As part of our Lunch & Learn series we were joined by Dr Abbie Laing of My Menopause Centre rated ‘outstanding’ by the Care Quality Commission.
She spoke to us about endometriosis, explaining more about what it is, the symptoms and diagnosis, and what you can do if you’re struggling.
Henpicked: What exactly is endometriosis?
Dr Abbie Laing:
To understand endometriosis, it is first helpful to understand what the endometrium is and how this responds to our changing hormones each month. The endometrium is the lining of the womb and this womb lining grows each month in response to rising oestrogen levels. If a pregnancy does not occur, oestrogen levels then drop and the endometrium is shed as a monthly period.
Endometriosis refers to the presence of ‘endometrium like deposits’ that is located outside of the womb. For example, endometriosis or ‘endometrium like deposits can be present on the ovaries, on the ligaments that support the womb or on the bowel, rectum, bladder or diaphragm. Because endometriosis behaves like the endometrium, when a person’s oestrogen levels rises each month, endometriosis deposits can grow and this can cause pain. In addition, when oestrogen levels drop there is nowhere for these deposits to shed and the body needs to reabsorb them which can cause irritation and additional pain.
Henpicked: What causes it?
Dr Abbie Laing: We do not know the exact cause of endometriosis however there are some theories. One theory is called retrograde menstruation and this refers to blood flowing backwards through the fallopian tubes and into the abdomen each month, rather than all of it flowing into the vagina causing a period. Another theory is called metaplasia and this means that cells in the body completely change into another type of cell. We also know that endometriosis is more likely to run in some families and there therefore may be a genetic predisposition.
Henpicked: Does it usually occur at a particular age?
Dr Abbie Laing: It’s more common in the reproductive years as that’s when hormones are fluctuating, and endometrium can grow in response to oestrogen going up. Those aged 25-40 are the most commonly diagnosed. It’s less common post menopause when our hormones settle. There can sometimes be a family history of endometriosis, so this can be a higher risk.
Henpicked: What symptoms might people experience?
Dr Abbie Laing: Endometriosis is more common in the reproductive years because this is when hormone levels are fluctuating which affects the endometrium or endometriosis deposits. Diagnosis is less common post menopause when hormone levels are low and stable.
Henpicked: Why does it take so long to diagnose?
Dr Abbie Laing: In my opinion this is because there is not a good screening tool for endometriosis. Unfortunately, endometriosis is very hard to identify on an ultrasound scan and the gold standard investigation to diagnose endometriosis is a laparoscopy. This is a surgical procedure that involves looking into the abdomen with a small camera which is usually inserted through the belly button with a person under a general anaesthetic.
n my opinion it’s because there’s not a good screening tool. It is very hard to see on ultrasound scan. The gold standard for diagnosis is a laparoscopy, which is a camera through your belly button.
Henpicked: What advice would you give to someone with symptoms?
Dr Abbie Laing: It can be very helpful to keep a diary of your symptoms and make a note of the date in relation to your monthly bleed. Often symptoms are worse in the lead up to a persons bleed and the first few days of it, and if your symptoms suggest this, it might point towards endometriosis. If you think that you have endometriosis you should ask your clinician to refer you to a Gynaecologist with a special interest in this.
Henpicked: Are there any risks with endometriosis?
Dr Abbie Laing: Endometriosis can be located close to or on the ovaries and sometimes cause cysts here, these are called endometriomas, or sometimes they are also called chocolate cysts. Cysts can cause pain and sometimes, although not commonly, they can twist and damage the ovary itself. Endometriosis is associated with infertility, with a prevalence of 25-40% of infertile women compared with 0.5-5% of fertile women. Adhesion formation may occur due to endometriosis or secondary to surgery and women can develop chronic pain. This can affect emotional well-being.
Henpicked: What happens during perimenopause?
Dr Abbie Laing: In the perimenopause oestrogen levels fluctuate and become erratic and bleeding can become highly irregular, often with bleed patterns becoming heavier and closer together in the early perimenopause. Initially, the effect of erratic oestrogen levels can make endometriosis symptoms worse. However, usually as a person goes into the menopause and post menopause, oestrogen levels become low and stay low and usually symptoms of endometriosis improve.
Henpicked: Can you take HRT with endometriosis?
Dr Abbie Laing: HRT is not contraindicated in somebody with endometriosis, however it is important to pick the type of HRT carefully. HRT, is traditionally made up of two hormones, oestrogen and progesterone. Oestrogen is used to improve symptoms of the menopause and a progesterone is needed to prevent the endometrium (womb lining) growing in response to oestrogen.
In the same way that oestrogen can make the womb lining grow, oestrogen can make endometriosis grow however taking a progesterone should prevent this from happening. Therefore, when considering HRT the principles to follow would be to use a low dose of oestrogen with a daily progesterone. If endometriosis is confined to your womb or is close to your womb then the Mirena coil is a very good progesterone option in HRT.
It is not known how well the Mirena coil protects endometriosis that is located outside of the womb, for example on the diaphragm and sometimes additional progesterone is prescribed to prevent extrauterine deposits growing.
When someone has had a total hysterectomy usually that person can use oestrogen-only HRT because the endometrium will have been removed. However, if someone has endometriosis, and there are concerns that some may still be present post-surgery, then that person might still need to take a progesterone.
Henpicked: What are some of the treatments?
Dr Abbie Laing: Symptoms of endometriosis can be helped by using hormone treatments such as the progesterone-only pill or injection, or the combined contraceptive pill in eligible women. For many women the mirena coil can significantly improve symptoms.
If symptoms are severe, sometimes GnRH analogues are recommended by Gynaecologists. These are injections that switch the ovaries off, which is called a chemical menopause and usually add back HRT is given. This takes out cyclical hormones which is why this treatment can be helpful. GnRH analogues are sometimes used before a person has surgery to have their ovaries removed.
There are simple options available to help with pain relief. This includes mefenamic acid which can reduce prostaglandin production at the time of menstruation. Prostaglandins have been associated with pain. Tranexamic acid can also be considered which can be helpful to reduce bleeding.
Henpicked: What’s the difference between endometriosis and adenomyosis?
Dr Abbie Laing: Endometriosis is endometrium-like tissue that is in the wrong place, meaning it is outside the womb. Adenomyosis is endometrium that has had grown into the womb muscle itself. This can thicken the womb muscle and make it more bulky which can cause heavier and more painful periods. Adenomyosis is easier to identify on an ultrasound scan.
Henpicked: Can endometriosis affect fertility?
Dr Abbie Laing: Not everybody who has endometriosis will have reduced fertility. However endometriosis is associated with more fertility problems. The mechanisms linking endometriosis and reduced fertility are poorly understood, and there is not causation, however severe disease might affect the health of the ovaries and fallopian tubes for example by causing tubal adhesions.
If a person is trying to conceive they will also need to stop taking their hormonal contraception which can sometimes cause more pain and subsequent problems, given these help endometriosis and are treatments for it.
Henpicked: Finally, how many people have endometriosis?
Dr Abbie Laing: 1:10 women of reproductive age have endometriosis which means it is not that uncommon. A woman can feel really alone with their symptoms of endometriosis and it can help to talk about it, the chances are that there is some else they know who also has it.
