Dysmenorrhoea and Endometriosis

Treatment and impact on fertility

It is crucial that your endometriosis treatment is tailored to your own specific circumstances and that you see a specialist in endometriosis who can advise you on this. Your treatment will depend upon your age, desire for a diagnosis, fertility requirements and pain symptoms.

Do not just accept the first treatment offered without understanding why it is being offered in your situation. A consultation for complex endometriosis will take at least 45 minutes.

Pain

There is no absolute cure for endometriosis and it tends to be an issue that remains with you for most of your fertile years.

Both medical and surgical treatments give a measure of relief from pain depending on the type of endometriosis you have. The amount of pain relief can vary greatly depending on many factors. Pain can recur after stopping medical treatments or at a later date after surgery.

If you are not keen to have a diagnostic laparoscopy (keyhole surgery) to confirm that you have endometriosis, then it may be reasonable to try medical treatments first and then consider a diagnostic laparoscopy later if the medical treatments do not work.

Medical treatments

All of the hormonal treatments have been shown to be equally effective as each other at relieving pain but none of them improve fertility. The choice of drug treatment is decided by your age, requirement for birth control and the potential side effects of the drugs.

1. Simple painkillers may be used. However, most women have already tried these before they see a gynaecologist.
   
2. Hormonal drugs can be used to mimic the hormone levels found in pregnancy as we know that endometriosis pain tends to improve during pregnancy. Your doctor may prescribe oral oestrogen and progesterone combined, progesterone only medication, or a progesterone impregnated coil that fits inside the womb.
   
3. You can also take hormone drugs to temporarily mimic menopause as we know that endometriosis tends to resolve once the menses have stopped. This is generally done by injections that temporarily switch off the ovaries during the treatment period. Your menses will return after the treatment is stopped without risk to your fertility. However, these drugs cannot be used long-term in most cases.

Surgical treatment

Some women may decide to proceed directly to a diagnostic laparoscopy because they wish to be certain if they do have endometriosis. Knowing the cause of the problem helps them psychologically to deal with it.

Surgical treatment requires the help of a gynaecologist who specialises in endometriosis and minimally invasive surgery (keyhole surgery).

For minimal to moderate disease (Stage 1-3), the surgeon should be comfortable to diagnose the problem during laparoscopy and surgically remove it, preferably by excision, and at the same time, to get the best chance of pain relief. Many general gynaecologists are not fully trained in these techniques.

If your gynaecologist discovers severe disease then, to treat it at the same time, they should have discussed with you the pros and cons of surgical removal. In severe cases, endometriosis surgery is a high-risk complex operation that should only be attempted by a fully-trained expert in specialist centres.

Not everyone requires surgical removal of severe disease as it can compromise your fertility. Robotic keyhole surgery now potentially offers the most accurate and precise surgery for severe cases of endometriosis with the lowest risks of complications. About 80 percent of patients undergoing surgery say that their pain improves to varying extents.

Your gynaecologist should also be able to offer you access to other specialists as required, for example:

• Pain, intestinal or urinary system specialists

• Psychological and psycho-sexual support

Fertility

If you are found to have endometriosisassociated infertility then the choice is whether to have surgery or assisted fertility treatments (IVF or IUI) or both.

With minimal to moderate endometriosis, there is evidence that surgically removing the endometriosis deposits and endometriotic ovarian cysts improves your chances of conceiving spontaneously reducing the need for assisted conception techniques.

There is some evidence that surgically removing severe endometriosis before infertility treatment improves your chances of success. However, there is a small risk of damaging your fertility with surgery in some cases and so assisted conception techniques may be recommended in the first instance so as not to risk affecting your fertility further from surgical complications.

Surgery may also be needed first if:

1. The pain is so severe that it is the major problem, rather than the fertility issue.
   
2. You have large endometriotic cysts on the ovaries that are interfering with the infertility specialist’s ability to collect eggs for IVF.

Dysmenorrhoea and endometriosis can be physically and mentally debilitating, affecting every aspect of a woman’s life.

Women with endometriosis tend to have more problems maintaining their careers and relationships as they may be fighting with chronic pain and fertility issues.

Seeing a gynaecologist who specialises in this area gives a good opportunity to keep the pain under control and achieve fertility aspirations.