Can endometriosis be asymptomatic?

Some endometriosis patients are truly asymptomatic, but in a significant number of such cases a deeper analysis of whether they have experienced symptoms like pain or bloating, can reveal the disease, says Dr. Abhishek Mangeshikar, an endometriosis excisional specialist at the Indian Centre for Endometriosis. It may also be diagnosed during routine checkups but only if a specialist is conducting an ultrasound or magnetic resonance imaging (MRI).

Endometriosis patients experience a variety of symptoms like pain during their period, ovulation and intercourse, fatigue, anxiety, stomach problems, and an inability to empty their bladder on their own. In this part of Femoai’s series of interviews on endometriosis, Dr. Mangeshikar talks about the risk factors, asymptomatic patients, its relationship with menopause, and some false beliefs that persist about the disease. Edited excerpts:

Can you have endometriosis and be asymptomatic? If yes, how is it diagnosed?

Yes, it may be asymptomatic. That either gets diagnosed accidentally via a routine scan if the patient is going in for a checkup and the doctor picks up a cyst or nodule or something. Nodules are missed unless there’s a specialist doing the ultrasound or the MRI. Sometimes, if a woman is infertile and she undergoes a fertility evaluation, the doctor may pick up endometriosis during a diagnostic laparoscopy.

The truly asymptomatic and the apparently asymptomatic are different groups. There is a smaller subset that are truly asymptomatic, but in most asymptomatic patients if you probe a little deeper you will see the history especially when you ask the patient questions about whether they have bloating, constipation, pain during ovulation or during intercourse. If any of those answers are a yes, then you can suspect endometriosis.

What are the risk factors for endometriosis?

There is some good evidence to show that there are genetic factors. But there are also epigenetic (how your behaviours and environment can cause changes that affect the way your genes work) factors. For example, identical twins may have different presentations of endometriosis. They may both have endometriosis but the way it develops in each of them may be impacted by environmental factors, but we don’t know exactly what those are. 

There is definitely genetic linkage but the problem is that it gets a little lost in history. Even now endometriosis pain is brushed under the rug, so we can only imagine what it was like in the previous generation especially without the diagnostics that are available today. They didn’t have those then. Unfortunately, there’s no way to test the genetic linkages but there is research going on.

What about various beliefs that weight gain or early menarche are risk factors for endometriosis?

There are spurious scientific articles citing ridiculous things like it’s got a higher predominance in the white race, or something to do with earlier age of menarche. The hypothesis here is that the longer a girl menstruates, the higher her risk of endometriosis. There is also this line that I remember from a medical textbook which said that fibroids are the fruit of virtue and endometriosis is a fruit of sin. It comes from a ridiculous belief that you see fibroids in women who don’t conceive and you see endometriosis in promiscuous women. It’s quite disastrous.

How does endometriosis impact your period?

Irregular periods are caused by hormonal fluctuations. Endometriosis doesn’t usually mess around with the regularity of the period. But there is a  cross link between endometriosis and polycystic ovarian syndrome (PCOS). Polycystic ovaries will lead to fluctuations in the hormonal profile, which will deregularise the menstrual cycle. There is a lot of overlap between endometriosis and PCOS, therefore endo patients may sometimes have irregularities. But usually in endometriosis, patients have regular cycles. Most women with endometriosis don’t have a hormonal imbalance, where they are not ovulating, like in PCOS. Which is why I say that most women with endometriosis are not necessarily infertile, unless there is an anatomical distortion of their tubes, or there’s a huge amount of pathology that is affecting the ovarian reserve.

What happens when someone with endometriosis undergoes menopause? What is the relationship with menopause and endometriosis?

There isn’t any; I have patients who have endometriosis and they have undergone menopause. There are patients who have undergone hysterectomy, removed their ovaries and they still have endometriosis. Endometriosis produces its own hormones and it may still persist after menopause, whether that menopause is natural or surgically induced. A hysterectomy and the removal of ovaries is not treatment for disease that is outside the uterus.

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