Individualized care in endometriosis key to successful management

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It is not until recently that endometriosis has become nearly known to a few individuals at personal, corporate and community levels. Endometriosis is a unique condition where cells that resemble the skin of the inside of the womb are also found in locations away from this natural location. This is an area whose tissue breaks away and becomes visible as menstrual flow. Menstrual flow commonly starts at pubertal age and will cease at the menopause.

Due to its similarity to the shed area of the womb lining, endometriosis tissue has almost identical behavior during a woman’s reproductive phase of life. In essence, there is a near mirror image of activities to the endometriosis cells as that happening to the womb lining, though invisible. Just as the womb lining immediately after a menstrual flow, the lining starts to develop in preparation for the mid-cycle when an egg is released from the ovary and ready for fertilization.

Corresponding changes are seen where growth in the lining stops as it becomes receptive to a fertilized egg. Whereas these changes are linked to reproduction in the womb, endometriosis tissue cannot support reproductive capacity as this is not biologically feasible nor desirable. However, other changes like inflammation continue to happen, accounting for the pain that is experienced.

Continued cyclic inflammation with pain results into a chronic pain state and also could cause scarring of organs adjacent to the area of endometriosis. This could be between the ovaries and uterine tubes, bowel or bladder.

This kind of scarring may cause organs not originally designed to be attached to each other to get stuck together, a situation that may cause changes in function. For example experiencing pain while opening bowels, passing urine or at sexual intimacy. Where uterine tubes or ovaries are caught up in the scar tissue, fertility may be compromised.

Endometriosis can be diagnosed at any age from the adolescent years till the menopause. Sadly, due to a variety of reasons women tend to receive a diagnosis of endometriosis after long periods of delay or incidentally when investigating for delay in conception. Whereas the diagnosis may require an operation called laparoscopy, it is not enough in managing the various symptoms that come with endometriosis.

Removal of endometriosis tissue may greatly improve function and relief of symptoms, however, this has to be balanced very carefully against inadvertent damage to organs bearing endometriosis such as bowel, bladder, ureters and ovaries and the risk of recurrence in future. Central to decision making is desire for fertility.

In young adolescent girls or women with no immediate fertility aspirations, the approach to managing symptoms is centered on minimizing long term adverse effects on fertility and maximizing symptom control with an approach that has the least side effect.

Exclusion of severe disease in a woman without immediate fertility concerns provides headroom to maneuver and try disease modifying treatments such as hormone medications. This approach comes with benefits such as control of menstrual flow and regularity, provision of contraception and prevention of cancer of the uterus and ovaries.

Women should not be put under pressure to get children as the consequences of unplanned pregnancy may be dire and no evidence exists to suggest that child birth cures endometriosis.

For those women who have immediate desire to complete a family and have endometriosis related symptoms, consideration is to optimise fertility, improve symptoms and quality of life and minimise complications that may arise from endometriosis
More often than not women may find that use of hormonal medications or surgery has not taken away all symptoms, especially movement induced pain, fatigue or symptoms of anxiety and depression.

Working in a multidisciplinary team involving other specialties is shown to greatly improve such symptoms than offering repeated surgeries.

Equally important is to practice a holistic lifestyle that guarantees healthy living, including regular exercise, taking fruits and vegetables, cutting down on alcohol and stopping smoking.

It is known that most women with endometriosis will have relief of symptoms at the time of menopause as the hormones naturally decrease when ovaries become inactive. Whereas for the majority of women without endometriosis, this occurs around the age of fifty, women with endometriosis may experience the menopause earlier.

This may be the case when multiple operations are performed to treat endometriosis on the ovaries. Inasmuch as the symptoms of endometriosis may improve with this natural transition, early menopause poses a great challenge as there are associated potential risks.

The female bones lay down the matrix for strength during reproductive years and especially after childbearing due to absence of competition from pregnancy and breastfeeding. This benefit is accrued more in the years immediately before the age of fifty. Lack of hormone activity due to early menopause in endometriosis therefore deprives the woman of a crucial source of bone laying catalyst and also poses risk to cardiovascular health.

It is therefore essential that individualized hormone replacement is offered to women aiming to continue till the age of natural menopause. The choice of medication should however be well thought out so as not to cause a return of endometriosis symptoms.

Resolution of endometriosis symptoms could be counteracted by emergence of treatment side effects and anticipation will be a reassuring tool, rather than surprise, when these occur. Usually, this is well handled by a specialist with good clinical experience and understanding of these conditions, endometriosis and menopause.

The paradigm shift in the management of endometriosis is that of a holistic approach, with very individualized care. Understanding that various women will have different needs and that the same woman will have needs that change with time provides a good platform to lay the foundation of care. At the centre of this is usually the patient who is fully involved in decision making.

(Dr Muteshi is an Obstetrician/Gynecologist and Fertility Specialist at Aga Khan University Hospital in Nairobi, Kenya)

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