Question 1

What is the difference between endometriosis and an endometriotic cyst? Are they the same?

Dr. Tripti Sharan · Accepted Answer

The disease is the same. Endometriosis is a lesion. The lesion can be very small, even microscopic, or a little bigger, and when it becomes a large one it forms a cyst: a collection of blood. Endometriotic cysts are found in the ovaries. When you see a complex, cystic mass in the ovary, cystic meaning full of fluid, which here is generally blood, it is called an endometriotic cyst. Endometriosis elsewhere can be a small, soft lesion anywhere.

Question 2

If a woman with an endometriotic cyst in the ovary becomes pregnant, does the cyst create a risk for the pregnancy?

Dr. Tripti Sharan · Accepted Answer

No, it does not. It can prevent a pregnancy and cause infertility, but once a pregnancy is established the periods stop, and most of the time small cysts regress. Even a cyst of 5 or 6 centimetres usually does not cause a problem. When cysts are big, they can sometimes twist during pregnancy and cause pain. Otherwise, it does not affect the pregnancy or the baby in any adverse way. The only things a cyst can do during pregnancy are twist, rupture and cause pain.

Question 3

Does suppressing endometriosis with GnRH therapy improve spontaneous fertility after treatment? Could you explain in detail?

Dr. Tripti Sharan · Accepted Answer

Endometriosis is a continuous disease. GnRH injections are always temporary, never lifelong, and you have to stop them because the patient wants to conceive. The maximum we generally give is about 6 months. During the 6 months that GnRH is given, the patient cannot conceive, and after you stop, the disease often starts growing again. The evidence shows that suppressing the disease beforehand does not improve her chance of a spontaneous pregnancy afterwards. So we give GnRH generally for pain, to patients who are not good candidates for surgery or who want to conserve their fertility, and not as a fertility treatment: a woman who wants to conceive should not have her attempts delayed by suppression.

Question 4

How does endometriosis affect fertility? Does it reduce AMH or ovarian reserve?

Dr. Tripti Sharan · Accepted Answer

It can, particularly when there are endometriotic cysts in the ovaries, but reduced ovarian reserve is usually not the main cause of infertility. Generally, infertility arises because endometriosis affects the tubes and the ovaries. The tubes should be mobile and free, able to pick up the egg and carry it inside, where fertilisation happens. If the tubes become fixed and adherent, stuck to surrounding structures and inflamed, they cannot pick up the eggs and become functionally useless. When endometriosis is in the ovaries there is a lot of hormonal imbalance: the ovaries may not make eggs, or eggs form but do not rupture. The surrounding area can be inflamed, which works against pregnancy. Substances secreted by endometriotic tissue impair sperm, and even the inner lining of the uterus, where the embryo implants after fertilisation, becomes less receptive. So infertility in these patients is due to multiple factors, not a single one.

Question 5

What causes ectopic endometriosis, and how is it managed?

Dr. Tripti Sharan · Accepted Answer

Ectopic endometriosis is endometriosis outside the uterus, for example in tissue such as the bowel or the urinary tract. The most widely accepted explanation is reverse flow of menstruation: rather than flowing forward into the vagina, it flows in the reverse direction, from the tubes into the abdominal cavity, although other mechanisms are also involved. Management depends on how bad the symptoms are, how big the lesion is and exactly where it is. If the pain and other symptoms are very severe, you have to go inside, localise the endometriosis and remove it. I am currently seeing a patient whose lesion is in the umbilicus, the navel. I have put her on medicine first; if she does not respond, she will need surgery. Medicine is temporary and cannot be continued indefinitely, whereas surgery is a one-time procedure, but here it would mean removing the whole umbilicus, so it is an extensive operation. Similarly, removing very small lesions on the bowel carries a danger of injuring the bowel. So many times we prefer to give medical management first, and these patients do respond, though it may have to be given for a long time, perhaps 2 to 3 years.

Question 6

You briefly mentioned Mirena. Could you elaborate?

Dr. Tripti Sharan · Accepted Answer

In medical management we give contraceptive pills or progestogens. Mirena is a progesterone-containing intrauterine device, like the loop or the copper T that many countries use for contraception and spacing between children. It is inserted inside the uterus, so the patient does not need to take a hormone daily; it stays in place for 5 years. Because of the progesterone, the endometrial glands atrophy and do not bleed, the patient often goes into amenorrhoea and her periods stop. When the periods stop, the endometrial glands do not grow, and the pain from endometriosis outside the uterus, in the ovaries, tubes, bowel and bladder, also generally improves. The issue is that it will not help her conceive: as long as the Mirena is inside, she cannot conceive. So it cannot be used in every woman, only in women who have completed their family, and where the cyst is not big. Endometriotic cysts bigger than 5 or 6 centimetres need to be removed.

Question 7

How common is adenomyosis in patients with endometriosis?

Dr. Tripti Sharan · Accepted Answer

It is very common, because endometriotic tissue that grows within the wall of the uterus is adenomyosis; it is a type of endometriosis. I cannot give you the exact rate, but the incidence is high. I would say about 50 to 60% of patients with endometriosis have a degree of adenomyosis as well.

Question 8

How can an ovarian endometrioma affect ovarian reserve?

Dr. Tripti Sharan · Accepted Answer

Imagine an ovary with a cyst in it: the cyst starts destroying the other follicles. If the endometrioma is big and is replacing most of the ovary, the ovarian stroma, the ovarian tissue, gets destroyed. Every woman is born with a fixed number of follicles, and they sit within that tissue, so the follicles are destroyed too. Second, the remaining follicles do not grow well; if a follicle is not growing every month there is anovulation and the woman cannot conceive. So ovarian reserve falls because of follicles that are destroyed and follicles that cannot grow. Both factors matter, for infertility and for lowering ovarian reserve, and AMH is lower in women with endometriomas, especially in both ovaries. But a decreased AMH is not the only factor: the other factors I have already discussed are often more important.

Question 9

Why can surgery for an endometrioma paradoxically worsen fertility in many cases?

Dr. Tripti Sharan · Accepted Answer

A very good question. It is now said that in a young woman who has not completed her family and does not have a very big cyst, say an endometriotic cyst of around 5 cm, or endometriosis elsewhere such as on the bowel, not every patient needs to be operated on. When you touch the ovary, you destroy natural ovarian tissue as well. And surgery causes more adhesions: endometriosis causes adhesions that lead to infertility, and surgery adds to them. So one should refrain from operating on every patient, and operate only when there is a larger lesion, when it is causing adhesions or a lot of pain, or when there is infertility and you suspect the tubes are blocked and stuck and need to be released. Otherwise, in the majority of patients, the first line of treatment should be medical. One should avoid touching the ovaries, because the more you burn, the more follicles you destroy. So initially you should try medical management, to prevent surgery destroying normal ovarian tissue.

Question 10

How can one distinguish endometriosis-associated pain from other chronic pelvic pain syndromes, especially in resource-limited settings outside big cities where diagnostic procedures are not easily available?

Dr. Tripti Sharan · Accepted Answer

I fully understand the dilemma; we also have many resource-starved hospitals. As I said at the start, the diagnosis should be clinical to a large extent. The history will guide you. The pain occurs with periods and is getting more severe; she needs a lot of painkillers; it is no longer only on the first or second day but on all five days, and it is not relieved. She has pain during intercourse, especially on deep penetration. Painful urination and painful bowel movements, especially at the time of periods: all of these point towards endometriosis. Second, on pelvic examination, a fixed uterus or masses. If masses are present you will need an ultrasound, but they still raise the clinical suspicion of endometriosis, especially with the other symptoms I described. Other ovarian tumours or other pathology will not cause symptoms only at the time of menstruation; they will be present at other times too.

Question 11

What is the risk of malignant transformation in endometriosis, and how can it be prevented?

Dr. Tripti Sharan · Accepted Answer

Very low. The risk of malignancy is not much, and there is not much you can do to prevent it. You can treat the endometriosis with contraceptive pills, and contraceptive pills as such reduce the risk of ovarian tumours. So I would say malignant transformation is very rare in endometriosis. And most of the time, endometriosis subsides by menopause.

Question 12

For a woman who has completed her family and has severe endometriosis, can she stay on contraceptive pills long term instead of having surgery?

Dr. Tripti Sharan · Accepted Answer

Yes. There is also elagolix, which can be given, and leuprolide injections, a GnRH agonist. The problem with these GnRH drugs is that patients start having hot flushes, though if you think they are needed, you can give them. Otherwise, contraceptive pills are a very good alternative: they do not produce hot flushes, they provide hormonal support, and they suppress the endometrial glands, so the endometriosis regresses. Oral contraceptive pills are an ideal way forward in a woman who has completed her family.

Question 13

If a woman who is planning a pregnancy is diagnosed with an endometriotic cyst in the ovary, how do you manage it?

Dr. Tripti Sharan · Accepted Answer

If the endometriotic cyst is not very big, less than 5 centimetres, you may not do anything about it. Support her and tell her to try for pregnancy, because once she is pregnant her periods stop automatically and the endometriosis will regress. If she is not very symptomatic, even with a little pain, painkillers are enough; she can do without contraceptive pills and try for pregnancy. Hormonal treatments that suppress endometriosis also stop ovulation, so they do not help her conceive and should not delay her trying. These patients should be treated conservatively while they try for pregnancy.

Question 14

If she has widespread endometriosis and cysts larger than that threshold, would you then go for minimally invasive surgery?

Dr. Tripti Sharan · Accepted Answer

Yes. If she is planning a pregnancy, you cannot keep her waiting; the waiting time becomes too long. If the lesion is large and very symptomatic, you have to operate, and you have to do it very carefully, avoiding much thermal damage. You go only around the endometriotic cyst and clear the adhesions, because the adhesions are another factor preventing pregnancy.

Question 15

Could that surgery also disturb the ovary and reduce her egg reserve?

Dr. Tripti Sharan · Accepted Answer

We have to weigh the pros and cons. If she wants a pregnancy, the lesion is not very big and she can easily wait, let her try for pregnancy first and control the pain with painkillers. Contraceptive pills, or dienogest, a progestogen that causes amenorrhoea and stops the periods, can control her symptoms, but they stop ovulation and do not improve her chance of conceiving afterwards. If she is not able to conceive, or if the lesions are very big, then there is no alternative to surgery.

Question 16

How would you investigate suspected urinary tract endometriosis?

Dr. Tripti Sharan · Accepted Answer

Clinical suspicion has to be high, with symptoms around the periods. Here you take the help of your urology colleagues: a cystoscopy to look at the lesions. If there is a strong suspicion of urinary tract involvement, a routine urine examination will show red blood cells, and for that you may also do a CT urography. I would say cystoscopy is a very good procedure to rule out endometriotic spots; it can show them directly.

Question 17

What complications can occur from bowel endometriosis?

Dr. Tripti Sharan · Accepted Answer

Without surgery, bowel endometriosis causes painful defecation: she may not be able to sit on the toilet because of the pain when passing motions. The bowel can also become stuck to the uterus, tubes and ovaries and cause infertility through that adhesion. Third, at surgery there is always a risk of injury to the bowel, even when lesions are superficial, so you should have the gastrointestinal surgical team on standby.

Question 18

If a woman with severe endometriosis decides to have surgery, which carries a risk of reducing egg reserve, does it make sense to freeze her eggs before the operation?

Dr. Tripti Sharan · Accepted Answer

Yes, that is an option. It depends on her age, her present AMH level and the extent of the disease. If the disease is very extensive, it has happened that we have ended up removing the whole mass, which carries most of the ovarian tissue, and if it is affecting both ovaries, egg freezing is a very attractive option. It should be done if the disease is extensive.

Question 19

Why does retrograde menstruation occur in most menstruating women, yet only a minority develop clinically significant endometriosis?

Dr. Tripti Sharan · Accepted Answer

That is a very interesting question, and I do not have an answer to it. None of the books do; they give you many theories. There is the coelomic epithelium theory, that tissues originating from the same coelomic epithelium can develop it; there are immunological factors and genetic factors. But to date no one has been able to pinpoint exactly what causes it. Menstruation happens to every woman, so why only some develop endometriosis is a very difficult, tricky question to answer.

Live Discussion with Dr. Tripti Sharan