Endometriosis

Causes and Risks:
The cause of endometriosis is unknown, however, a number of theories have been proposed. The retrograde-menstruation theory proposes that endometrial cells (loosened during menstruation) may "back up" through the Fallopian tubes into the pelvis where they implant and grow in the pelvic and/or abdominal cavities. The immune-system theory suggests that a deficiency in the immune system allows menstrual tissue to implant and grow in areas other than the uterine lining. A genetic theory proposes that certain families may exhibit predisposing factors that lead to endometriosis.

Once the endometrial cells implant in tissue outside of the uterus they become a problem. Each month the ovaries produce hormones that stimulate the cells of the uterine lining to multiply and prepare for a fertilized egg (swell and thicken). The endometrial cells outside of the uterus also respond to this signal, however, they lack the ability to separate themselves from the tissue and slough off during the next menstrual period. They sometimes bleed a little bit but they heal and are stimulated again during the next cycle. This ongoing process causes scarring and adhesions in the tubes and ovaries, and around the tubal fimbriae. These adhesions can make transfer of an ovum from the ovary to the fallopian tube difficult or impossible. They can also stop passage of an ovary down the fallopian tube to the uterus.

Once in a while the growing cells will penetrate the tough covering of the ovary and begin to multiply. These cells can collect large amounts of blood and form what is called, appropriately, an ovarian blood cyst . These have been known to grow to the size of a hen's egg or even an orange, and as you can imagine, are usually very painful. Over time the collected blood darkens and for this reason the cysts are frequently called "chocolate cysts".

Endometriosis is a common problem among women and occurs in an estimated 10 to 20% of them during their reproductive years. The prevalence may be as high as 15 to 40% among infertile women. Although endometriosis is typically diagnosed between the ages of 25 and 35, the problem probably begins about the time that regular menstruation begins. Adolescents may experience symptoms such as severe cramping or discomfort, however, they are frequently ignored or written off as normal. A woman who has a mother or sister with endometriosis, has a risk of developing endometriosis that is 6 times greater than that of the general population. Other risk factors include having a menstrual cycle lengths of 27 days or less, early onset of menstrual periods, and periods lasting 7 or more days. Orgasm during the menstrual cycle has also been noted as a potential risk factor (linked to the retrograde menstruation theory).

Prevention:
There is no proven prevention for endometriosis, however, some women with endometriosis who successfully become pregnant find that they are free of the disease afterwards. Pregnancy also tends to delay the onset and progression of the disease in susceptible women.

Symptoms:
  • onset of increasingly painful periods
  • steady dull-to-severe lower abdominal pain which can be felt just before or during menstruation, or for a week or two preceding it.
  • pelvic or low back pain that may occur at any time during the menstrual cycle
  • typically, severe pelvic cramps or abdominal pain that may start 1 to 2 weeks before the menstrual period
  • more frequent or totally irregular periods
  • premenstrual spotting
  • pain during or following sexual intercourse
  • pain with bowel movements
  • infertility

Note: Frequently, symptoms may not be present. In fact, some women with severe cases of endometriosis have no pain at all, while some women with only a few small adhesions have severe discomfort.

Signs and Tests:
A pelvic examination may reveal the presence of tender nodules , with a lumpy consistency. These are often found in the posterior vaginal wall or adnexa (ovary regions) and may sometimes be felt in healed wound scars (especially episiotomy and C-section ). There may be pain with uterine motion. The uterus may be fixed or retroverted.



Treatment:
Treatment depends on the extent of the disease (decided through laparoscopy ); the woman's desire for future childbearing; the degree of symptoms experienced; and the woman's age.

Observation may be the appropriate treatment for younger women with minimal disease and symptoms. It is important to have the woman maintain a regular schedule of woman's health care examinations (every 6 to 12 months) to note any changes or progression of the disease.

Treatment with medications may focus on several strategies:
Analgesic therapy, treating the discomfort of the disease only, may be indicated for women with mild to moderate premenstrual pain, with no pelvic examination abnormalities, and with no immediate desire to become pregnant .

"Pseudopregnancy" (a state resembling pregnancy ) may be achieved through hormonal drug regimens. This approach was developed in response to the observed regression of endometriosis during pregnancy. Pseudopregnagncy can be induced using oral contraceptives containing estrogen and progesterone. This procedure takes six to nine months and relieves most of the symptoms, but does not prevent scarring and adhesion left by the disease. Potential side effects of depression and/or significant breakthrough spotting may limit this option for treatment.

Similarly, "pseudomenopause" (a state resembling menopause ) was developed as a means of treatment because of the observation that endometriosis regresses after menopause. Danazol, a weak androgenic (male characteristic) hormonal drug may be used to reduce natural levels of estrogen and progesterone to low levels. It appears that the use of Danazol may be superior to the "pseudopregnancy" regimens in controlling symptoms and progression of the disease in women with moderate-to-severe endometreosis. However, in cases of mild disease, Danazol may prove to be much more expensive and no more effective than simple observation.

A new class of antigonadotropin drugs has been developed that also produces a "pseudo menopausal" state in women. Both Synarel and Depolupron (trade names) prevent stimulation of the pituitary for the production of FSH ( follicle stimulating hormone ) and LH ( luteinizing hormone ). This stops the ovary from producing estrogen. Potential side effects of these drugs include menopausal symptoms such as hot flashes, vaginal dryness, mood changes , and early loss of calcium from the bones.

Surgery is usually reserved for women with severe endometriosis, including adhesions and infertility . Conservative surgery attempts to remove or destroy all of the outside endometriotic tissue, remove adhesions, and restore the pelvic anatomy to as close to normal as possible. Nerve removal (neurectomy) may be performed during surgery as a means of relieving the pain associated with endometriosis.

Definitive surgery is appropriate for the woman with severe symptoms or disease, and no desire for future childbearing. This type of surgery involves abdominal removal of the uterus , both ovaries, both Fallopian tubes, and any remaining adhesions or endometrial implants. Hormonal replacement therapy may be indicated after total hysterectomy and should be tailored to the individual woman's needs.

Prognosis:
Enhanced fertility (frequently a goal of conservative surgery) is indirectly proportional to the extent of the endometriosis. Pregnancy rates, achieved after conservative surgery in women previously considered to be infertile , are approximately 75% for mild endometriosis, 50 to 60% for moderate cases, and 30 to 40% for severe cases. These are approximate values based upon statistics because endometriosis is a very individualized disease process.

Complications:
Infertility may result from endometriosis. Therefore, if a woman desires to have children and knows she has the disease, it may be recommended that she plan to have her children earlier and with shorter time spans in between children. Endometriosis has been known to recur even after a hysterectomy . Other complications are rare. In a few cases endometriosis implants may cause obstructions of the gastrointestinal or urinary tracts.

Call Your Healthcare Provider:
Call for an appointment with your health care provider if symptoms of endometriosis occur, or if back pain or other symptoms recur after treatment of endometriosis.

Screening for endometriosis should be considered if your mother or sister has been diagnosed with endometriosis, if you are unable to become pregnant after 1 year of attempting to conceive.


Pelvic laparoscopy is a surgical procedure used to view the interior of the lower abdomen without major surgery. Small optical instruments can be inserted through the abdominal wall to directly visualize the interior of the abdomen. Some surgeries can be done using laparoscopic techniques. Recovery from this type of surgery, unlike open surgery, often takes only a day and the patient usually returns home the next morning.