This information package is designed for general information and is not a substitute for a medical opinion. It will help you to make an informed decision after you have discussed your options with your doctor and a tailor-made care plan has been formulated.

What is endometriosis?
The uterus (womb) has a cavity in which a baby grows. Part of this lining (called endometrium) is shed every month and results in menstruation (a period). When this lining grows outside the uterus, we call it endometriosis. One in ten women (10%) of menstruating age have endometriosis, so it is considered common. It can occur from the age of puberty to beyond the menopause as well.

 

Although the exact cause of endometriosis is still unknown, there are a number of theories about how it develops. It is believed that a number of causes exist together to cause this disease.

The most likely explanation is that cells lining the tummy change into the type of cell that line the uterus. Some endometriosis probably results from menstrual fluid flowing backwards through the fallopian tubes and deposits in the tummy. There is a genetic component to endometriosis and women who have a mother or sister with endometriosis, are more likely to have it as well. There is a change in the immune system in women with endometriosis. Most women have a natural defense which gets rid of menstrual fluid in the tummy. Women with endometriosis have a reduced ability to clear it or to prevent its growth once it has settled on the lining of the tummy. The hormone oestrogen produced by the ovaries is also required to grow endometriosis. That is why after the menopause when the ovaries stop functioning and the oestrogen becomes very low, usually the pain with endometriosis settles down.

This is the most common pain with endometriosis. Period pain usually starts with the first time a woman has her periods. In many women period pain may start after many years of having fairly pain-free periods. These women particularly are likely to have endometriosis. However one needs to remember that about 70% of women in the world have period pain that is normal without any underlying reason except that they are having periods. A woman may not have any pain despite quite advanced endometriosis. She may see her doctor because she cannot get pregnant. The severity of endometriosis often does not correlate with the severity of pain. Women with little endometriosis may have a lot of pain or they may have a great deal of endometriosis and not much pain at all.

If there is endometriosis on the vagina and forms scar tissue, it can be painful during sex because the vagina cannot stretch. Pain may also occur due to nerves being involved in that area. Pain can particularly be painful when vaginal intercourse occurs just prior to periods (or during periods if vaginal intercourse occurs during that time).

Pain that occurs when a woman opens her bowels is usually an indication of advanced endometriosis. Endometriosis would involve the wall of the bowel or may just cover the space between the uterus, vagina and bowel. This area is called the pouch of Douglas and basically is the area a woman sits on, that is, the bottom of the tummy. Here is a diagram and a photo of this area.

A gynaecological examination by your doctor is very important. Your GP or gynaecologist would have a feel of your tummy, and then examine the vagina with a speculum. This is the instrument used to take a Pap smear. A vaginal examination is then performed which may reveal an area of tenderness. The doctor may also feel some nodularity in the vagina which would indicate scar tissue behind the vagina or on the bowel.

The only abnormality an ultrasound would pick up is a cyst of endometriosis in the ovaries. This is called a ?chocolate cyst? because it is filled with old blood that looks like melted chocolate.  When we see chocolate cysts in the ovaries, it usually means advanced endometriosis. In general these cysts develop once endometriosis has grown in a lot of areas of the tummy already.

Laparoscopy is the only way we can make a definite diagnosis of endometriosis. This is also called ?keyhole surgery? which is done under general anaesthetic in hospital. Very small cuts (half a centimeter) are made in the tummy and a laparoscope (this is like a telescope) is inserted through the belly button. The laparoscope is connected to a camera and television, so the surgeon can visualize all the gynaecological organs.

 

The peritoneum is the lining of the pelvic organs. Endometriosis most commonly affects the peritoneum.

 

A cyst of endometriosis in the ovary is called a ?chocolate cyst? because it is filled with old blood that looks like melted chocolate. The medical word for it is endometrioma. Here is an example of an endometrioma.

 

  Click to view Image Endometriosis of right pelvic sidewall extending underneath ovary. Right ovary densely attached to sidewall.

 

When endometriosis affects the vagina, women often feel pain during sex. This occurs because scar tissue prevents the vagina from stretching or because nerves are affected by endometriosis. The rectum is the lowest part of the bowel behind the anus. The anus is where one opens the bowels. When endometriosis affects the bowel, women have pain with sex and on opening bowels. Rarely bleeding from the anus may occur during periods. Here is an example of endometriosis affecting the rectum and vagina.

 

 

Endometriosis often affects the lining over the bladder. Rarely it can go deeper into the muscle of the bladder and cause pain when a women passes urine or there may be blood in the urine. Here is an example of endometriosis affecting the lining over the bladder.

 

Rarely a women may have endometriosis in the lining underneath the ribs higher up in the tummy. This can cause pain in the upper tummy during periods. Here is an example of endometriosis below the ribcage on the right.

 

Endometriosis is commonly associated with infertility. About 30% of women requiring IVF infertility treatment (in vitro fertilization or ?test tube babies?) have endometriosis. It is important to find out about endometriosis early , so it can be treated and infertility is
prevented or minimized.
 A woman may decide to take the pill for pain control rather than opt for a laparoscopy because a laparoscopy is an operation with associated risks and she does not want to go down that path.
 

 

Fibroids are the most common benign (non-cancerous) growth of muscle and fibrous tissue that grow in the uterus and form a hard ball shaped mass.

Fibroids that grow inside the cavity of the uterus usually cause the most problems with heavy bleeding. Fortunately they are also the easiest to remove. Fibroids that are on the outside of the uterus, on the other hand, rarely cause a problem.

Fibroids shrink after the menopause when the ovaries stop producing the hormone oestrogen. Fibroids are more common in obese and African women.

The possibility of cancer in a fibroid is very small. This occurs in only about 7 out of 1000 fibroids. This increases as a woman gets older and the risk doubles if a woman is postmenopausal. The small risk of cancer does not justify surgery or a hysterectomy for all women with fibroids. However, unexplained rapid enlargement of a fibroid, particularly in a postmenopausal woman, raises the possibility of cancer and surgery is needed.
 

There are three main problems fibroids can cause :

 

Fibroids, especially those that are inside the cavity, can cause heavy periods or bleeding outside periods.

 

If a fibroid is large, it can press on the bladder and cause urgency to pass urine or discomfort when voiding. Pressure on the bowel can rarely cause constipation. A fibroid can also press on the ureter (tube that connects the kidney to the bladder) and cause obstruction to the kidney.

 

Large fibroids inside the uterine cavity can interfere with getting pregnant or result in miscarriage.

 

Fibroids are usually painless. Rarely when the blood going the fibroid is not enough for its size and growth, the centre of the fibroid goes soft which then can cause pain.

 

A fibroid may become so big to cause a large swelling in the tummy and a woman may look pregnant.

Most fibroids do not cause any problems to a woman and hence can be left alone. Your doctor will probably monitor growth of the fibroid(s) with a physical examination by your doctor and an ultrasound at a specified time, usually in 6-12 months.

 

If a fibroid causes any of the above problems, treatment would be required.

 

Fibroids are not removed and a physical examination and / or ultrasound are done in 6-12 months to check for growth. It is important to note that fibroid surgery in itself can in some cases cause infertility because adhesions occur in the tummy and the tubes can become blocked.

If the fibroid is inside the uterine cavity (submucosal), it can be removed by hysteroscopy as a day procedure. Please see section under ?hysteroscopy? for further information. This involves inserting a telescope-like instrument from between the legs into
the vagina and uterus. The fibroid is then cut out.

This means the fibroid is cut out of the uterus and the uterus is left intact. This is done laparoscopically or with an open procedure, depending on the size and position of the fibroid(s). This would usually mean that deliveries of children would need to be done by caesarean sections. The reason is that a scar would form in the uterus where a cut was made to remove the fibroid(s) and there is a small risk of this scar opening up if the uterus was allowed to contract with normal labour pains.

 

Because cuts are made into the uterus, some bleeding occurs during the operation. A blood transfusion may be required and there is a small risk of needing a hysterectomy during a myomectomy to stop heavy bleeding.

 

This is a day procedure which is performed by interventional radiologists. They are doctors who specialize in ultrasounds, X-rays, CTs, MRI scans etc. Local anaesthetic is given in the groin and a very small cut is made in the skin. A catheter (small tube) is then inserted into the femoral artery and fed upwards until the uterine artery is reached. The uterine artery is the blood vessel that gives blood to the uterus. The uterine arteries are then blocked off by putting a material in it. The fibroid(s) then also will not get any further blood and shrink. It is usually painful afterwards and women need admission to the ward for pain management.

 

Uterine artery embolization is associated with a 4% risk of ovarian failure. That means that in 4 out of 100 women who have this procedure done, the ovaries will stop functioning and early menopause will happen. Therefore this option is really only for women who have completed childbearing and are in their late forties and older.

Hysterectomy means removal of the uterus. That means a woman will not have periods anymore and she will not be able to have any more children. Hysterectomy is therefore reserved for those women who have completed their family and despite more conservative treatments, continue to have problems from the fibroids. Hysterectomy is a good option if fibroids are large and / or involve the cervix. The cervix is the opening part of the uterus which is at the top of the vagina. When a fibroid involves the cervix, it may not be possible to remove the fibroid and leave the uterus because of its position.

It is not uncommon to be pregnant and have fibroids in the uterus because fibroids are so common. About 20% of fibroids enlarge during pregnancy, 20% decrease in size, and 60% remain unchanged.

 

Fibroids will never squash or deform a baby inside the uterus. Most pregnancies in the presence of fibroid will proceed without any problems.

 

Some of the problems a fibroid can cause with pregnancy and delivery are :

If a fibroid outgrows its blood supply, a part of the fibroid dies and becomes soft. This can cause pain which is treated with non steroidal anti-inflammatory tablets such as Nurufen, Naprogesic, Brufen etc.

If the fibroid is large enough and in the lower part of the uterus, the baby may not be lying head first but with its bottom first or lie sideways because they are better fits for the baby in the uterus.

Again if the fibroid is large enough and in the lower part of the uterus, the cervix may not open up normally during labour and the baby would need to be delivered by a caesarean section.

Fibroids may prevent the uterus to shrink after delivery of the baby, and bleeding can result. This may require a blood transfusion and further intervention to stop the bleeding.

 

 

 

A Pap smear is a screening test to see if abnormal changes are present in the cervix of the uterus. The cervix is the lowest part of the uterus which can be seen at the top of the vagina.

Your doctor inserts a speculum into the vagina so that the cervix can be visualized and a scraping of the cells from the cervix is taken with a little brush. The scrapings are then prepared on a microscope glass slide and also placed into a vial of preparation fluid (Thin Prep). These are then sent to a pathologist who looks at the specimens under a microscope.

 

If the cells are abnormal, your GP or gynaecologist will explain the result to you. Dr Varol will also give you a pamphlet for your reading. Abnormal cells are precancerous and some abnormalities may need treatment to be removed, so cervical cancer does not develop.

 

Every women should have a routine Pap smear every two years, so precancerous abnormalities can be detected early and treated, if necessary. Precancerous abnormalities usually do not cause any pain or other physical symptoms, so a Pap smear by your doctor is the only way to find out whether everything is ok or not.

The important abnormality of the cells is called dysplasia which is not cancer, but can develop into cancer over a long but unpredictable period of time. Abnormalities on Pap smear are graded and classified as low or high grade. The precancerous changes involve only cells in the surface layer of the cervix.

Pap smear results are reported as low or high grade abnormalities, CIN (cervical intraepithelial neoplasia) or dysplasia. Intraepithelial means ?within the tissue? and neoplasia ?new growth of abnormal cells?. They all describe changes of the cervix which may develop into cancer. The more severe the abnormality, the less likely it is to go away and the more likely it is to get worse and become cancer. So treatment is necessary for the more severe abnormalities to prevent cancer of the cervix from happening. The table below shows these terms.

 

These minor changes seen in a Pap smear are usually due to tissue inflammation, the human papilloma virus, or other infections such as bacteria, yeast (?thrush?) etc. Usually this Pap smear goes back to normal by itself and needs to be repeated in 12 months. It is very important that you come back for your Pap smear in 12 months.

 

If the abnormality persists, you will advised to have an examination called colposcopy see under heading ?colposcopy?

CIN 1 falls into the low grade abnormality category, whilst CIN 2 and 3 into the high grade group. In about 60% of women with CIN 1 this abnormality will disappear by itself. In the remaining 40%, CIN 1 will persist or become a higher grade. Your doctor will advise you whether you just need another Pap smear in 6 months to see if the abnormality has gone, or you may need to have a colposcopy and biopsy by your gynaecologist.

 

CIN 2 and 3 mean that the precancerous abnormalities are high grade. These abnormalities require treatment to remove the abnormal cells. Depending on your doctor"s examination findings with the microscope (colposcopy) and the biopsy of the cervix, some women with CIN 2 may have the conservative option to repeat all the investigations again in four to six months.

If a minor abnormality persists with repeat Pap smears or if a high grade abnormality is present, an examination called colposcopy is needed. The gynaecologist will insert a speculum into the vagina so the cervix can be seen. He/she then looks at the cervix with a colposcope which is a magnifying instrument similar to pair of binoculars on a stand and a light attached. The colposcope itself does not enter the vagina. The cervix is then painted with a solution called acetic acid (dilute vinegar) and the doctor looks for abnormal cells.

This examination takes 10-15 minutes and is not a painful procedure. Some women experience discomfort from having the speculum in the vagina.

Your doctor may need to take a very small sample of tissue from the abnormal part of the cervix. This is called a biopsy. A special solution is then applied to the biopsy site to stop bleeding. You may experience some pain or discomfort similar to menstrual cramping. After the biopsy you may have slight vaginal bleeding and a vaginal discharge for up to a week. Avoid vaginal intercourse, tampons, swimming and baths (shower instead) for a week to allow the cervix to heal.

The precancerous abnormalities are caused by the Human Papilloma Virus (HPV), also called wart virus, and cigarette smoking. HPV is similar to the virus which causes warts on other parts of the body, such as the hands and feet. HPV is part of being sexually active and most men and women who are sexually active, do have HPV. In the vast majority of people, HPV infection is transient and harmless and the body"s immune system clears it within about two years.

 

So if the Pap smear just shows HPV only, then no further treatment is necessary. However, in some women persistent infection with some types of HPV causes precancerous abnormalities on the cervix. The doctor would then recommend a colposcopy and biopsy.

 

The tobacco in cigarettes has been shown to cause precancerous abnormalities on the cervix and cervical cancer. So if a woman smokes and has an abnormal Pap smear, she should very seriously consider stopping smoking.

If the results of the colposcopy and cervical biopsy show a high grade abnormality, treatment is required to remove the abnormal cells. There are several methods to remove the abnormal area of the cervix which depends on the type and severity of the abnormal cells and the gynaecologist"s preference.

In this method, the abnormal cells are scooped from the cervix with a wire loop.

 

A local anaesthetic is needed and the procedure takes 15 to 30 minutes and is performed in a day procedure centre, doctor"s surgery or hospital outpatient department. A bloody brown, or black discharge will be present for up to four weeks after the procedure. Some mild tummy cramps or pain may persist for a day or two afterwards as well. Most women can return to work within two or three days after the procedure.

 

The abnormal part of the cervix that has been removed is then sent to the pathologist

who :

For a cone biopsy a cone-shaped section of the cervix containing the abnormal cells is removed.

 

This usually requires a general anaesthetic and a day hospital stay. A cone biopsy is donewhen :

No, treatment does not cause infertility. However, there is a slightly increased risk of cervical incompetence with a cone biopsy and loop excision. Cervical incompetence means that the cervix does not stay closed during pregnancy and can open up, resulting in a miscarriage in the mid trimester of pregnancy, that is, between about 3 to 6 months of pregnancy. If it is recognized in time, the obstetrician would place a stitch into the cervix under a general anaesthetic in the operating theatre. The stitch is removed when it is time to deliver the baby.

 

Another complication can occur called cervical stenosis. This means scar tissue has formed in the cervix and it has become closed off. Menstrual fluid cannot flow into the vagina and tummy pain may occur. The gynaecologist would need to dilate the cervix in the operating theatre under a light anaesthetic.

Following treatment to remove the abnormal cells of the cervix, bleeding and infection may occur. This may require antibiotics through a drip in the arm and admission in hospital. For the bleeding the doctor may place a tissue pack into the vagina to keep pressure on the cervix for about 24 hours. Alternatively a suture may be needed in the cervix in the operating theatre.

 

Cervical incompetence and stenosis have been explained above.

Follow-up depends on the abnormality and your doctor will formulate a plan with you. You may need to come back in six or 12 months for a low grade abnormality. Following treatment for a high grade abnormality, follow-up is usually at four to six monthly intervals initially, then yearly until two consecutive Pap smears, colposcopy and HPV tests are negative (normal).