What Are the Early Signs of Endometriosis?

Endometriosis is the implantation of uterine lining cells outside the uterus. It can lead to intense menstrual pain and infertility.

The endometrium is the inner lining of the uterus, which changes  throughout the menstrual cycle, shedding during menstrual periods. Endometriosis is the presence of normal endometrial tissue abnormally implanted in locations other than the inner wall of the uterus. 

The abnormally located endometrial tissue (endometrial implant) nevertheless responds to natural cyclic hormonal fluctuations in much the same way as the tissue located in the uterus. The result is, thickening, hormone secretion and cyclic sloughing of menstrual material. Thus, the symptoms of endometriosis depend on the cyclic production of menstrual hormones as well as where it has spread.

Typically, the abnormal sites of endometrium implants are in the pelvis: 

• Ovaries
• Fallopian tubes
• Vagina
• Cervix 
• Soft tissue

More unusual sites include:

• Surgical scars 
• Lungs and their covering (pleura)
• Diaphragm 
• Kidney
• Spleen
• Gallbladder
• Nose
• Around spinal cord
• Stomach
• Breast  

Almost a third of women with endometriosis do not have any symptoms. When symptoms are present, they depend on the site where endometrial implant has occurred. A common complaint is pain in the pelvic region, which varies with the menstrual cycle. The main symptoms include:

• Pain during menstrual periods (dysmenorrhea)
• Heavy or irregular bleeding
• Pain in the pelvic region
• Lower abdominal or back pain 
• Infertility
• Pain or discomfort during intercourse (dyspareunia)
• Pain on passing feces (dyschezia), often with cycles of diarrhea and constipation
• Bloating, nausea, and vomiting
• Pain in the groin
• Pain on passing urine and/or increased urine frequency
• Pain during exercise
• Blood in sputum
• Seizures that change in severity with the menstrual cycle

The diagnosis of endometriosis is based on a detailed history, including the symptoms mentioned above, physical examination, and investigations. 

Usually, the findings on physical examination are subtle. The most common finding is pain on applying pressure in the pelvic area.

Diagnostic examinations include:

• Laparoscopy
• Studying tissue samples (histopathological examination)
• Ultrasonography imaging
• MRI imaging

Risk factors for endometriosis include the following:

• Family history of endometriosis
• Getting the first menstrual period at an early age
• Short menstrual cycles (less than 27 days)
• Long duration of menstrual flow (more than seven days)
• Heavy bleeding during menses
• Delayed childbearing
• Defects in the uterus or fallopian tubes
• Anemia

Although there is no permanent cure available, several treatment options exist.

Management with medication 

The following drugs form the mainstay of pharmacologic care:

• Combination oral contraceptive pills
• Danazol
• Progestational agents
• Gonadotropin-releasing hormone analogs

Surgical management

• Conservative: when the reproductive potential of the patient is retained
• Semiconservative: when reproductive ability is eliminated, but the function of ovaries is preserved
• Radical: when the uterus and ovaries are removed (hysterectomy)