Introduction

Endometriosis is a chronic disease affecting an estimated 10% of girls and women globally during their reproductive years. This translates to roughly 190 million individuals in which the tissue similar to the lining of the uterus (endometrium) grows outside it. This misplaced tissue can be found mostly on ovaries, tissues around the uterus and ovaries (peritoneum), fallopian tubes, intestines, bladder, and other pelvic tissues. In rare cases, it can even appear in different body parts.

Endometrial tissue outside the uterus leads to a chronic inflammatory response. This inflammation can cause the formation of scar tissue (adhesions) within the pelvis and sometimes other areas. The disease has diverse signs and symptoms, including mental health complications.

Symptoms

Endometriosis manifests through various symptoms that can significantly impact the woman’s quality of life. Check with your gynaecologist if you experience any of these symptoms. The most common symptoms include:¹

• Life-impacting pain during periods and menstrual cycle
• Lower back pain
• Pain during urination or bowel movement
• Nausea
• Vomiting
• Diarrhea
• Constipation
• Chronic fatigue
• Difficulty getting pregnant
• Pain during and after intercourse

Causes

The cause of endometriosis remains unclear despite several postulated theories, none has been scientifically proven. What happens during the disease development is that during the regular menstrual cycle, the blood of the lining of the uterus flows out of the vagina to settle in other organs or places in the pelvis resulting in lesions on the affected parts. Those lesions continue to grow and bleed responding to the hormones the same way the lining inside of your uterus does every month during the menstrual cycle causing all those painful and hinder-life symptoms the patients of endometriosis complain about.

Diagnosis

The following tests are usually done to confirm endometriosis diagnosis:¹

• Pelvic exam: Your gynaecologist will examine you for cysts or lesions, but small ones are hard to detect through such an examination
• Imaging: Your doctor may choose between two options: an ultrasound examination to check for endometriosis ovarian cysts or Magnetic Resonance Imaging (MRI) for a more precise detection of these cysts or lesions
• Laparoscopy: Doctors perform laparoscopic surgical biopsy to remove the suspected lesions or cysts and to confirm the diagnosis through histologic verification

Risk factors

• Family history: Having a family member (mother, aunt, sister, etc.) with endometriosis increases your risk of developing it ²
• Menstrual cycle: Starting your period early or having short periods may increase the risk
• Altered immunity: Endometriosis may be associated with an impaired immune response. This could contribute to the development of the condition by making it difficult for the body to clear endometrial cells that implant outside the uterus during retrograde menstruation
• Race/Ethnicity: Studies suggest a racial/ethnic disparity in endometriosis diagnosis. Black women are diagnosed with endometriosis at a significantly lower rate compared to white women. Conversely, Asian women appeared to be diagnosed at a higher rate

Endometriosis treatment

Currently, there is no cure for endometriosis. Instead, treatments are used to treat symptoms and complications associated with it. Usually, doctors consider certain factors when they establish the treatment protocol. Factors include the severity of the condition, whether you want to have children and the associated symptoms. Treatment options include: ³

• Pain-management medications: When the pain is mild, they can help manage it. Options range from readily available over-the-counter drugs to stronger prescription medications. The most commonly used pain relievers for endometriosis are nonsteroidal anti-inflammatory drugs (NSAIDs)
• Hormonal therapy for endometriosis: Hormonal therapy can be a helpful option for managing pain associated with endometriosis. Hormones, particularly oestrogen, influence the growth and activity of endometriosis lesions. Hormonal therapy aims to reduce oestrogen production and usually prevents ovulation from slowing the growth of existing lesions and may prevent new ones from forming

Treatment options include oral contraceptives (Birth Control Pills). They combine estrogen and progesterone to regulate the menstrual cycle, leading to lighter periods and reduced pain. They are often well-tolerated but not suitable for women with high-risk factors like high blood pressure and blood clots. 

Another option is Gonadotropin-Releasing Hormone (GnRH) Antagonists which suppress the production of certain hormones from the pituitary gland, essentially putting the body into a temporary menopause state, leading to effective pain relief, often with symptoms improvement within a few months. Side effects can incorporate hot flashes, vaginal dryness, mood swings, bone loss, and increased risks for heart complications. It is not recommended for long-term use. 

Also, Progesterone and progestin-like hormones can be taken as pills, injections, or through an intrauterine device (IUD). They work by thinning the uterine lining and potentially reducing or stopping periods. Side effects may include weight gain, mood changes, or irregular bleeding.   

• Surgical options for endometriosis: While not a permanent option, surgery can offer significant pain relief for women experiencing severe endometriosis. Laparoscopy is a minimally invasive surgery that uses a laparoscope, a thin lighted instrument inserted through a small abdominal incision. The surgeons can visualise the endometriosis lesions, assess their size and extent, and potentially remove them. Surgeons may have to carry out a laparotomy which is a major abdominal surgery that involves larger incisions to assess and remove endometriosis lesions. In severe cases, the surgeon may also consider removing the uterus (hysterectomy) or the ovaries, and fallopian tube, However, major surgery is the last resort due to the invasiveness and the fact that it does not guarantee complete resolution of endometriosis pain

Endometriosis and mental health: A neglected connection

Beyond the physical challenges of pain and fatigue, endometriosis often carries a significant emotional burden. The chronic nature of the condition can take a toll on mental health. Researchers suggest a strong link between endometriosis and mental health. Women with endometriosis are more likely to experience anxiety, depression, and body image concerns compared to those without the condition. This creates a difficult cycle, where chronic pain and fatigue can lead to emotional distress, stress, and other mental health issues, which in return may worsen the physical symptoms of endometriosis.^4,5

Figure (1) Adopted from this study

In a systematic review and meta-analysis of 15 observational studies involving over 4600 women with endometriosis. A significant result emerged that nearly two-thirds (68%) of these women experienced moderate to high levels of stress. There is a strong link between endometriosis and depression. A systematic review and meta-analysis of 24 studies including about 99,600 women with endometriosis investigated the link between endometriosis and depression. The study uncovered that women with endometriosis were more likely to experience depressive symptoms compared to the control groups. Another study investigated the impact of endometriosis-related pain on quality of life, anxiety, and depression in women. It involved 102 women, 62 with severe pain, and 40 with mild/moderate pain. Women with severe pain had significantly longer treatment duration and reported higher levels of depression, anxiety, and poorer overall quality of life compared to those with mild/moderate pain.^4,5

Coping and treatment approaches to enhance life and mental health

Pain management: The first treatment approach is pain management through the options mentioned earlier tailored for each case, as the chronic pain they suffer from makes their lives very difficult as they are living in an infinite loop of distress.^6,7,8

Endometriosis-friendly diet: Researchers investigated the link between diet and endometriosis. Studies emerged that incorporating more healthy choices may reduce symptoms of endometriosis. Eating more greens and adding omega-3 fatty acids to your diet may reduce the risk of developing endometriosis. Also, studies supported that the consumption of a diet rich in red meat, soy, phytoestrogens, and alcohol is linked to a higher risk of endometriosis and the worsening of symptoms. Choosing a healthier diet will improve your overall health and the associated symptoms of endometriosis decreasing stress and improving your psychological status.

Exercise: A regular exercise routine may greatly help with endometriosis. Researchers have supported that it can lower estrogen levels, improve insulin sensitivity, and promote the production of anti-inflammatory molecules, potentially reducing the risk of endometriosis, enhancing symptoms, and decreasing stress.

Endometriosis coping strategies: There are two main coping strategies used by women suffering from endometriosis: ^9,10

1. Problem-focused strategy: It aims to manage physical and social challenges caused by endometriosis. This may include:
   • Managing physical activity as limiting activity during a painful period and making modifications allowing them to stay active despite the pain
   • Educate themselves about endometriosis to better understand their condition. This empowers them to make informed decisions about their health
   • Planning and scheduling activities around their menstrual cycle to be more productive, manage their energy levels, and decrease stress
   • Relying on family and partners for emotional and practical support for coping with the emotional burden of endometriosis

2. Problem-focused strategy: Here, the focus is on managing the emotional impact of the disease. You can seek a professional to help you with this strategy. Examples include:
   • Acceptance: Recognising and accepting that they have endometriosis is an important first step towards coping effectively
   • Positive thinking: Maintaining a hopeful outlook can help manage stress and anxiety associated with chronic conditions
   • Self-talk: Positive self-talk can be a powerful tool for managing pain and maintaining control
   • Spiritual practices: For some women, prayer or religion can provide comfort and strength in dealing with their illness

Endometriosis can significantly impact your well-being. The feelings of frustration and sadness are completely understandable. However, you are not alone on this journey. Always prioritise self-care and plan activities that nourish your mind, body, and spirit. Build a support system for emotional understanding and practical help. Consider joining an endometriosis support group to connect with others who share your experience. Do not hesitate to seek professional support. Therapy can equip you with valuable tools to manage stress, cope with chronic pain, and navigate the emotional challenges of endometriosis.^9,10

Summary

Endometriosis is a long-lasting condition affecting around 10% of women and girls during their reproductive years. In this disease, tissue similar to the uterus lining grows outside the uterus, mainly on the ovaries, fallopian tubes, and other pelvic areas, leading to inflammation and scar tissue. Symptoms can include severe menstrual pain, lower back pain, fatigue, nausea, and difficulties with pregnancy. The exact cause is not known, but it is linked to menstrual cycle issues, family history, and potential immune system problems. Diagnosis may involve pelvic exams, imaging techniques, or laparoscopy. While there is no cure, treatments focus on managing symptoms through pain medications, hormonal therapies, and possibly surgery. Endometriosis also has a significant emotional impact, often leading to anxiety and depression. Coping strategies include pain management, maintaining a healthy diet, exercising regularly, and seeking emotional support from professionals and peers. Prioritising self-care and connecting with support groups can greatly enhance well-being.