March is Endometriosis Month. Endometriosis is a disorder that affects women. It occurs when tissue that ordinarily grows inside the uterus starts growing outside of the uterus. It can be a painful disorder, especially during menstruation.
It’s also a common disorder, affecting around 100,000 women in the UAE. Endometriosis typically affects the ovaries, fallopian tubes and the tissue lining the pelvis. When the disorder affects the ovaries, cysts can form, irritating the surrounding tissue. Unfortunately, despite growing awareness, many women still endure the condition undiagnosed, believing that their discomfort is simply part of their physical life cycle.
Professor Arnaud Wattiez, Head of Gynaecological Surgery, Latifa Hospital, said that previously, the time from the onset of symptoms to the diagnosis of endometriosis was nine years. He believes that this has now improved, although many women still don’t receive the specialist care they need. Endometriosis affects women from menstruation age until the menopause. The symptoms include consistent pain during menstruation, heavy menstrual flows and irregular menstrual cycles.
Aside from the physical pain, one of the most painful psychological aspects of the condition is that it can affect women’s ability to become pregnant. “When you have pain and endometriosis, you have two types of patient. You have the patient that wants to get pregnant and you have the patient that doesn’t want to get pregnant at the time of the diagnosis,” says Prof. Wattiez.
“For those who want to get pregnant, the medical treatment is quite limited because any treatment we give for endometriosis is contraceptive. If you treat patients with hormonal treatments, then mainly, they cannot get pregnant.”
For women who want to become pregnant, surgery is usually the first avenue of treatment. “The surgery consists of a laparoscopy to excise the lesion as much as we can, preserving your ovarian reserve [capacity of the ovary to provide egg cells that are capable of fertilisation],” says Prof. Wattiez. “We know that every time we operate on the ovary, we are reducing the ovarian reserve.”
In some cases though, the surgery can actually increase women’s chances of fertility but the current norm is to try to avoid it unless it’s necessary. “Above 3cm in size, the trend today is to remove the cyst,” he says. “The endometriosis cysts are different sizes and they are full of chocolate cysts, which is the blood of the secretion of the mucus of the endometrium.
“For patients who don’t want to get pregnant — such as with early diagnosis on a 22-year-old patient who would like to get pregnant at a later stage — this opens the door to medical treatment. I will use a treatment such as progestin, an adapted hormone therapy. If it works, we can keep the patient on the same treatment for a long period.”
In cases where medications fail to relieve the patient’s symptoms, then surgery must be considered.
The importance of early diagnosis
Dr Shila Waghmare, Specialist Gynaecologist at Aster Clinic Muteena, believes that early intervention is vital for achieving the best results. “It’s very important to diagnose endometriosis early because with simple hormone therapy we can prevent it spreading to the other major organs,” she says. “The more severe the case, the more severe the symptoms will be.”
Dr Waghmare acknowledges that the complications with fertility can have a profound effect on women suffering from the disorder. “Endometriosis can be very depressing for women as it affects their relationships and childbearing ability. I would encourage all women who think that they might be suffering from endometriosis to come to the clinic for a proper diagnosis,” she says.
DHA has specialist endometriosis clinics that aim to cover all aspects of care, beyond a medicinal or surgical approach. “Endometriosis patients have a long story of chronic pain and it can become a little bit neurogenic so they need to be supported in every way. This is not only through surgery and medical treatment but also through psychological support and more,” says Prof. Wattiez.
Progressive treatments
He believes that the biggest advancements in the treatment of endometriosis have been in the field of surgery. “We have shifted from laparotomy to laparoscopy, to minimise the invasive access.
“We are also much more respectful to the tissue, where we preserve much more tissue and nerve vascularisation. Before, we were of removing 25 per cent of the sigmoid [pelvic colon] for a small nodule and now we are much more accurate and precise.”
Prof. Wattiez refers to a progressive method called alcoholisation of the cyst, which may become a more common treatment in the future. “We aspirate the liquid, which is inside the cyst, and we replace it with alcohol that is 95 degrees Celsius and with the alcohol, we burn the cystic wall. We leave the alcohol there for 15 minutes and then we rinse and we don’t touch the ovary wall. The idea of this is to try to avoid impairing the ovarian reserve. The elementary studies are ongoing now but they are very promising.”
The improved accuracy of surgery means that endometriosis sufferers now have a far higher chance of retaining their fertility than previously. DHA is working more with augmented reality and new techniques to further improve results.
“We had a recent project using fluorescents that can be seen with illumination using special wavelengths of light that show the lesion and then we can excise the lesion and when the fluorescents disappear, it means that we are complete,” says Prof. Wattiez. In fact, for women visiting DHA’s clinic, the pregnancy rate is around 60 per cent. “This is an accumulative number that comes from spontaneous pregnancy after surgery and IVF pregnancies.”
Specialist approach
Dr Waghmare believes that GPs need to refer patients that show symptoms of endometriosis to specialists as soon as possible. She is also keen to highlight the difference between the disorder and cancer. “It is not a form of cancer and even though the cyst exists in your ovary because of the endometriosis, it is not cancerous. Most women think they have cancer.”
Prof. Wattiez agrees that highly qualified professionals should be called upon to treat endometriosis if the best results are to be achieved.
“Endometriosis is a matter for specialists. You should not be treated by a general gynaecologist. When it comes to surgery, it is quite high-risk, even in safe hands. Surgery should be carried out in a well-equipped centre, with well-trained surgeons who have a high volume of patients.”
