Introduction and background:
Endometriosis is a long chronic condition that affects women of any age from puberty to menopause. It is a condition where cells similar to the inner lining” of the womb(uterus), also known as endometrium, are found in places they are not supposed to be, mostly in other female reproductive organs such as the ovaries, fallopian tubes, and the space between the bladder, uterus, and vagina. They are rarely found in the large and small bowel, appendix, diaphragm, lungs, and rectum (What Is Endometriosis?, n.d.). It produces a chronic inflammatory response that causes scar tissues and pain in that area when they grow (Understanding Endometriosis, n.d.).
It is estimated that two million women in the UK have endometriosis. Each month, if pregnancy does not occur; the womb’s lining breaks down and is shed as a menstrual period. The endometriotic tissue (endometriosis) will respond to the monthly fluctuations of the menstrual cycle and eventually bleed. As mentioned above, this may cause pain during periods, inflammation, and scarring. The scarring can cause organs or structures to stick to each other and form small lumps called ‘endometriotic nodules,’ which can be very painful to touch. These will cause women to experience pain during sexual intercourse (General information about Endometriosis: University College London Hospitals NHS Foundation Trust, 2021).
There are several theories about the cause of Endometriosis, such as retrograde menstruation. However, the exact cause is unknown (Seckin, 2020). Normally, the menstrual blood flows out of the body during a period, while in retrograde menstruation, menstrual blood and tissue from the uterus flow backward and into the fallopian tubes (Endometriosis: Endometriosis Symptoms, Treatment, Diagnosis – UCLA, n.d.). On the other hand, several risk factors might increase the chances of getting endometriosis. Some have a family history of endometriosis, menstrual cycles less than 27 days, and menstrual flow of more than 7 days (Davila, Kapoor & Alderman, 2021).
Endometriosis causes a variety of symptoms in women. The pain can be intense during the period, but with Endometriosis, pain is extremely severe that might affect day-to-day activities. Endometriosis patients may experience very long or heavy periods, severe headaches, and low back pain during periods—also, vaginal bleeding between periods and blood in the urine. Infertility is common because the endometriosis tissue grows outside the uterus, causing scarring, affecting the fallopian tubes, and preventing the egg from meeting the sperm. It can also stop a fertilized egg from implanting in the uterus lining (Pathak, 2021). If endometriosis continues to spread, it can put pressure on nerves located in the back or upper legs, which can press on the sciatic nerve that runs from your lower back down each leg and causes leg pain that feels like an aching or stabbing sensation (Todd, 2021).
Endometriosis is classified by its anatomical location within the pelvis into four categories: Peritoneal endometriosis, Ovarian endometrioma, Deep Infiltrating Endometriosis (DIE), and frozen pelvis. Firstly, Peritoneal endometriosis is the minimal form of endometriosis in which one or two endometriosis lesions invade the peritoneum (the membrane that lines the abdomen). Lesions are typically non-pigmented, so it becomes obvious after putting them in contrast and visualizing them with the aid of laparoscopic light (Seckin, 2020). Secondly, Ovarian Endometrioma, also known as chocolate cysts, is the most common type after Peritoneal Endometriosis. It is a large, fluid-filled cyst that forms on or fully surrounds the ovaries. They are at risk of breaking and spreading endometriosis within the abdominal cavity (Endometriosis Stages: Understanding the Different Stages of Endometriosis, n.d.). Thirdly, Deep Infiltrating Endometriosis (DIE) is a type of endometriosis that is extremely invasive. It penetrates the bladder and bowel wall. The most severe form of advanced endometriosis is the frozen pelvis, including the most severe cases of Deep Infiltrating Endometriosis (DIE). In this rare condition, deep invasive lesions attach to muscle tissues, nerves, and pelvic ligaments (Seckin, 2020).
To diagnose endometriosis, a medical history of menstrual symptoms is taken. The doctor does a pelvic exam to feel for signs of cysts or scar tissues. As well as a screening tool such as an ultrasound to look for Ovarian endometrioma (a large, fluid-filled cyst that forms on or fully surrounds the ovaries) and magnetic resonance imaging (MRI) which is used to take a clear picture of the body from the inside and help doctors to prepare for surgery on women with endometriosis (Endometriosis: How do I know if I have it?, 2020). It can be misdiagnosed with several conditions. These include irritable bowel syndrome (IBS), appendicitis which is a painful swelling of the appendix (Seckin, 2020).
No cure is currently available for Endometriosis. However, different treatments are used for pain and infertility caused by the disease (Seckin, 2020). The treatment options are based on age, symptoms, past drug history, and whether the patient is considering getting pregnant. Non-surgical treatments are used to control the patient’s pain and symptoms, such as anti-inflammatories (painkillers), birth control pills. Surgical treatments and hormone treatments are also used to stop or limit estrogen production in the body. Oestrogen is a hormone the urges endometriosis tissue to grow (Endometriosis – Treatment, 2019).
Endometriosis affects approximately 190 million women at their reproductive age worldwide. It is the second common gynecological condition in the UK, affecting 1 in 10 women from puberty to menopause. Yet, 64% of women aged 16-24 don’t know what Endometriosis is, which indicates the poor awareness of the condition (Endometriosis Awareness Month launches to tackle the fact 54% don’t know about endometriosis, 2020).
The UK government has recently announced an investigation aiming to understand better how endometriosis is experienced and treated and improve it. They worked alongside the All-Party Parliamentary Group (APPG), the BBC, charities, and campaigners who surveyed sufferers to find out the shocking fact that endometriosis takes an average of 8 years to be diagnosed, and this has been the case for the past 10 years without any improvement. This showed a failure of the healthcare system and the lack of support to those living with the condition. As an illustration of this is, 58% of patients visited their GP more than 10 times before getting a diagnosis (The All Party Parliamentary Group on endometriosis: report October 2020).
The recommendations made after this investigation were reducing the average diagnosis time to be four years or less by 2025 and only a year by 2030 ((Leigh Day, 2021. In England, menstrual wellbeing has been implemented into the school curriculum as a mandatory part, and more funds have been given for research to understand the causes and identify better diagnostic techniques. (The All Party Parliamentary Group on endometriosis: report October 2020).
Section 2- Sociology:
Social determinants of health are defined by World Health Organization as the conditions in which people are born, grow, and age, and other systems that form the conditions of everyday life. This section will be mainly discussing the different social determinants that play a role in endometriosis prevalence and possible impacts on patients suffering from this chronic condition. The main social factors that will be assessed and studied are age, ethnicity, lifestyle, and associated mental health disorders and sexuality.
Those who suffer from endometriosis may need various types of medical treatment, repeated surgical procedures, and sometimes infertility treatments. The Royal College of Obstetrician and Gynaecologists published an article in 2017 which showed that 10.8 per 1000 women were affected by endometriosis and that the age group that ranged between 40 and 44 witnessed the highest prevalence of 18.6 per 1000 (Eisenberg et al., 2017). However, confirming endometriosis diagnosis can be delayed for many reasons and this delay plays an essential role in condemning these women for a life of unnecessary suffering and reduced quality of life. Most women start experiencing symptoms before the age of 20 (Hribar, 2018), yet according to another study most newly-diagnosed patients aged between about 26 and 42 years old (Eisenberg et al., 2017). This significant delay in diagnosis results in various negative impacts on these women’s lives and one of these impacts is subfertility. A retrospective cohort study that was published recently in Oct 2021 shows a clear connection between delayed diagnosis and subfertility. The study showed that one in three women who resort to Assisted Reproductive Technology (ART) had endometriosis and 34.4% of these women did not know of their diagnosis before the ART (Moss et al., 2021).
Race and Ethnicity:
Another important social determinant to be taken into consideration is race and ethnicity. Many reviews show that there is a statistically significant difference in the prevalence of endometriosis in different races and ethnic groups found in Britain. A systematic review about the Influence of race/ethnicity on prevalence and presentation of endometriosis shows that black women were less likely to receive the diagnosis of endometriosis when compared to white women (OR 0.49, 95% CI 0.29–0.83). However, it was evident in the study that endometriosis in Asian women had a higher rate of incidence in comparison to white women (OR 1.63, 95% CI 1.03–2.58) (Bougie et al., 2019). The same held true for women with Hispanic origins (OR 0.46, 95% CI 0.14–1.50). Furthermore, the study sheds light on the scarcity of literature that explores the effect of race/ethnicity on symptoms’ presentation in these different groups and different treatments’ access and success.
Quality of life and lifestyle:
The third prospect that will be discussed in this section is the relation between various lifestyle habits and endometriosis. Endometriosis is a chronic and common disease in the world, and extensive experiments have, therefore, been conducted in an attempt to find modifiable risk factors. Different aspects such as dietary habits, alcohol consumption, physical activity, and smoking have been studied. One study has shown that there is no definite relation between certain lifestyle habits and the prevalence of endometriosis in infertile women (Vaghar, 2019). Furthermore, another study shows shocking results that smoking is, in fact, connected with a lower incidence of endometriosis and even endometrial cancer. In this study where mice were exposed to cigarette smoke and this showed an increase in the production HOXA10 and progesterone receptor PGR. Both substances increase endometrial differentiation and they are found in lower quantities in endometriosis (Zhou et al., 2011).
Even though there was no direct correlation between certain lifestyle habits and the incidence of endometriosis, it is important to mention that there is a significant impact of changing lifestyle on endometriosis related pain (Ghonemy & Sharkawy, 2017). This study was conducted on a group of 50 women diagnosed with endometriosis, and the results reveal that there is a statistically significant decrease in the severity of disease-related pain after three months of eating a healthy diet. The recommendations that were given to these women included eating food rich in fibers, learning healthy ways of cooking meals such as boiling or grilling, and increasing diet that has an anti-oxidant effect such as Omega3. In addition, they received important information about what types of food to avoid and exercise recommendations. The results of this study showed that patients post-education reported a significant decrease in the severity of the pain after adopting a healthier lifestyle and particularly a healthier diet (Ghonemy & Sharkawy, 2017).
Various studies have shown a relationship between endometriosis and mental health disorders such as anxiety and depression, which in turn impair significantly the quality of life of the affected women. One of these studies was conducted on 104 women with endometriosis to evaluate depressive and anxiety symptoms and has found that 86.5% showed depressive symptoms and 87.5% presented anxiety disorder (Laganà et al., 2017). Quality of life and sexual health have become increasingly important in women with endometriosis. It has been shown a relationship between endometriosis and painful sexual intercourse (dyspareunia) and over a period of six months, sexual dysfunctions and sexual distress were presented in 32% and 78% of the studied women, respectively (Jose Marques Lopes, 2017).
Endometriosis is a chronic disease that affects many women of childbearing age. Its symptoms affect daily life and reduce the quality of life. However, many measures can be taken to help these patients as shown in this section. Starting with educational programs that ensure an increasing awareness in the society. Hopefully, increased awareness of this condition can lead to earlier diagnosis and thus fewer sequelae, reduced suffering, and fewer women with subfertility.
Section 3 – Behavioral intervention:
An unhealthy lifestyle is a major risk factor for many diseases. Implementing lifestyle changes and behavioral interventions is considered a way to promote better health in individuals. Lifestyle interventions are relatively safe, simple, and inexpensive, and it stimulates healthy behavior. When it comes to endometriosis, evidence suggests that there is a clear connection between endometriosis and dietary changes. This section will be focusing mainly on evidence supporting the benefits of dietary changes including the increase of food containing anti-inflammatory and anti-oxidants components and decreasing harmful dietary habits.
Science does not yet know the exact reasons why endometriosis develops. The most widely accepted theory is origin via retrograde menstruation (Sampson’s implantation theory). At the same time, there is an inflammatory response from the body which leads to the growth of blood vessels and nerves as well as scarring and sometimes adhesions. This condition is Oestrogen dependent, which means that the oestrogen levels in the patient’s body play a significant role in that condition (Chantalat et al., 2020). This helps in understanding the effects of alcohol and dietary changes on endometriosis and its symptoms.
International Organization of Scientific Research published a study that examined 50 women diagnosed with endometriosis and how dietary changes for three months reduced the disease-related pain which is the most significant symptom of endometriosis. This group of patients received thorough information about dietary changes that could be beneficial for endometriosis in a form of oral instructions supported with a written booklet. The advice was directed mainly to changing eating habits which included: an increase in fiber-rich food such as vegetables and fruits, increasing the amount of anti-inflammatory and antioxidants such as fish and seafood that contain Omega-3, and avoiding red meats and fried foods. They explained the benefits of adopting healthier eating habits on endometriosis and its symptoms (Ghonemy and Sharkawy, 2017).
On the one hand, Fruits and Vegetables are rich in two types of metabolites which are called flavonoids and carotenoids. They are known to have important anti-inflammatory and anti-oxidant properties. In addition, many vegetables are known to be rich in vitamins such as Vitamin A, B, and C which certain studies have shown to be low in endometriosis patients. On the other hand, red meats should be limited as they have been shown to have a pro-inflammatory effect which as mentioned before inflammation is an important part of endometriosis’ mechanism of causing symptoms (Jr and MS, 2017).
The previous study shows how various behavioral intervention methods can be implemented to ensure a positive effect on patients. The information was first introduced to the patients verbally by health care professionals who delivered the information in a simplified manner without any medical jargon. In addition, they provided the patients with healthier alternatives to substitute harmful cooking techniques such as grilling or boiling instead of frying. Moreover, they provided the patients with a written booklet that included the previously mentions advice. Patients were followed up by three educational sessions each one was held for 30 minutes, to ensure a full understanding of the importance of this behavioral change. Another important method that was used is Telephone follow-up with every patient to reinforce the acquired knowledge and to attend to their questions.
The study results shows that adequate health education and continuous follow-up resulted in a significant improvement in patients’ symptoms that are caused by endometriosis. Every patient was assessed before and after the completion of the three months of the study. The study shows that pre-education, 74% of the patients in the study suffered from severe pain. In comparison, three months post education the percentage decreased dramatically to 32%. Even though this study should be replicated on a larger scale to confirm the results, it shows how behavioral intervention in regards to dietary changes can in fact improve the quality of life for endometriosis patients.
A metaanalysis on alcohol consumption and endometriosis shows that there is a clear connection between alcohol consumption and endometriosis risk. However, studies cannot confirm yet if alcohol could exacerbate an existing condition or affect the severity of its symptoms (Parazzini et al., 2013). Alcohol is known to increase estrogen levels in the body and therefore, could increase the severity of endometriosis symptoms. It is therefore very important for women who suffer from endometriosis to adopt a lifestyle with minimum consumption of alcohol (Buntajova, 2021).
The measures that can be taken to motivate this behavioral change can vary. The first step in such a behavioral intervention would start by raising awareness in this patient group. This can be done most efficiently by introducing the theoretical information by a health care professional. In addition, it is of high importance to ensure the complete comprehension of the provided knowledge by continuous follow-up. This is also beneficial to provide the needed support for the patients. Furthermore, educating these patients in small groups can provide a higher sense of support for the patients who might adhere more to the medical advice that is being provided when they know that others go through the same behavioral changes. Last but not the least, all the information should be provided in a written form for the patients to take home and ask questions to their health care providers when needed.