ENDOMETRIOSIS AND POLYCYSTIC OVARIAN SYNDROME (PCOS)

ENDOMETRIOSIS

Endometriosis is a condition where the endometrial tissue from the lining of the uterus forms and grows in places outside the uterus. Theses growth leads to pain and infertility. Up to 50% of women who have endometriosis experience infertility.
The lost endometrial cells respond to the body hormones the same way they would inside the uterus.
Normally the endometrium within the uterus thickens to prepare for an embryo. When pregnancy does not occur, the extra lining breaks down and is shed during menstruation.
With endometriosis, the endometrial tissue that is outside the uterus also thickens, break down and bleeds, except that it cannot be expelled vaginally like the endometrial tissue. Instead the endometrial tissue outside the uterus builds up over time and forms patches, scar tissues, cyst and adhesions.
Usually, these endometrial growth form in the pelvis region, near the ovaries, but can also appear in rectum, vagina, fallopian tube, urinary tracts, bowels and rarely in the lungs, arms, thighs, umbilicus e.t.c.
Beside infertility, it causes painful period and painful sexual intercourse. Other women experience no symptoms, and it is only discovered accidentally during infertility evaluation.

How Endometriosis Cause infertility

Endometriosis is believed to be involved in up to 30% of female infertility. However, not every woman with endometriosis will have trouble in conceiving, and ironically, pregnancy may help alleviate the symptoms and reduce the progress of the disease.
The connection between endometriosis and infertility isn’t completely understood. Even when there is no obvious barrier to fertilisation and the number of implants are small or not blocking the egg or sperm from meeting, infertility can still result.

However, some other ways that endometriosis can affect fertility are:-

Endometriosis scar, adhesions or cysts around the ovaries may prevent the eggs from entering the fallopian tubes and may also prevent ovulation from occurring.
Endometriosis inside the fallopian tubes may form scar and adhesions, blocking the tubes.
The cause of endometriosis is not fully known, but some researchers suspect, it is related to the body immunity, so whatever it is that causes endometriosis may also cause infertility.
Endometriosis can make sexual intercourse painful, and pain may be more around ovulation period hence interfering with ability to conceive.

How is Endometriosis Diagnosed?

The only way to confirm a diagnosis of endometriosis is with a direct view diagnostic laparoscopy or accidentally during open pelvic surgery for other ailments.
Laparoscopy is an outpatient procedure that involves making a small incision in the abdomen, through which the gynaecologist inserts a tube with special camera and instruments to see the pelvis.
Because the use of laparoscopy is not widespread in Nigeria, the diagnosis of endometriosis is underreported. Its symptom is similar to that of pelvic infection (PID), hence pelvic infection (PID) is over diagnosed instead.

How is Endometriosis Treated?

Treatment of endometriosis is dependent on its severity, if the patient is experiencing pain, the patient’s age, and whether pregnancy is desirable.
Some treatment of endometriosis will lead to decreased fertility, which would not be an option if pregnancy is desirable are:
Laparoscopic surgery to remove the endometrial growth, scar, and adhesions caused by the endometriosis.
This is not a cure as the endometriosis may return later.
However, some women will have increased fertility for up to 9 months after the surgery.
IVF treatment is an option pre or post surgery.
In mild to moderate endometriosis, intrauterine insemination (IUI) along with fertility drugs may be used. The pain of endometriosis may be treated with pain relieving medications, acupuncture, and lifestyle changes such as regular exercises and diet changes.
If you do not wish to get pregnant, the treatment options may include hormonal treatments which stops ovulation and prevents pregnancy.
In severe cases the removal of the womb (Hysterectomy) and ovaries might be the only solution.

POLYCYSTIC OVARIAN SYNDROME (PCOS)

Polycystic ovarian syndrome is an endocrine disorder and a common cause of infertility in women.
In PCOS, hormones that affect the reproductive system are abnormal leading to irregular or absent ovulation. PCOS is a common disorder affecting up to 10% of women.
Women with PCOS often have polycystic ovaries. This means that the ovaries have many tiny, benign and painless cysts. During an ultrasound examination, the tiny cysts resemble a string of PEARLS.
A common finding with PCOS is abnormal high levels of Androgens (male) hormones. Whilst Androgens are found in both men and women, they are considered to be primarily male hormone.
High Androgen (male hormone) levels are associated with some of the more distressing symptoms of PCOS such as ACNE, and abnormal hair growth in women.
What are the Symptoms of Polycystic Ovarian Syndrome (PCOS)?
Some of the symptoms of PCOS include:

• Infertility
  
• Irregular or absent ovulation
  
• Absence of monthly menstrual cycle (Amenorrhea)
  
• Irregular monthly cycle (Oligomenorrhea)
  
• Recurrent miscarriage
  
• Abnormal hair growth on upper lip, chin, around nipple or on abdomen (Hirsutism)
  
• Acne
  
• Especially oily skin and hair
  
• Male pattern balding
  
• Obesity
  
• Insulin resistance
  
• High level of androgens
  
• Elevated LH hormone level (making ovulation prediction kits unreliable)
  

PCOS does not present in the same way for all women. A woman does not need all those symptoms to be present, before a diagnosis of PCOS is made.
For example, many women with PCOS do not have abnormal hair growth or obesity.

How Does PCOS Cause Infertility?

The abnormal hormone level associated with PCOS leads to problems with ovulation. These irregularities in ovulation are the main cause of infertility.
PCOS is associated with a higher risk of early miscarriages, which may be as high as 20-40%, nearly twice as high as in the general population.
Some of the reasons for the higher miscarriage rate are; poor egg quality related to premature or late ovulation. A less favourable environment for an embryo to implant in the uterine lining due to the abnormal hormone levels is another reason for the higher miscarriage rate.
Another reason has to do with the insulin resistance associated with PCOS.

How is PCOS Diagnosed?

Not every doctor agrees on the criteria for diagnosing PCOS. Its definition has been changed over the years.
However, the commonly used diagnostic criteria currently used require 2 out of the 3 of the following:

• Irregular or absent menstrual cycle caused by chronic anovulation.
• Either blood test confirmation or outward signs of high level of androgens (abnormal hair growth)
• The presence of polycystic ovaries as seen by ultrasound scan.

Taking a detailed history is an important part of PCOS diagnosis. Your doctor will want to know about how regular your menstrual cycles are and will ask about any unwanted hair growth. You may be tempted not to mention the unwanted hair growth because of embarrassment, but it is important you tell your doctor this problem if you have it.

Treatment of PCOS

Treatment of PCOS will depend on whether or not you are trying to get pregnant. If pregnancy is not a priority, the birth control pill (contraceptive) will help to regulate your cycle and help to reduce ACNE and unwanted hair growth.
For those trying for pregnancy, the treatment of PCOS is similar to the treatment used for treating anovulation.
The first line of treatment is ovulation drugs such as CLOMID which is used to help stimulate ovulation.
Metformin (Glucophage) a drug usually used to treat insulin resistance is sometimes used for treatment, even if you do not have insulin resistance.
If these medications do not help, then Gonadotrophins injections may be tried.
If drugs alone do not work or there are other factors leading to infertility, IVF treatment may be recommended.
Studies have shown that women who are overweight with PCOS may be able to restart ovulation naturally by loosing just 10% of their current weight. A healthy diet and regular exercise may also help to restore ovulation in some but not all women with PCOS.