will need hormone replacement therapy. But unlike women who come to menopause without their uterus for other reasons, like prolapse or fibroids, one who has had their uterus removed for severe endometriosis is not suited to taking just oestrogen. This is because any remaining spots of endometrium would be stimulated by the oestrogen alone and could become abnormal to the point of endometrial cancer.
When their periods have completely stopped and you go into menopause then these women will be well suited to a continuous combined regime of oestrogen and progesterone, which can be given orally or through the skin as a combination.
Henpicked: Does this mean women are faced with choosing to manage their menopause symptoms or endometriosis?
Dr Karen Morton: I know it can seem difficult, but there will be a solution. There may be some fine tuning and you might need to try a few different preparations. It can be tough if you’re getting conflicting advice from a GP and a gynaecologist, so it’s worth looking for a gynaecologist with specialist menopause interest.
Watch the video here:
Henpicked’s Deborah Garlick was joined by Dr Karen Morton, Consultant Obstetrician and Gynaecologist, Founder and Medical Director of Dr Morton’s, The Medical Helpline. Dr Morton trained at Cambridge, Oxford, Queen Charlotte’s Maternity Hospital, Chelsea Hospital for Women and St Thomas’ Hospital, before becoming a consultant in Guildford in 1991.
She believes in empowering women to make informed choices about their healthcare, starting Dr Morton’s in 2013 to help make that happen.
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Check out the rest of Henpicked’s Lunch & Learn video series!
