Complex Benign Conditions



Endometriosis is a common condition where tissue that normally lines your womb starts to grow in other parts of your body. It affects about 1 in 10 women and may cause pain or infertility. However some women have few or no symptoms. The causes of endometriosis are not fully understood. 


It most often occurs on or around reproductive organs in the pelvis or abdomen, including:

  • Fallopian tubes
  • Ligaments around the uterus (uterosacral ligaments)
  • Lining of the pelvic cavity
  • Ovaries
  • Outside surface of the uterus
  • Space between the uterus and the rectum or bladder

More rarely, it can also grow on and around the:

  • Bladder
  • Cervix
  • Intestines
  • Rectum
  • Stomach (abdomen)
  • Vagina or vulva

Symptoms of endometriosis

The most common signs of endometriosis are pain and infertility. Endometriosis pain typically presents as:

  • Painful menstrual cramps that may go into the abdomen (stomach) or lower back
  • Pain during or after sex

Other symptoms may include:

  • Diarrhoea or constipation during a menstrual period
  • Fatigue or low energy
  • Heavy or irregular periods
  • Pain with urination or bowel movements during a menstrual period
  • Spotting or bleeding between menstrual periods

Each person’s experience with endometriosis is different. Women with endometriosis may have some of these symptoms, all of these symptoms or none of them. Having severe pain or other symptoms is not necessarily a sign of more severe endometriosis.

Diagnosis of endometriosis

It can be difficult to diagnose endometriosis because individual symptoms can vary. The most effective way to diagnose endometriosis is by examination with ultrasound or through a laparoscopy.

A laparoscopy examination involves your gynaecologist making a very small incision (cut) near your tummy button. They then insert a thin camera (laparoscope) through the cut to examine the pelvis and abdominal cavity.

They may take a small tissue sample (biopsy) which is sent to the pathology lab for diagnosis.

Treatment of endometriosis

Various medications can be taken to suppress endometriosis. These all suppress endometriosis quite well on a temporary basis but it tends to recur once the medication is stopped. Complete removal of endometriotic lesions (excisional technique) using laparoscopic or robotic surgery appears to offer significant and long-term relief of pelvic pain and improved fertility. On the other hand, the ablation technique ('burning' of endometriotic lesions) is associated with rather high risk of recurrence.

Hysterectomy may not be the best solution for relief of pelvic pain associated with endometriosis. This is because endometriosis lies principally outside of the uterus in the pelvis.

Medical treatment will not improve fertility. However surgical treatment of endometriosis improves the chances of spontaneous pregnancy by 40% or more.  It is recommended they take progestogen as well as oestrogen even after an excision of endometriosis (with or without hysterectomy).



Fibroids, also known as uterine leiomyomas or fibromyomas, are benign (non-cancerous) tumours that grow in and around your uterus. Fibroids can be found in up to 40% of women. Most of these women will not experience any symptoms.  In some women, due to the fibroid’s size or location, it may cause problems requiring treatment. Fibroids grow at a very slow rate and will often have been present for many years before they are diagnosed. They will continue to grow slowly until the menopause after which they usually shrink in size.

Fibroids are categorized by their location, which includes:

  • Intramural – growing in the uterine wall. Intramural fibroids are the most common variety
  • Submucosal – growing in the uterine lining (endometrium). This type tends to cause excessive menstrual bleeding and period pain
  • Subserosal – growing on the exterior wall of the uterus. They sometimes appear like balloon on a stick

The most common fibroid symptoms are heavy, prolonged or painful periods and a feeling of pressure in your lower abdomen. Other symptoms include:

  • Bleeding between periods
  • Abdominal swelling or bloating
  • Feeling pressure in the lower part of your abdomen
  • Frequent urination
  • Lower back pain
  • Constipation, as fibroids can sometimes press against the rectum
  • Haemorrhoids
  • Pain during sex

Diagnosis of fibroids

When a clinical history or examination suggests fibroids, an ultrasound will be organised to confirm the diagnosis.

Other investigations, such as hysteroscopy (video imagining of the uterine cavity), Computed Tomography (CT) scan or Magnetic Resonance Imaging (MRI) may be required.

Treatment of Fibroids

  • Treatment of fibroids depends on the age of the patient, their location, and the symptoms they cause.
  • Most women will require no treatment at all.
  • If the presenting problem is menstrual irregularities then it is usual to investigate for other causes of heavy periods. When these have been ruled out, a trial of medication may be used as first line management.
  • Women who have a very large fibroid or multiple fibroids that are causing symptoms, and who have completed their family, will usually be offered a hysterectomy. This is usually performed via laparoscopic or robotic surgery.
  • Women with large fibroids who are symptomatic and who still want children may be offered a myomectomy. In case of submucosal fibroids, a hysteroscopic excision is performed. For intramural or subserosal fibroids, the myomectomy is usually carried out via laparoscopic or robotic surgery.

Pelvic Organ Prolapse


When the muscles and ligaments supporting a woman's pelvic organs weaken, the pelvic organs can drop lower in the pelvis, creating a bulge in the vagina (prolapse). Women most commonly develop pelvic organ prolapse years after childbirth, after a hysterectomy or after menopause.

Several types of vaginal prolapse conditions have been indentified and they include:

  • Cystocele – When the front wall of the vagina is weakened the bladder pushes into the vaginal canal
  • Rectocele – When the back wall of the vagina is weakened the bowel bulges into the vaginal canal
  • Vaginal vault prolapse – Top portion of vagina collapses into vaginal canal
  • Uterine prolapse – Uterus prolapses into the vagina

The pressure from prolapse can cause a bulge in the vagina that can sometimes be felt or seen. Women with pelvic organ prolapse may feel uncomfortable pressure during physical activity or sex.

Other symptoms of pelvic organ prolapse include:

  • Seeing or feeling a bulge or "something coming out" of the vagina
  • A feeling of pressure, discomfort, aching, or fullness in the pelvis
  • Pelvic pressure that gets worse with standing or coughing or as the day goes on
  • Leaking urine (incontinence) or problems having a bowel movement
  • Problems inserting tampons

Some women say that their symptoms are worse at certain times of the day, during physical activity, or after standing for a long time. 


Treatment for pelvic organ prolapse depends on the type of prolapse you have, your symptoms, your age, other health problems, and whether you are sexually active.

Your treatment may include one or more of the following: