DR ROOMA SINHA – MD, DNB
Hon Professor, AHERF
Associate Professor, Macquarie University, Australia
Senior Consultant Gynecologist & Laparoscopic & Robotic Surgeon
In association with Apollo Hospitals, Endometriosis Society of India & ISOPARB
EndoMarch is an international event where awareness regarding endometriosis is done all over the world on 30th March. Endometriosis is a chronic inflammatory disease which affects one in ten women which results in pain heavy menstrual bleeding and infertility. This disease can start from an early age in adolescent girls and can trouble her all through her life.
The awareness is required as there is no simple way to diagnose the problem. The usual delay in diagnosis is about 5 to 7 years from the onset of symptoms and this is because there is no sure shot blood test that can confirm that one is suffering from endometriosis. The gold standard method to diagnose endometriosis is laparoscopy which is an invasive surgical procedure and difficult to do just to make a diagnosis. So awareness both in public as well as doctors is important to keep this disease in mind women present with severe pain during periods. It is okay to have a little bit of pain but when this pain becomes intractable interfering with day-to-day life then a gynecologist opinion must be sought to rule and endometriosis.
It is important to diagnose endometriosis early in life because long-term medical and intermittent surgical therapy can give the best outcome in terms of pain management and fertility outcome. Apollo hospitals in association with ISOPARB and an Endometriosis Society of India has joined hands with this worldwide movement called EndoMarch to create Awareness about this disease to one and all.
This year the march is starting from Park Hyatt Banjara Hills at 6:30 AM p.m. since this being the venue for 35th National ISOPARB conference.
Mrs Sangita Reddy joint managing director Apollo group of hospitals and Mrs. Swati Lakra IGP Law and Order and i/c. Women Safety(including SHE Teams and Bharosa) will flag off the march along with media interaction.
WHAT IS ENDOMETRIOSIS
Endometrial tissue outside the uterus also responds to changes in hormones. It also breaks down and bleeds like the lining of the uterus during the menstrual cycle every month. Anyway, the seeping inside the uterus has a section to turn out as menstrual seeping through a vagina, the seeping in endometriotic site amasses and frames sores (chocolate growths) or attachments. This can cause torment, especially beforehand and in the midst of the period. 33% of occasions of desolateness is a direct result of endometriosis.
WHO IS COMMONLY AFFECTED
- Young women in the reproductive age group (20-40years)
- Endometriosis commonly presents as infertility
- Women with uterine defects like septum or bicornuate uterus(double uterus)
- It can run in the family
WHAT ARE THE SYMPTOMS
- Pelvic pain Such pain may occur with sex, during bowel movements or urination, or just before or during the menstrual cycle.
- Heavy Bleeding during a menstrual cycle.
- Pain during sex.
- Feeling of bloating & Fullness in the abdomen around the periods.
- Few women with endometriosis disease may have no symptoms.
HOW DO WE DIAGNOSE
- Pelvic examination
- LAPAROSCOPY- is the gold standard in diagnosing endometriosis
WHAT ARE THE TREATMENT OPTIONS?
Treatment for endometriosis depends on the extent of the disease, presenting symptoms, and whether one wants to have children. It might be treated with a prescription, medical procedure, or both. Despite the fact that medications may ease torment and fruitlessness incidentally, it is a = issue and preservationist treatment (medicinal or careful) can’t give a changeless fix.
Medications– is used both to relieve pain and to keep the disease under control. Painkillers like paracetamol or mefenamic acid relieve the pain up to a great extent. Hormones like progesterone or combined pills not only relieve the pain but also help to control the disease process. Hormonal injections or Mirena (an intrauterine contraceptive device with progesterone) are also used in some situations. These medications cannot be used for long as women are not able to tolerate the side effects that these medications. Medications do not provide a permanent cure.
Surgery – In extreme cases, the medical procedure is the best decision for treatment. A medical procedure is done quite often by LAPAROSCOPY. Amid laparoscopy, endometriosis can be evacuated or consumed with smoldering heat. A degree of medical procedure relies upon the patient’s needs. On the off chance that fruitlessness is the issue, at that point moderate methodology and endeavoring to spare the ordinary tissues is endeavored trailed by dynamic treatment for barrenness. On the off chance that the lady does not want any more kids the total expulsion of uterus alongside the two ovaries and all endometriotic tissue is finished. Once in a while, extreme endometriosis can’t be dealt with laparoscopy and a technique called laparotomy might be required.
Robotic surgery is the latest addition in approach to management of endometriosis. Da Vinci ® surgical intervention is a new category of minimally invasive surgery that combines the best of open and laparoscopic surgery. With the assistance of Robotic ARMS (controlled by the surgeon of course!), we can perform surgeries through small incisions with unmatched precision and control. Robot-assisted surgery allows superior 3D visualization of the surgical field with 10 times magnification with human wrist like maneuverability. Advantages of Robotic surgeries are-
Minimal scarring. Due to precise movement, tissue trauma is less.
Less blood misfortune. Better dismemberment in the correct planes and the capacity to suture all the more rapidly, there is fundamentally less intra-usable blood misfortune
Less post-employable agony.
Quicker recuperation. Most patients can continue ordinary exercises inside about fourteen days, contrasted with about a month and a half for the open medical procedure. Moreover, patients can return home that day of the strategy
Excellent suturing The excellent precision and visualization offered by the da Vinci Si system enhances the surgeon’s ability to suture the uterus appropriately.
Endometriosis is a progressive disease. The source of the problem is the hormonal changes associated with menstrual cycles and the presence of endometrial tissue at abnormal places. After conservative surgery, the disease can recur. Patients who are treated with both medical procedure and meds have broadened side effect free period.
- How do I know if I have endometriosis?
One can know that they have endometriosis if they have symptoms like pain in periods, heavy bleeding, difficulty in getting pregnant or simply altered bowel habits with gaseous distension around the time of their periods. A definitive diagnosis usually requires visual inspection by laparoscopy. Ultrasonography can also pick up the disease if ovarian cysts have already developed.
- My sister was diagnosed with endometriosis. Does that mean I have it too?
Not necessarily. If one has a family history of endometriosis then there is an increased chance of developing endometriosis. But does not necessarily mean that all family members will have it.
- I have been diagnosed with endometriosis. Will I have difficulty in getting pregnant?
30% of women who have endometriosis can have difficulty in conceiving. But difficult to say if you will particularly have difficulty as every case is different and we don’t know for sure until you try to conceive. However laparoscopic surgery increases the chance of conception by 30-40% in early-stage disease (stage 1 & 2). Another fact to understand is that pregnancy in a way also treats the endometriosis due to continuous high dose progesterone secretion that takes place during the nine months of pregnancy. Advanced reproductive technology also is helpful in women with endometriosis.
- I was treated for endometriosis two years ago by laparoscopic surgery. Now I seem to have the same symptoms again.
Endometriosis is a chronic disease and recurrences are therefore common. The usual reasons for recurrence are inadequate resection during the first laparoscopic surgery or conditions that predisposed its appearance in the first place are usually still present. On average, one in three patients who had a laparoscopy for endometriosis will require a repeat procedure within five years. Complete removal of all implants during the first surgery is therefore important. Robotic-assisted laparoscopic surgery these days gives the advantage of precise and complete removal of all endometriosis with preservation of ovarian tissues for future childbearing.
- Is there a permanent cure for endometriosis?
There is no definitive cure for endometriosis, but there is treatment. Surgical treatment aims at removing all the endometriosis, which would mean removing the uterus, both ovaries and all the endometriotic implants in the pelvic cavity. Medical treatment aims at alleviating the symptoms and can provide relief to an extent. Different women may require different treatments or a combination of treatments. Surgical treatment is at times difficult due to adhesive nature of the disease and here also robotic assistance helps to complete laparoscopic removal with negligible chance of conversion to open surgery.
- Is endometriosis cancer?
No. Usually, endometriosis is a benign (non-cancerous) disease but can behave and affect areas around the uterus like cancer. Some research shows that women with endometriosis have a slightly higher risk of developing a particular type of ovarian cancer, but it is still not confirmed by hard scientific facts. There are also some reports where endometriotic ovarian cysts have become cancerous.
- Whom should I consult if I think I have endometriosis?
A gynecologist should be the person to consult. However, many, both patients and doctors often ignore dysmenorrhea as an inconvenience of having menstrual cycles. A gynecologist can help you assess your symptoms initially. Treatment of endometriosis often requires special care and experience. If one needs surgical correction it is better one at center with gynecological surgeon having extensive experience in managing endometriosis by laparoscopy or robotic-assisted surgery. Depending on the level of endometriosis the operation can be quite complex and not everyone is trained or have the experience to do it. The first surgery gives the best chance of controlling the disease. Surgery is often a delicate balance between what to remove and what to preserve so as to give the best outcome in terms of pain relief and pregnancy outcome.
WHAT IS ENDOMETRIOSIS
Tissue that forms the lining of the uterus (endometrium) is sometimes present in other places inside their abdomen in some women. These sites can be ovaries, fallopian tubes, cul-de-sac (behind uterus), intestines, rectum, urinary bladder. Endometrial tissue outside the uterus also responds to changes in hormones. It also breaks down and bleeds like the lining of the uterus during the menstrual cycle every month. However the bleeding inside the uterus has a passage to come out as menstrual bleeding through the vagina, the bleeding in endometriotic site accumulates and forms cysts (chocolate cysts) or adhesions. This can cause pain, especially before and during the period. One-third of cases of infertility are due to endometriosis.
1 in 10 women suffers from endometriosis in their reproductive years. There are about 200 million women around the world who suffer from this disease which on rough estimation affects 25 million Indian women. About 30 % of women with endometriosis have difficulty in conceiving.
Q1 How is the awareness level in India among women? Do they come in early or too late with this problem?
The awareness about this disease is not much across the globe as well as in India. Most women ignore nonspecific symptoms and they keep ignoring them thinking it is part of life. A symptom like pain during the period is almost always brushed aside saying it is part of growing up and will reduce after childbirth. This may be true in some but in many, it may just be the initial symptom of endometriosis. So is the pain is preventing you from attending college or work, do get yourself evaluated by a gynecologist who specializes in this area. Hence we have demarcated MARCH as the month of endometriosis awareness month world over.
Q2. Is it a hereditary problem? Does it run in the family?
Endometriosis is sometimes believed to be hereditary, being present in some members of the same family. It is quite common in Asian women including Indian women. However, most women whom we treat do not have any family members suffering from the same disease. There are some environmental factors also that may contribute to its development.
Q3. How do women deal with this problem? Is medication lifelong or it can be treated within a short time?
Dealing with endometriosis is a life long process. What kind of treatment advised depends on what they present with and what is their age of presentation. If it is a young woman and pain is the main problem then medical therapy is the first line of treatment to give pain relief as well as to reduce the progress of the disease. If infertility is the presentation then surgical treatment by Laparoscopy or Robotic-assisted surgery can improve pregnancy results in first and second stage disease. After laparoscopic treatment, there can be an almost 30% increase in pregnancy rates. However, if the disease is advanced then procedures like IVF is advised to women with endometriosis. If women have already completed her family then removal of the uterus and often both ovaries remains the treatment of choice.
Q4. As the lining of the uterus is also in the intestines and stomach region they have other problems like constipation, flatulence and painful bowel movements? Hence how can it cure?
Yes if the disease is sometimes spread to other organs surgical treatment can cure, but many times these women require some kind of medication lifelong.
Feeling of bloating or altered bowel habits is one of the nonspecific symptoms often ignored by women. In fact the gold standard method of diagnosis of endometriosis is laparoscopy.
Q5. It is also one of the reasons for three types of ovarian cancer, which are they and how many such cases are found in India?
Yes, studies have shown that women who have endometriosis can have 2-3 times higher chances of developing certain types of ovarian cancer namely endometroid or clear cell ovarian carcinoma.
Q5. At which stage does cancer develop in these women?
This is s difficult to answer this question. We do not know if all women with endometriosis will develop cancer and if so when. It is important for women with endometriosis to be in follow up of a doctor and take appropriate treatment as and when required.
Robotic surgery is the latest addition in approach to management of endometriosis. Da Vinci ® surgical intervention is a new category of minimally invasive surgery that combines the best of open and laparoscopic surgery. With the assistance of Robotic ARMS (controlled by the surgeon of course!), we can perform surgeries through small incisions with unmatched precision and control. Robot-assisted surgery allows superior 3D visualization of the surgical field with 10 times magnification and reduces the chance of open surgery.