Endometriosis is painful and can affect your fertility. We discuss treatment options, plus, your chances of conceiving…



Norjana Juma’at never had any problems with her periods until she delivered her third child.

Says the 46-year-old single mother of four, “My menstruation became irregular, the flow became heavier and the cramps got more intense and were usually accompanied by headaches.”

Worried, Norjana saw her gynae, only to learn that she has endometriosis, a bulky womb and a 4.5cm-wide cyst. Still, she overcame the odds and went on to have a fourth child.

Norjana’s gynaeDr Heng Tun Lan of Singapore O&G Clinic for Women — was also surprised that Norjana was able to not just conceive but also deliver a full-term baby.

Endometriosis is a condition where the tissue of a woman’s uterine lining is found outside the uterus. Dr Heng notes that while some women with endometriosis experience few or no symptoms at all, others may experience:

* Severe menstrual cramps.
* An urge to pass motion or pain while passing motion, especially during menstruation.
* Chronic pelvic pain.
* Painful intercourse.
* Heavy menstrual bleeding.
* Infertility ― this may also be the only symptom.

“Women whose female relations — such as their mothers, sisters and aunts — had endometriosis are more likely to suffer from it.”

However, Dr Heng reassures women that an endometriosis diagnosis may not mean your baby-making hopes are dashed. She explains that your chances of conceiving naturally will depend on where these cells are found.

“If the cells are found on the ovaries or fallopian tubes such that they disrupt or block the passage of sperm to the egg, the woman’s chances of conception are much lower than if they were found attached to the appendix or stomach.”

Dr Heng answers your burning endometriosis questions….

What is the incidence of endometriosis in Singapore?

While there has not been a wide-scale study done in Singapore, the accepted consensus is that endometriosis affects about 10 per cent of Asian women of childbearing age. The incidence of endometriosis rises to about 40 per cent in patients who are being seen for subfertility.

How does a woman determine if she has heavy menstrual bleeding (HMB)?

An average woman loses about 40ml of blood every menstrual cycle. Those with HMB are said to lose twice that amount — about 80ml. However, this may not be a feasible way to determine if you have HMB.

It’s more practical to observe the following symptoms:
* Soaking through one or more sanitary pads or tampons every hour for several consecutive hours.
* Needing to rouse during the night to change your sanitary pad or tampon.
* Bleeding exceeds a week.
* Passing large blood clots.
* Severe cramping.
* Anaemia or its associated symptoms such as fatigue, shortness of breath and headaches.

What risk factors will increase a woman’s chances of getting endometriosis?

Genes play a part in the incidence of endometriosis. Women whose female relations — such as their mothers, sisters and aunts — had endometriosis are more likely to suffer from it.

What common misconceptions are there about women suffering from endometriosis?

It is thought that endometriosis only affect older women. The truth is it can occur in any female of childbearing age from their teenage years to their 40s. A lack of awareness and the perpetuation of myths such as “girls will grow out of their menstrual cramps”, or “cramps will get better when you get married or become pregnant”, contribute to a delay in diagnosis for many young patients.


What about treatment options?

Endometriosis may be treated with medication or surgery. The doctor will explain your options and help you make a decision based on the severity of your symptoms as well as size of any cysts and lesions. Treatment will also depend on whether you are planning a pregnancy in the future. Generally, doctors recommend trying conservative treatment options like taking medication first and leaving surgery as a last resort. For milder symptoms, over-the-counter pain medication such as non-steroidal anti-inflammatory drugs may provide some relief in the short term.

How is endometriosis managed?

Common therapies include:

* Gonadotropin-releasing hormone (GnRH) agonist injections These stop the production of certain hormones to prevent ovulation, menstruation and the growth of endometriosis. On the downside, you will start to experience side effects that are similar to menopause such as hot flashes, tiredness, poor sleep and headaches. You will need to inject yourself either monthly or once every three months. The injections are also usually prescribed for short periods of time — about six months — with a rest period of several months between treatments if they are repeated because there’s an increased risk of bone loss.

* Contraceptives Besides oral contraceptives, slow-release contraceptives like progestin-only intrauterine implants can help to reduce or eliminate any pain. These contraceptives control the hormones responsible for the build-up in endometrial tissues. As a result, your periods will be shorter and lighter, too.

“GnRH agonist injections stop the production of certain hormones to prevent ovulation, menstruation and the growth of endometriosis.”

* Oral progestin medications It reduces the production of certain hormones associated with menstruation. Most women find they stop menstruating after taking them for a few months, so they are effective at reducing period and pelvic pain but it does not cause the menopausal state associated with GnRH agonists. Over time, this oral medication not only prevents the spread and growth of lesions and cysts but can actually cause some lesions to shrink. Women who hope to conceive after therapy often choose this option as their fertility will return to normal after they stop using the medication.

* Surgery A surgical procedure will be carried out to remove as much endometrial cells as possible while preserving your uterus and ovaries.

What pregnancy complications can endometriosis cause?

Some women are asymptomatic. Others have cramps or if you have a large cyst, this can result in ovarian torsion or rupture. An ovarian torsion occurs when an enlarged cyst causes the ovary to move and increase the chances of it twisting around other tissues. It can also lead to blood-supply being cut off from the area. The cyst may also rupture, resulting in severe pain and internal bleeding. Otherwise, adenomyosis — a condition where the inner lining of the uterus, called the endometrium, breaks through the wall of muscle in the uterus — can also cause the growth of your foetus to slow and result in premature delivery.

Photos: iStock

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