Endometriosis is a common gynecological condition, affecting around 1 in 10 women. It occurs when tissue similar to that which lines the inner wall of the uterus, the endometrium, grows in other locations, such as the ovaries, fallopian tubes, sacroiliac ligaments, bladder, kidneys, or any other organ in the body. The result is to cause a severe inflammatory reaction, with adhesions and severe pain.

Are women nowadays shying away from talking openly about endometriosis?

Period pain is almost taken for granted among women. It is often even dismissed among women’s conversations and with a short “how do you do that, period pain is normal!”, it is treated as something to be expected. This can be very stressful and demoralizing for women with endometriosis, so they avoid speaking out. In addition, endometriosis often goes unnoticed precisely because it is confused with “totally normal pain.” A related study from Canada of 30,000 women showed that it took an average of more than 5 years to diagnose endometriosis in women who had chronic abdominal pain, mainly during their periods. This situation is made difficult by the fact that the disease was for a very long time almost unknown in medical education. It has, however, been known for over a hundred years and has been proven to actually exist.

What is the incidence of endometriosis in Greece?

The incidence of endometriosis ranges from 10 to 18%. In infertile women, in fact, it is much higher (20% to 50%) and can exceed 70% in women with chronic abdominal pain. It is the second most common gynecological disease after uterine fibroids and it is estimated that in Greece there are at least 3,000 – 4,000 new cases of endometriosis every year. Also, it seems that there is a hereditary predisposition to the manifestation of the disease. It is also noteworthy that the daughter or sister of a woman suffering from endometriosis is 7 times more likely to develop the condition than any other woman.

What are the symptoms of endometriosis?

The symptoms caused by endometriosis are very different from patient to patient, which often makes it difficult to diagnose. For this reason, after all, endometriosis has been characterized worldwide as the “chameleon of gynecology”. Severe period pain is a very common symptom among sufferers. However, the pain can occur both period-dependent and period-independent and can be caused almost anywhere in the body.

Typical symptoms of endometriosis are very painful periods and heavy or irregular menstrual bleeding. Women with endometriosis also often suffer from:

• pain in the abdomen or lower back
• pain when urinating or defecating
• pain during intercourse
• bloating in the intestine
• nausea and vomiting

Less frequent symptoms, which appear with less intensity or in advanced stages of the disease, are the feeling of fatigue, insomnia, mood changes, premenstrual syndrome, bleeding from the anus during the days of the period.

Endometriosis, however, also presents the following paradox: patients with many foci in the abdomen may not experience any pain, while on the contrary, women with endometriosis may complain of severe pain even if they have very small foci in the abdomen.

How is endometriosis diagnosed?

The diagnosis must be made by an endometriosis specialist Obstetrician-Gynaecologist and includes initials taking a detailed history from the patient. With a thorough history, doctors can test for the presence of endometriosis by describing severe period pain or lower abdominal pain. An unfulfilled desire to have children could also indicate endometriosis. Subsequently, the gynecological examination with palpation of the gynecological field and the visual examination of the vagina and cervix can strengthen the suspicion of the presence of endometriosis, but often these tests alone do not lead to a diagnosis of the disease. The gynecological examination is completed and accompanied by its performance ultrasound. Ultrasound examination of the abdominal wall and/or vagina can show endometriotic foci in all anatomical structures of the abdomen and especially the small pelvis. Deep penetrating foci of endometriosis affecting the vagina, bladder or bowels can be detected by an Obstetrician – Gynecologist using vaginal ultrasound. In addition, larger foci can be visualized using MRI.

If endometriosis is still present, only laparoscopy or robotic surgery can give a clear diagnosis. In this endoscopic surgery, endometriosis foci are safely removed from the patient and then sent for histological examination. Only then can it be said with certainty whether this patient actually had endometriosis.

Does endometriosis affect a woman’s fertility?

It is now indisputable that endometriosis can make it difficult or even cancel a couple’s desire to have children. One reason for this is that the disease can change a woman’s anatomy, such as blocking the fallopian tubes or pushing eggs into the ovaries. This makes the natural process of pregnancy impossible. The second point is that egg quality is significantly worse in patients with endometriosis. Consequently, the ability to fertilize decreases more rapidly than in women without endometriosis. We also have to consider that women today give birth on average ten years later than they did 50 years ago. As a result, endometriosis can develop ten years longer. The same applies to the quality of the eggs available.

Since numbers can reveal a lot of the truth, let’s look at some statistics. In general, endometriosis can cut a woman’s fertility in half. More specifically: for a 22- to 23-year-old patient with endometriosis, the probability of getting pregnant is about 15%, while for a healthy woman of the same age group, it is about 30%. The pregnancy rate for a healthy 35-year-old is about 15%. A 35-year-old woman with endometriosis, on the other hand, has a 7.5% chance of getting pregnant per cycle. For a healthy woman over 40, the pregnancy rate per cycle is between 5 and 8%, while if she suffers from endometriosis it drops to 4%.

For a woman diagnosed with endometriosis, when is the right time to start trying to conceive if she wants to?

Even if endometriosis is severe, it is still possible for a woman to become pregnant. It is estimated that 60-70% of affected women can become pregnant despite having endometriosis. However, due to a lack of research, the relationships between fertility and endometriosis are not fully understood. If a woman with endometriosis so wishes, she can immediately start trying to conceive, taking certain facts into account.

The latest data shows that:

• Of the 100 women with minimal to mild endometriosis who try to conceive, 75 of them will become pregnant naturally after one year.
• Of the 100 women with moderate endometriosis who try to conceive, 50 of them will become pregnant naturally after one year.
• Of the 100 women with severe endometriosis who are trying to conceive, by the end of one year 25 of them will be naturally pregnant.

To understand the difference, according to the latest statistics, if 100 women without endometriosis try to conceive, 84 of them will be pregnant naturally by the end of a year.

Therefore if a woman has been diagnosed with endometriosis and wishes to conceive, it is recommended that she seek the help of a specialist after six (6) months of unsuccessful attempts, as opposed to the one year usually recommended for women without endometriosis. However, women over 35 would be wise to seek the advice of an endometriosis and infertility specialist even earlier.

Is IVF the only way for a woman with endometriosis?

In vitro fertilization it is not a one-way street for a woman with endometriosis. As previously mentioned, it is estimated that 60-70% of women with endometriosis can become pregnant despite having endometriosis. A percentage of women with endometriosis who have fertility problems do become pregnant after medical help, either through surgical removal of endometriosis lesions or through technologies assisted reproduction.

Even after a successful surgical removal of endometriosis foci, the disease can return and recur, making it even more difficult for a couple to conceive. Especially for women, who for various and often unexplained reasons endometriosis reappears, after a successful surgical removal, experts advise that women do not necessarily proceed with a new surgery if they want to have children. After all, such interventions always produce scar tissue, which can prevent an egg from implanting. Many couples, therefore, choose her IVF because numerous studies have shown that it has a very good chance of conceiving in women with recurrent endometriosis.

What are the latest developments in modern surgical techniques for endometriosis and which do you consider most effective?

Management of endometriosis should be individualized according to the needs of the patient (symptoms, age, desire for pregnancy). The surgical treatment of endometriosis cases is apparently a simple matter, but in fact it is highly specialized and serious, as in advanced cases there is infiltration of the pelvic nerves, bowel, diaphragm, ureter and bladder.

The attending physician must be prepared to deal with such situations with its use laparoscopic or robotic surgery and specialized techniques, often used in Gynecological Oncology. With these techniques, the recognition of all endometriosis foci, wherever they are located in the patient’s body, is ensured to the maximum extent. Simultaneously with the use of laparoscopic or robotic surgery, endometriosis removal is carried out with maximum safety, without injuring adjacent healthy tissues and organs in the woman’s body. That’s why, after all, with the modern surgical techniques we ensure the ideal combination of patient safety and successful endometriosis removal.

The incomplete cleaning of the foci of the disease with the first surgery significantly complicates the success of a supplementary surgery due to adhesions, increasing the possibility of complications. The most effective, perhaps, surgical treatment of endometriosis mainly has more to do with the experience and expertise of the treating physician than with the method itself.

Therefore, the most effective surgical treatment of endometriosis must be performed by gynecologists very well trained in laparoscopic and robotic surgery, as the total removal of endometriosis can be of maximum difficulty and requires very good surgical training of the Obstetrician-Gynaecologist.