If you are following us on social media @ballaratwomensclinic you may have seen that I have recently done a five-part series on Endometriosis. March is Endometriosis Awareness month and I have put together a 101 on endo. You can watch it here: https://www.instagram.com/ballaratwomensclinic/

What is endometriosis?

The endometrium is the lining of the uterus. Endometriosis is a chronic inflammatory condition that is defined as the presence of endometrium-like tissue outside of the uterus.

Approximately 1 in 9 women and those who identify as gender diverse have endometriosis.

Endometriosis can cause pain mostly in the pelvis, but other organs can be impacted. It can also cause infertility.

The symptoms of endometriosis vary from woman to woman. Some women have many symptoms and severe pain, whereas about one third of women with endo have no symptoms. Often for a woman with no symptoms, endometriosis is found when they are trying for a pregnancy or during an operation for another reason.

Endo symptoms can start on the first day of your very first period. I see many young women who have period pain that prevents them from going to school and enjoying social activities. For some women the symptoms of endo progress through their lives, for others, symptoms progress rapidly and affect multiple areas of the body.

Symptoms of endo that are commonly described by my patients include:

• Fatigue
• Pain on or around your period that prevents you from participating in normal day-to-day life
• Pain on or around ovulation
• Pain during or after sex
• Pain with bowel movements
• Pain when you urinate
• Pelvic, lower back and leg pain
• Frequent urination, or the frequent urge to urinate

You may hear the severity of endometriosis referred to as stage one, two, three or four. Or even referred to as deep infiltrating endometriosis (DIE).

However, the severity the symptoms you experience may not reflect the severity of the ‘stage’ of endo. And we don’t really know why. One hypothesis is that symptoms might be linked to where the endometrial like tissue is found or a heightened sensitivity to inflammation and pain.

Maybe I have endo?

To achieve a diagnosis for endo it is important to acknowledge the difference between and normal period and an abnormal period.

A normal period is different for everyone and can change throughout your lifetime. Periods tend to be longer and more irregular in younger women and become shorter in length and more consistent as you get older.

• On average a menstrual cycle should last around 21-35 days.
• An average period should be around 2-7 days in length.
• Flow should equal about 1 soaked pad or tampon every 3 hours at the start of a period.
• Possible sleep disturbance, food cravings, mood changes, bloating, pelvic cramps.
• The level of normal pain should be able to be managed with OTC medications or wheat bag.
• A normal period should not stop you from doing the activities you want to do, still go to work, or school.

Symptoms of an abnormal period can also be symptoms of endo.

When we talk about endo the following symptoms are common:

• Heavy bleeding
• Bleeding between periods
• Changes to your bowel movements – constipation, diarrhoea etc
• Pain with bowel movements
• Pelvic pain and pain in between periods
• Lower back pain
• Pain during sex

So, you think you have endo what’s the next step?

Endometriosis can take a long time to diagnose, the average diagnosis time is 6.5 years. Anecdotally, this is longer in regional and rural areas.

I believe this is due to both procedural issues where a woman spends time waiting for an appointment with the appropriate specialist PLUS a normalisation of abnormal periods by family, peers and society. Great organisations like @endometriosisaustralia are trying to change this thinking through public education programs.

My hope is that we start accepting that bad periods aren’t just a woman’s lot in life and that women are referred earlier to a specialist gynaecologist.

If you suspect you have endo, starting a period diary is a helpful way to give a good picture of your symptoms to your GP, make sure to include the following information in your period diary:

• The start/end date of the period
• How heavy or light the flow is
• Any cramping
• A record of your pain
• Gut and bowel symptoms
• Any irregular bleeding during your menstrual cycle
• Any pain with sex

Once you have seen your GP and have described your symptoms, you may be sent of for an MRI or ultrasound. It is important to note that these both have a limited ability to diagnose endometriosis. It is important to see an ultrasound provider with a lot of experience in women’s health.

You may also be given prescription medication for pain relief and/or hormonal control to help medically manage symptoms and suppress menstruation or ovulation.

If symptoms do not improve within 3-6 months or if endo is immediately suspected, it is time for a referral to a specialist Obstetrician and Gynaecologist for further surgical treatment and diagnosis.

What is the process of diagnosis and treatment?

Getting an endo diagnosis is not easy and even though invasive, the best diagnostic tool at the moment is laparoscopic surgery. This is keyhole surgery performed under general anaesthetic, usually as a day case where you go home that night to recover. At Ballarat Women’s Clinic, in most cases, diagnosis and treatment occurs in the same surgery with any endometriosis found in the pelvic removed at the same time. Rarely, you may need to be rebooked for a more complex surgery depending on the stage of endometriosis we find at your diagnostic surgery.

You might hear the surgical terms, excision and ablation in your research. Excision surgery is when the endometrial tissue is removed with cutting, and ablation surgery involves using diathermy which is a high-frequency electrical current that produces intense heat. The technique I use and recommend is excision surgery which I have performed in more than 1200 cases.

Depending on where endometriosis has been found, we might need the involvement of other surgeons. A colorectal surgeon for example, may be involved to help excise any endo found in the bowel.

What’s the cure for endometriosis?

It was once thought that pregnancy was a cure, or a hysterectomy. And these things can help some women, but it is false thinking that there is a ‘cure’ for endo.

I believe if we start seeing endometriosis as a chronic disease, we can help a woman manage her health goals over her lifetime.

The success of treatment can be varied.

Some women can have their symptoms controlled through hormonal contraception, either the pill or with an IUD. Many women after surgery can live pain free for life with minor and manageable ongoing impacts from endo. Some report symptoms returning after 2-5 years and need a second laparoscopy.

Some women, about 20%, have minimal relief from surgery or hormonal contraception and need further pain management care.

Mostly symptoms cease with menopause, however for about 2-5% of women, endometriosis can affect them their whole life.

What else can you do to manage endo?

The ongoing management for endo post-surgery is dependent on what area in your life is being the most impacted. What is your health goal at the moment? Is it to be as pain free as possible? Have better mental health? Protect your fertility? Have less painful sex? Get pregnant? Enjoy life and engage in social activities? Improve your gut and bowel habits?

I believe every woman with endometriosis could benefit from allied health involvement to help in areas such as mental health, pelvic floor retraining and diet.

At Ballarat Women’s Clinic we have set up a multidisciplinary approach to endo treatment to include allied health and specialists. Our practitioners work together to help you work out the area in your life that is impacted the most by endometriosis. We aim to proactively work with you so you can gain some control back over the areas of life that have been diminished by endometriosis.

Written by Obstetrician and Gynaecologist Dr Patrick Moloney