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Endometriosis refers to when tissues similar to that of Endometrial cells grow aberrantly and outside of the uterus. These lesions are estrogen-dependent, benign, inflammatory, stem-cell-driven, and at times progressive.

Endometriosis is a whole-body disease. It is a chronic condition associated with severe and life-impacting pain during periods, sexual intercourse, bowel movements, and/or urination, chronic pelvic pain, abdominal bloating, nausea, fatigue, as well as depression, anxiety, and infertility. Aside from these effects, the condition has a far-reaching influence on multiple organ systems of the body. Many complications such as cardiovascular disease and ovarian, breast, cervical, and endometrial cancer, alongside autoimmune disorders, and more are related to endometriosis.

Endometriosis affects 1 in 10 people assigned female at birth. That is more than 200 million people worldwide. For a condition that’s so widespread, it shockingly takes an average of seven and a half years for patients to receive a diagnosis.

Endometriosis can be symptomatic or asymptomatic. Those who have experienced symptoms have reported effects such as:
  • Dysmenorrhea These are painful periods characterized by dull pain in the hypogastrium, iliac fossae, sides, or lower back. It is frequently associated with menorrhagia or heavy periods.
  • Dyspareunia Pain during sexual intercourse is deep dyspareunia. These are ballistic dyspareunia triggered by deep penetration, generally in the posterior group.
  • Digestive Symptoms Digestive symptoms associated with menstruation are varied and non-specific. Pain during defecation or distension of the rectum is sometimes increased during menstruation suggesting endometriosis. The rectum or sigmoid colon in particular together represents 2/3rd of digestive disorders.
  • Urinary Symptoms Catamenial Cystalgia, daytime and nocturnal frequent urination, and the impression of regularly having urinary infection during menstruation are grounds for looking for deep endometriosis of the bladder. The nodules of deep endometriosis can infiltrate or even envelop the ureters resulting in episodes of back pain, but most often these lesions are asymptomatic for a long time. They may lead to stenosis of the ureter or even to ureteral and pyelocaliceal dilation upstream, complicated in extreme cases by low-level renal atrophy and complete destruction of the kidney.
  • Intermenstrual Pain Often associated with advanced endometriosis, intra-abdominal adhesions and neuropathic mechanisms, these can lead to chronic pain that is resistant to usual analgesic drugs. These pains occur in between periods.
  • Other Catamenial Symptoms Cyclic pain and is concomitant with menstruation may suggest endometriosis. These are scapular or thoracic pain, pain in the buttocks, perineum or sciatica, catamenial dysuria and episodes of catamenial pneumothorax.
  • Infertility Endometriosis is a risk factor for infertility and is found in 1/3rd of people assigned female at birth seeking treatment for infertility for more than a year.

Endometriosis is usually classified into four stages – I, II, III & IV with increasing severity. Minimal, mild, moderate and severe respectively. This widely followed classification had been given by American Society of Reproductive Medicine (ASRM), with criteria based on the location of the disease,the extent and depth of endometriosis implants, the presence and size of ovarian endometriomas, and the presence of severity of adhesions.

  • Drawbacks of this classification

The classification had been developed in 1973 and had been revised multiple times. The stages of endometriosis are graded on a point system to determine classification. A score of 1-15 indicates minimal or mild endometriosis, while a score of 16 or higher indicates moderate to severe endometriosis.

The scoring and stage of the endometriosis have no specific correlation with any symptoms. It is not indicative of the level of pain the patient experiences. Instead, the system was developed as an indicator of endometriosis-associated infertility.

  • The Enzian Classification of Endometriosis

To overcome the above limitations, a comprehensive classification system for a complete mapping of endometriosis, including anatomical location, size of the lesions, adhesions, and degree of involvement of the adjacent organs can be used with both diagnostic and surgical methods has been developed through a consensus process.

  • This classification uses compartments to classify the disease

A – Vagina, rectovaginal space (RVS).

B – Utersacral ligaments (USL).

C – Rectum.

F – Far locations like urinary bladder (UB), Uterus (FU) and extragenital lesions (FO).

P – Peritoneum

O – Ovary

Other intestinal locations include the sigmoid colon, small bowel as well as adhesions, involving the tubo-ovarian unit (T) and optionally tubal patency.

Endometriosis is one of the most underdiagnosed, misdiagnosed, and mistreated diseases with an average of seven and a half years of diagnosis period from the onset of symptoms. That is a very long wait for the reported 176+ million people that are reported to be suffering from this disease, 25+ million of them here in India.

The first step to receiving successful treatment is a proper diagnosis. And so it is imperative to find an endometriosis surgeon who is an expert and experienced to deal with the medical condition. This includes using of techniques such as Sonography, MRI, and Laparoscopy along with the physical exam.

Symptoms like painful periods, dyspareunia, gastrointestinal distress, painful bowel movements, and diarrhea are good indicators of Endometriosis. A surgeon should have a keen eye and should be knowledgeable about them. More importantly, they should be patient and compassionate.

Steps to diagnose endometriosis

  • Diagnosing endometriosis requires diagnostic evaluation during pre-surgery and during the surgery.
  • First, initial testing including pelvic exam and ultrasound is done. This is the time when you share your symptoms with the doctor and the doctor figures out a recovery plan. A physical examination can indicate the presence of endometriosis in the cervix, pelvic side, and posterior thigh tenderness, which can radiate as far back to the cervix at the rectal wall. Ultrasound/sonogram technology can help confirm the cause of this tenderness. A rectal exam might be necessary to detect diffuse pelvic tenderness and to determine localized rectovaginal tenderness.
  • Second, laparoscopy is the gold standard for the diagnosis of endometriosis. It is a minimally invasive technique where a small incision is made for the laparoscope to go in and detect the lesions. The excision surgery is performed then and there eliminating prolonged pain.
  • Many patients diagnosed with endometriosis undergo multiple surgeries, only for their symptoms to return. Often the reason for this is because the surgeon has left behind a considerable amount of scar tissue. Choosing an experienced surgeon with the right amount of expertise is the key to relief.

Laparoscopy remains the gold standard for the diagnosis and treatment of Endometriosis. Incomplete surgeries often lead to the persistence of disease and symptoms. Choose your surgeon wisely!