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Only 10 percent of endometriosis patients are affected by bowel endometriosis, but those without endometrial lesions in this area may experience bowel-related symptoms as well. What do you need to know?

What is bowel endometriosis?

If you're reading this, you almost certainly know all about endometriosis — a painful and chronic inflammatory condition in which the tissue that ought to line the uterus spreads to other areas of the pelvis and even beyond. Bowel endometriosis refers to endometrial lesions of the bowel.

Though gastrointestinal symptoms aren't uncommon in endometriosis sufferers, only about one in 10 women with endometriosis have these lesions on their bowels. Among those who do have bowel endometriosis, the rectum and sigmoid colon are by far the most common spots for endometrial lesions, while a smaller number have endometriosis in the small bowel, caecum, and appendix. 

You don't need to have endometrial lesions in your bowels to have symptoms relating to that area, though, as inflammation caused by endometriosis in other parts of the body can radiate out. Your body releases prostaglandins, interleukins, cytokines, and tumor necrosis factor (TNF) in response to inflammation, and these can lead to extensive alterations within your tissue. Contractions within the bowel and the growth of new blood vessels in turn contributes to scar tissue formation. This process leads to bowel-related symptoms, which affect more than half of women with more severe endometriosis (stages III and IV). 

Bowel endometriosis: Symptoms

The symptoms of bowel endometriosis can include intestinal cramps, diarrhea, constipation, painful bowel movements, blood-stained bowel movements, and abdominal bloating. Some additionally feel nauseous. These symptoms are similar to those Crohn's disease patients suffer from, but unlike them, women with endometriosis will notice that they are hit hardest around the time of their periods. 

Research indicates that various bowel-related symptoms are more common in endometriosis sufferers than you may think:

  • More than half of patients experience frequent diarrhea
  • Over a third encounter bouts of constipation
  • A quarter have to endure pain while moving their bowels, and experience gastrointestinal cramps

The real numbers may be much higher, as those interviewed were suffering from debilitating symptoms and talked to their doctors about them. How many more are suffering in silence?

How can bowel endometriosis be treated? 

Your options are:

  • Expectant management (wait and see, then intervene if the situation gets worse) — this is suitable for women with very minimal symptoms
  • Pharmacological treatment
  • Alternative remedies
  • Surgery

Women who have symptomatic bowel endometriosis will often be advised to:

  • Use nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce the pain as well as inflammation. (Note that opioids do not just have a high addictive potential, but can also lead to constipation. They are, as such, not recommended.)
  • Hormonal treatments — suitable for women who are not trying to conceive — can include combined hormonal contraceptives, progesterone-only contraceptives, or hormone therapies not also designed to have a contraceptive effect. Examples of the latter include gonadotropin-releasing hormone (GnRH) agonists like triptorelin (Trelstar) and Danazol.
  • Alternative treatments, including acupuncture, aren't held to the same high scientific standard as pharmacological treatments, but they offer relief to some patients.

When do you need to consider surgery for bowel endometriosis?

The treatments above focus on symptom management — they can make you feel better, but do not halt the progression of endometriosis. For more severe bowel endometriosis, surgery may be the only option that offers you long-term relief. Various surgical options are available to bowel endometriosis patients, and less invasive laparoscopic operations are often the surgical mode of choice. The vast majority of patients can have their endometrial lesions removed in this way. In some cases, open surgery is preferred, however. 

Here's an overview of surgical options for bowel endometriosis:

  • Disc resection is often the first surgical point of call. During this operation, your surgeon removes the diseased tissues within the inestine and then sutures it. This surgery is suitable for smaller endometrial lesions.
  • Rectal shaving sounds terrible — but it refers to a procedure in which endometrial lesions are removed from the surface of the bowel. It is generally used for smaller endometrial lesions of up to three centimeters, though it is suitable for deeper lesions that penetrate the rectum. Because the surgery may fail to remove all endometrial cells, around four percent of women who undergo rectal shaving will experience recurrences. 
  • A segmental bowel resection may be an option for women with more extensive bowel endometriosis. To eliminate the diseases areas of the intestine, portions of it are removed altogether. After this, the healthy sections of your intestines are joined up again, a procedure called reanastomosis. Depending on the length of the intestinal portion that is removed, this surgery may lead to changes in bowel function that require dietary alternations. A segemtal bowel resection is, however, very effective, with recurrences being unlikely.
Some bowel endometriosis patients require a temporary colostomy, in which case open surgery is more likely to be needed. In addition, recovery from any of these surgical procedures will take time (up to a week for laparoscopy, and around two weeks for open surgery), require painkillers, and often a urinary catheter. Surgery isn't an "easy fix", then, but it may be just what you need to improve your quality of life. Discuss the advantages and risks of surgery as well as those of not having surgery with your physician in detail before you make the decision.

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