Endometriosis is defined as the presence of tissue that resembles endometrium, that normally lines the inside of the uterus, in sites outside the uterine cavity - the ovaries, utero-sacral ligaments, pelvic structures, lower genital tract, lymph nodes, laparotomy scars, lungs or umbilicus. It is called Adenomyosis when the endometrial stroma is found in the uterine muscle.  Endometrioid carcinoma is diagnosed when endometriosis and ovarian cancer exist together. Endometriosis is a debilitating condition with an incidence of 7-10% among women in the general population and 5% in the post-menopausal women, on hormone replacement therapy. The typical blue-black spots or the chocolate cysts visualised at laparoscopy are the 'gold standard' for diagnosing endometriosis.

Causes of Endometriosis:

1.There are many probable causes attributed to endometriosis, but it does not fit a definite mould.

2.Retrograde Menstruation: tubal regurgitation of menstrual blood allows implantation of endometrial cells in the pelvis. Pregnancy may even cure the disease permanently.

3.The Coelomic Theory: the metaplastic changes of the coelomic epithelium into endometrial glands could explain endometriosis in unusual sites; genital tract mucosa is derived from the primitive coelomic peritoneum.

4.Direct Implantation Theory: direct extension into the myometrium focuses on the most likely cause for adenomyosis.

5.Lymphatic and Vascular Theory: this probably explains the presence of endometriosis in the lymph nodes and lungs.

6.Changes in the immune system and genetics, increasing the susceptibility to endometriosis showing a familial tendency

Endometriosis Symptoms:

There is no real correlation between the extent of endometriosis and the symptoms; there may not be any symptoms - a chance finding at laparoscopy. Dysmenorrohea and abdominal pain are the most common symptoms. Severe dyspareunia and back pain due to scarring of utero-sacral ligaments and other structures, and cyclical pain and bleeding from the rectum, the umbilicus or the bladder are also seen. Hip-joint pain due to scarring of the utero-sacral ligament and the involvement of the sciatic nerve can be excruciating. Rupture of the endometriotic cysts in the ovary, called chocolate cysts, can cause severe pain. There is a known increased risk of ovarian cancer; but the diagnostic laparoscopy and histology differentiate the two. Adhesions in the pelvis can lead to infertility.

 Treatment of Endometriosis:

 1.Symptomatic treatment for pain is by ibuprofen or paracetamol. Combined oral contraceptive pills or progestogens can be used initially.

 2.Suppression of ovarian function, using a non-cyclical oral contraceptive pills, progestogens, or Gonadotrophin releasing hormone analog that may require an ad-back therapy to prevent osteoporosis.

 3.Ablation of the endometriotic lesions by laser, laparoscopic cystectomy for chocolate cysts, conservative surgery by laser ablation and division of adhesions are preferred in younger women to preserve fertility. Hysterectomy with cytoreduction and removal of ovaries may also be required in severe endometriosis, but surgery does not guarantee a complete cure. Post-operative treatment with progestogens, with hormone replacement has been tried to prevent osteoporosis and vascular symptoms. 

 Endometriosis is an enigma that is still undergoing scrutiny, regarding its causes, detection of a less invasive diagnostic tool and the best form of treatment - for a better future and improved quality of life for all its victims. Yoga and deep breathing exercises, diet improvement and avoiding coffee and alcohol may improve symptoms.