Endometriosis: a Singaporean Gynaecologist explains

Endometriosis: a Singaporean Gynaecologist explains undefined
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Did you know that Endometriosis is the leading cause of infertility in Singaporean women? This is also the case everywhere else, with 50% of all infertile women around the world suffering the condition [1].

Endometriosis is one of the most common gynaecological conditions. Globally, it affects 22% of all women [2].

You might have seen this disease mentioned in my hysterectomy article. This time around, I am going to focus fully on explaining all you need to know about Endometriosis and its management in Singapore.

Also read: Hysterectomy: All You Need to Know with a Singaporean Gynaecologist

Read on to find out more!

What is endometriosis?

endometriosis

Endometriosis is a common medical condition where an endometrium-like tissue grows outside the uterus. The endometrium itself refers to the layer that lines the walls of the uterus. This is the layer that breaks down and is shed each month during your period.

This external growth is most commonly found around the pelvis, especially:

  • Ovaries
  • Fallopian tubes
  • The surface of the uterus
  • Pouch of Douglas (the space behind the uterus)
  • Bowel
  • Bladder and ureters
  • Rectum

Very rarely, they can also be found in other areas such as the lungs, brain, and skin [3].

They are classified into four different stages:

  • Stage 1: Minimal
  • Stage 2: Mild
  • Stage 3: Moderate
  • Stage 4: Severe

Note that for endometriosis, the stages have no relation to the amount of pain or discomfort. There are multiple ways endometriosis may appear and cause a problem. Someone with stage 1 can feel more pain than another person with stage 4 endometriosis.

This classification of endometriosis is based on the tissues’: [4]

  • Location
  • Amount
  • Depth
  • Size

They can cause chronic pain

why-is-external-growth-problematic

The tissue is endometrium-like in how they respond to hormonal changes during your period. They can break down and cause bleeding in the pelvis. This pool of blood causes inflammation and build-up of scar tissue called adhesion. They can bind organs together and cause pelvic pain.

When these tissues appear in the ovaries, they can also form cysts [4].

They are non-cancerous and also non-contagious. Even so, they can cause great discomfort to affected patients. Endometriosis is highly associated with chronic pelvic pain [2].

Who are at risk of endometriosis?

risk-factors-of-endometriosis

Though we do not know the exact cause of endometriosis, we know that it is related to changing hormone levels. This is why endometriosis is more common in women of child-bearing age [2]. This refers to women in their 20s – 40s.

That said, endometriosis can be found in any female after their first menstruation. I have seen patients across a range of ages suffering the condition. Though uncommon, I have also met teens with endometriosis. Unfortunately, diagnosis may be very hard as painful and irregular menstruation are normal characteristics of the first few cycles [5].

You might have a higher chance of developing the condition if you have: [6]

  • Never given birth
  • Family history of endometriosis, especially in your immediate family
  • Gynaecological abnormality (blocked vagina, deformed uterus, etc.)
  • Asian [7] or Caucasian [8] ancestry

Symptoms of endometriosis

symptoms-of-endometriosis

The experience might be different in every woman. Common symptoms are: [9]

  • Heavy, painful, and/or irregular periods
  • Pain during sex, especially during penetration
  • Constant pelvic pain in between periods
  • Bowel and urinary problems
  • Blood in the urine (haematuria) and stool during monthly periods
  • Infertility

Often times, the pain caused by endometriosis may also affect women’s mental well-being [10].

There might also be blood in the lungs during your periods if endometriosis tissue is found there. Though uncommon, some women may also cough blood because of this.

Remember, this might not be your case! Endometriosis may show other symptoms and at times, they can also present no symptoms at all.

You might realize that the symptoms mentioned above are very similar to other gynaecological diseases. They are also similar to the symptoms of appendicitis. This is why endometriosis is often undiagnosed or misdiagnosed.

If you experience any symptoms, it would be best to visit your doctor as soon as possible!

How is endometriosis diagnosed?

diagnostic-test-most-commonly-used-in-singapore

The first step is always a consultation with your gynaecologist. If your doctor suspects the condition, they may recommend one of the following tests: [1]

  • Pelvic (transvaginal) ultrasound scan
  • Detailed vaginal and rectal examination
  • CT scan or Magnetic Resonance Imaging (MRI)
  • Blood test (Ca125)
  • Laparoscopy

Above is just a list of diagnostic tests commonly used in Singapore. Depending on your condition, gynaecologists may use either one or a combination of the tests. To know exactly which ones you need, do consult your doctor!

Infertility

untreated-endometriosis-could-lead-to

About 20-50% of infertile women have endometriosis. Research has also found that 30-50% of women with endometriosis have difficulties in becoming pregnant [10].

Infertility can be caused by a lot of different factors. It could be in the male, the female, or in both. As a general guide, you should seek a doctor if you are unable to conceive after:

  • 1 year of regular intercourse for women under 35 years old
  • 6 months of regular intercourse for women above 35 years old

The longer endometriosis is left untreated, the worse its symptoms may be. On top of that, endometriosis is also known to have a high recurrence rate.

The build-up of endometrium-like tissue can:

  • Block fallopian tubes
  • Form cysts that damage the ovaries and uterus

This is a huge concern as scarring in the fallopian tubes accounts for 30% of women infertility cases. Ovulation problems account for another 20% [11]. You should note that even though a link between endometriosis and infertility has been established, we still do not understand the complete cause and effect relationship.

Surgical treatments may increase the chances of pregnancy. However, they do not cure the underlying condition. Your doctor can also prescribe oral medications and hormonal therapies to prevent recurrences.

You can read on to find out more!

Pregnancy & breastfeeding

managing-the-symptoms

For some women, being pregnant can help manage the symptoms of endometriosis. This is because pregnancy suppresses the hormones that trigger the menstrual cycle. It is important to note that this does not cure the disease. Symptoms may or may not recur after the birth of the child.

I would generally advise women with endometriosis not to delay having children. This is because the symptoms tend to worsen over time. The longer you wait, the harder it may be for you to conceive.

If you have problems conceiving, you might have to get surgical treatments. A study found that laparoscopic ablation can significantly improve live birth rates [12]. However, you should note that pregnancy rates are highest within a year of the surgery. Unfortunately, endometriosis tends to recur regardless of surgical treatment.

Does breastfeeding help manage endometriosis?

Most women can delay the recurrence of symptoms by breastfeeding. However, this is only when you breastfeed frequent and intense enough to stop your menstrual cycle.

A study found that women who breastfed were at a significantly decreased risk of endometriosis compared to women who do not. This is true for 5 years after giving birth [13].

The same study also states that breastfeeding for a longer term can decrease the risk of endometriosis recurrence. This is because the longer you breastfeed, the longer you might stop your menstrual cycle.

Non-surgical treatments for endometriosis

non-surgical-treatments-for-endometriosis

Currently, there is no cure for endometriosis. However, there are medications and therapies you can take to help manage the symptoms.

Treatments are aimed to:

  • Relief pain
  • Prevent recurrences
  • Suppress the development of endometriosis tissue
  • Treat infertility

The first line of treatment is usually non-surgical [14]. They come in the form of:

  • Pain Medication

    Anti-inflammatory drugs (NSAIDs) can help with menstrual cramps and chronic pelvic pain. If you are taking over-the-counter painkillers, remember to declare them when you consult a doctor.

  • Hormonal Therapies

    They help relieve pain by suppressing the hormones related to the menstrual cycle. They decrease your menstrual blood flow by limiting the thickness of the endometrium. Along with that, they also decrease the growth of endometriosis tissues.

    Examples of hormonal therapies include:

    • Combine oral contraception pill (Yaz, Yasmin)
    • Intrauterine contraception (Mirena)
    • Depot progesterone injections (Depo-Provera)
    • Oral progesterone (Visanne)
    • Gonadotropin-releasing hormone (GnRH) agonists (Lucrin, Zoladex)
    • Danazol

    Though these can effectively relieve pain, they also limit fertility. If you are planning to have children, you might have to find other alternatives. You should always consult your doctor to find which one is most suitable for you!

Surgical treatments to improve fertility

surgical-treatments

Surgical treatments should only be taken if non-surgical medical treatments have failed. You might also need surgery to treat:

  • Infertility
  • Severe chronic pain
  • Enlarged cyst

Surgical treatments can remove endometriotic lesions, ovarian cysts, scar tissue (adhesions), and also visible endometriosis tissue. On top of providing significant pain relief, they can also improve fertility.

Generally, women with no fertility problems have an 84% chance of getting pregnant within one year of unprotected sexual intercourse. For women with endometriosis, the chance decreases to 30-50% [10]. This may be different in all patients, depending on the severity and location of their endometriosis.

A study found that after the surgical procedure, there is a significant increase in chances of pregnancy: [15]

  • For patients with mild endometriosis, the chances improve to:
    • 81% with laparoscopy
    • 84% with laparotomy
  • For patients with moderate or severe endometriosis, the chances improve to:
    • 54-66% with laparoscopy
    • 36-45% with laparotomy

This is not accounting for other factors such as sperm quality, egg quality, and whether or not the women ovulate in the first place.

Currently, laparoscopic (key-hole) surgery is much more common. This is because they are: 

  • Less invasive
  • Have rapid recovery time

In any case, always consult your doctor! Endometriosis may present differently in each person. The most effective treatment is always one that is individualised to you.

What to expect after the surgery?

Most women report:

  • Significant improvement in their pelvic pain
  • Better regulated menstruation
  • Improvement in fertility rates

What are the risk factors?

The procedure itself is generally safe. Though uncommon, some high-risk factors include bowel, bladder, ureteric, and blood vessel injury.

The most common side-effect is, unfortunately, the recurrence of symptoms. However, this risk should remain generally low with post-operative hormonal treatments.

Other risk factors include:

  • Tender skin
  • Wound infection

but in most cases, they resolve within a few days.

If you feel any prolonged discomfort or persisting pain after the surgery, it would be best to contact your doctor immediately.

Definitive surgical treatment

complex-surgeries-for-endometriosis

For some women, the pain might be so severe that they require more complex surgeries. These might include:

  • Cystectomy (removal of ovarian cyst)
  • Hysterectomy (surgical removal of the uterus)
  • Oophorectomy (surgical removal of the ovaries)
  • Or both hysterectomy and oophorectomy

A study has shown that women who only had a hysterectomy have a higher risk of pain recurrence as compared to women who had both procedures. They also have a higher chance of needing a second surgery [16].

However, it is important to note that when the ovaries are removed, women would no longer be able to conceive. They would also experience menopause (surgical menopause). The symptoms of menopause will also start within a few days of the surgery. 

On top of that, there are other surgical risks, both physical and psychological. You can find out more about that in my hysterectomy article.

Also read: Hysterectomy: All You Need to Know with a Singaporean Gynaecologist

If you are searching for treatment, it is always best to consult a doctor. Through a medical consultation and health screening, your doctor would be able to propose the most effective treatment that is specific to you.

Bottom line is, always do research to find out about all the available treatments! You should understand and discuss all the pros and cons of a certain treatment with your doctor before giving consent.

Women's mental well-being

mental-well-being-of-women-with-endometriosis

Even with oral medication, surgeries, and therapies, it could be quite devasting to know that the condition has no real cure. That outlook and the chronic pain it caused can really impact a woman’s mental well-being.

Research has shown that women report: [17]

  • Anxiety
  • Depression
  • Loss of focus and concentration
  • Limitations in social life
  • Overall poor quality of life

Some young girls with severe symptoms may also have to take time off school or sports to manage the condition. For that reason, endometriosis can affect their overall performance.

It is important to note that your psychological stress might trigger more pain. For that reason, it is quite important to take care of your mental well-being on top of medical treatments! They are as important as managing your physical pain. You can always consult your doctor for help.

There are support groups in Singapore that help endometriosis patients deal with their condition. Certain clinics also offer professional mental health services specific to endometriosis patients.


I wrote this article to help you understand more about endometriosis. It is a common gynaecological condition and its treatment can be quite complex.

I certainly help this helps your research! If you have any symptoms or discomfort around your pelvic area, it is best to consult a doctor as soon as possible. Be it endometriosis or under gynaecological conditions, it is best to diagnose and treat them early!


Dr Christopher Ng is a gynaecologist with GynaeMD Women's & Rejuvenation Clinic. He is accredited to perform Level 3 laparoscopic (minimally invasive) surgeries on top of general gynaecology surgeries. He also performs surgery for urinary incontinence and uterovaginal prolapse.

Read more of Dr Christopher Ng's QnA here.

 

Would you like to ask any related health questions? 

You can Ask A Doctor right away, or request for treatment quotes from doctors.

References

1. Academy of Medicine Singapore, Ministry of Health Singapore. Assessment and Management of Infertility at Primary Healthcare Level AMS-MOH Clinical Practice Guidelines 1/2013.; 2013. Accessed August 22, 2019.

2. Fong YF, Agarwal A. Cutaneous Endometriosis.; 2008. Accessed August 22, 2019.

3. Giudice LC. Endometriosis. New England Journal of Medicine. 2010;362(25):2389-2398. doi:10.1056/nejmcp1000274

4. Johns Hopkins Medicine. Endometriosis. hopkinsmedicine.org. Accessed August 22, 2019. 

5. Endometriosis UK. Endometriosis information for teenage girls. endometriosis-uk.org. Accessed August 23, 2019.

6. Ministry of Health Singapore. Endometriosis. Health Hub. Published 2019. Accessed August 23, 2019.

7. Arumugam K, Templeton AA. Endometriosis and Race. The Australian and New Zealand Journal of Obstetrics and Gynaecology. 1992;32(2):164-165. doi:10.1111/j.1479-828x.1992.tb01932.x

8. Bougie O, Yap M., Sikora L, Flaxman T, Singh S. Influence of race/ethnicity on prevalence and presentation of endometriosis: a systematic review and meta‐analysis. BJOG: An International Journal of Obstetrics & Gynaecology. April 2019. doi:10.1111/1471-0528.15692

9. Mayo Clinic Staff. Endometriosis - Symptoms and causes. Mayo Clinic. Published 2019. Accessed August 23, 2019.

10. Bulletti C, Coccia ME, Battistoni S, Borini A. Endometriosis and infertility. Journal of Assisted Reproduction and Genetics. 2010;27(8):441-447. doi:10.1007/s10815-010-9436-1

11. Harvard Health Publishing. Female Infertility - Harvard Health. Harvard Health. Published May 2009. Accessed August 26, 2019.

12. The Practice Committee of the American Society for Reproductive Medicine. Endometriosis and infertility. November 2006. doi:10.1016/j.fertnstert.2006.08.014

13. A Prospective Study of Endometriosis and Breast Health: Findings From the Nurses’ Health Study II.

14. NHS Choices. Treatment-Endometriosis. Published 2019. Accessed August 27, 2019.

15. The Women’s Health Council. Infertility Treatments for Women A Review of the Bio-Medical Evidence Full Report.; 2009. Accessed August 27, 2019.

16. Namnoum AB, Hickman TN, Goodman SB, Gehlbach DL, Rock JA. Incidence of symptom recurrence after hysterectomy for endometriosis*. Fertility and Sterility. 1995;64(5):898-902. doi:10.1016/s0015-0282(16)57899-6

17. Laganà AS, La Rosa VL, Rapisarda AMC, et al. Anxiety and depression in patients with endometriosis: impact and management challenges. International Journal of Women’s Health. 2017;Volume 9:323-330. doi:10.2147/ijwh.s119729

326 views 30 Aug 2019 Medically reviewed by Dr Christopher Ng on 6 Sep 2019.
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