Endometriosis

Painful, unpredictable, and discouraging. I could go on and on with words to describe the hardship associated with endometriosis. The true prevalence of the disease is unknown because you must have surgery to confirm its presence. We estimate it effects between 10-15% of the population. The disease may start at any time in the lifecycle.

The lining of the inside of the uterus is called the endometrium. During the menstrual cycle, this lining builds up to prepare for pregnancy. If the woman does not get pregnant, the lining is then shed during the menstrual period. Endometriosis occurs when the cells of the endometrial lining grow outside of the uterus. The condition is rarely life threatening, but it can do significant damage to the quality of a woman’s life.

What are the effects of endometriosis?

Endometriosis commonly causes inflammation, scarring and immobility on the outside of the uterus, ovaries, or on the bladder. While rare, the disease can also be found outside the reproductive tract including the colon and lungs.

We have not actually identified the cause of endometriosis to date. However, one theory suggests a “back flow” of menstruation where the menses flows backwards through the tubes into the abdominal cavity. The endometrial tissue then begins to grow on the organs in the pelvic and abdominal area. This “spreading” beyond the uterus can be compared to weeds sprouting up in your garden after the seeds blow in from neighboring fields. Other theories are based on spread of the endometrial cells via the vascular and lymphatic systems.

What are the risk factors?

Women with a mother, sister or aunt who have had endometriosis face a seven-fold increased chance of having the disease. A relationship has also been demonstrated between autoimmune disorders (lupus, rheumatoid disease) and endometriosis. Beyond family history, the predictive risk factors are few.

What are the symptoms?

Classic symptoms of endometriosis include cyclic pain beginning 1-2 days prior to onset of the period and lasting the first few days of the cycle. The disease is mysterious as some women have a minimal amount of disease with severe pain, while others have no pain at all although they have severe endometriosis. The pain can begin suddenly or develop over years. Patients sometimes report chronic pain in their pelvis or back, menstrual pain prior to and during their menses, pain with sexual activity, ovulatory discomfort, and any situation that puts pressure on the internal organs such as having a full bladder, physical activity, or straining to have a bowel movement. Abnormal bleeding only occurs in 20% of women.

How is it related to infertility?

Endometriosis is one of the most common diagnosis found in the initial evaluation of infertility. The disease can cause scarring within the tubes and on the ovaries that effect the mobility of the reproductive tract.

How is it diagnosed?

If you have some or all of these symptoms, do not be alarmed. Many women experience pain with ovulation and menstruation and do not have endometriosis. These symptoms may help predict if someone has endometriosis, but we are not certain until a surgical procedure called a laproscope is used to see the presence of the disease.

What are the treatment options?

To discuss treatment of endometriosis, one must remember that it is a chronic, progressive disease that varies widely from patient to patient. A patient who starts with mild disease may progress to severe disease in a matter of six months. Others may not progress over many years. Once the diagnosis of endometriosis has been made, your healthcare provider has many options to consider depending on the classification and symptoms. Each treatment must be individualized.

Medical therapies often reduce or eliminate estrogen production, which therefore, stops the growth and progression of endometrial cells. The whole idea is based on trying to achieve either a menopausal state where no estrogen exists at all or the “pseudopregnancy” state where no ovulation or menstruation occurs. Oral contraceptives are often used to inactivate endometriosis. With more severe discomfort or failure of contraceptives, we proceed to more aggressive medications that unfortunately can cause menopausal symptoms that can be difficult to tolerate including hot flashes, vaginal dryness, and irritability. Sometimes, we are able to prescribe other medications that can improve these symptoms.

Surgical treatment options include a laparoscopic procedure where we identify the disease with a small camera inserted in the abdomen. The surgeon can then identify the location of the problem and remove some of the scarring. Occasionally, we take a more aggressive approach and remove the uterus and ovaries. This is usually reserved for severe cases and only an option if the woman does not desire future fertility. Each patient’s care must be individualized according to her symptoms and extent of the disease. We would be happy to meet with you and review your symptoms and develop a personalized treatment plan to improve your symptoms.

The internal organs are all lined with a clear tissue known medically as the peritoneum.

This is like a piece of clear plastic food wrap that covers the uterus, tubes, bladder, etc. It is innervated by pain fibers so that the body has a way of recognizing when something goes wrong. So imagine endometriosis (the endometrial tissue that usually lines the inside of the uterus) attaching itself to the surface of this plastic wrap (the peritoneum) on the internal organs of the abdomen. Just a small bit can cause significant pain. It usually spreads with time and the more it grows and penetrates the more it irritates the peritoneum with an associated increase in pain. The process is particularly painful near the time of menses, since the tissue swell and bleed. Blood is very abrasive to the peritoneum, somewhat like sandpaper.