What is Endometriosis?
Endometriosis is defined by the deposition of endometrial glands and stroma (tissue normally found inside the uterine cavity) outside of the uterus, most commonly behind the uterus in the pelvis. The most common mechanism for the formation of endometriosis is the backflow of endometrium at the time of a patient’s menstrual cycle, which either implant and grow in the pelvis or induces other pelvic tissues to differentiate into endometrial tissue.
Endometriosis is a common disorder often resulting in painful menstrual periods, pelvic pain at other times in the cycle, as well as infertility. Roughly 10% of all women develop endometriosis, most commonly in their late twenties. This condition is highly associated with both chronic pelvic pain as well as infertility, affecting a large percentage of women who undergo laparoscopy for either pelvic pain or unexplained infertility.
The primary symptom of endometriosis is pelvic pain, often associated with your menstrual period. Although many women experience cramping during their menstrual period, women with endometriosis typically describe menstrual pain that's far worse than usual. They also tend to report that the pain has increased over time.
Common signs and symptoms of endometriosis may include:
- Painful periods (dysmenorrhea). Pelvic pain and cramping may begin before and extend several days into your period. You may also experience lower back and abdominal pain.
- Pain with intercourse. Pain during or after sex is common with endometriosis.
- Pain with bowel movements or urination. You're most likely to experience these symptoms during your period.
- Excessive bleeding. You may experience occasional heavy periods (menorrhagia) or bleeding between periods (menometrorrhagia).
- Infertility. Endometriosis is first diagnosed in some women who are seeking treatment for infertility.
- Other symptoms. You may also experience fatigue, diarrhea, constipation, bloating, or nausea, especially during menstrual periods.
Diagnosing endometriosis can be challenging, and sometimes requires laparoscopy. Laparoscopy is a procedure in which a scope is placed into the abdomen generally through the umbilicus (belly button), to look for and biopsy the endometrial lesions on the ovaries, behind the uterus, on the bladder, or elsewhere in the pelvis or abdomen.
An ultrasound may show the classic echogenic ovarian cysts or endometriomas that are common in advanced cases of endometriosis, but in more mild cases of endometriosis, there generally are no obvious signs on ultrasound. But mild endometriosis is less likely to be causal in chronic pelvic pain or infertility.
Tests to check for physical clues of endometriosis include:
During a pelvic exam, your doctor manually feels (palpates) areas in your pelvis for abnormalities, such as cysts on your reproductive organs or scars behind your uterus. Often, it is not possible to feel small areas of endometriosis, unless they've caused a cyst to form.
During a vaginal ultrasound, a wand-shaped scanner (transducer) is inserted into your vagina. In an ultrasound of the pelvis that is done through the abdomen, a small scanner is moved across your abdomen. Both tests use sound waves to provide a video image of your reproductive organs. Ultrasound imaging won't definitively tell your doctor whether you have endometriosis, but it is a useful tool for identifying cysts associated with endometriosis (endometriomas).
The only way for your doctor to know for certain that you have endometriosis is by looking inside your abdomen for signs of endometrial implants. This is usually accomplished during a minor surgical procedure called laparoscopy. You will receive a general anesthetic before the procedure begins. Using a special needle, your surgeon expands your abdomen with carbon dioxide gas so that the reproductive organs are easier to see. A tiny incision is then made near your navel, and a slender viewing instrument called a laparoscope is inserted. By moving the laparoscope around, your surgeon can view the pelvic and other abdominal organs, looking for signs of endometrial tissue outside the uterus. If you have endometriosis, laparoscopy will provide you and your doctor with information about the location, extent, and size of the endometrial implants. This information will help your doctor guide you through treatment options.
Your doctor may recommend that you take an over-the-counter pain reliever, such as ibuprofen (Advil, Motrin, etc.), to help ease painful menstrual cramps. However, if you find that taking the maximum dose doesn't provide full relief, you may need to try another treatment approach to manage your signs and symptoms.
Treatment options include:
Supplemental hormones are sometimes effective in reducing or eliminating the pain of endometriosis. That's because the rise and fall of hormones during a woman's menstrual cycle causes endometrial implants to thicken, break down, and bleed. Hormonal therapies used to treat endometriosis include:
- Hormonal contraceptives. Birth control pills, patches, and vaginal rings help control the hormones responsible for the buildup of endometrial tissue each month. Most women have lighter and shorter menstrual flow when they're using a hormonal contraceptive. Using hormonal contraceptives — especially continuous cycle regimens — can reduce or eliminate the pain of mild to moderate endometriosis.
- Gonadotropin-releasing hormone (Gn-RH) agonists and antagonists. These drugs block the production of ovarian-stimulating hormones. This action prevents menstruation and dramatically lowers estrogen levels, causing endometrial implants to shrink. Gn-RH agonists and antagonists can force endometriosis into remission during the time of treatment and sometimes for months or years afterward. These drugs create an artificial menopause that can sometimes lead to troublesome side effects, such as hot flashes and vaginal dryness. Taking a low dose of estrogen or progestin along with Gn-RH agonists and antagonists may decrease such side effects. If Gn-RH agonists don't relieve your pain, it's unlikely that endometriosis is responsible for your symptoms.
- Danazol. Another drug that blocks the production of ovarian-stimulating hormones, preventing menstruation and the symptoms of endometriosis, is danazol. In addition, it suppresses the growth of the endometrium. However, danazol may not be the first choice because it can cause unwanted side effects, such as acne and facial hair.
- Medroxyprogesterone (Depo-Provera). This injectable drug is effective in halting menstruation and the growth of endometrial implants, thereby relieving the signs and symptoms of endometriosis. Its side effects can include weight gain, decreased bone production, and depressed mood.
- Aromatase inhibitors. Although not specifically approved for the treatment of endometriosis, studies suggest that aromatase inhibitors may significantly reduce endometriosis-related pain. Aromatase inhibitors work by blocking the conversion of hormones such as androstenedione and testosterone into estrogen and by blocking the production of estrogen from endometrial implants themselves. This deprives endometriosis of the estrogen it needs to grow. To reduce the risk of side effects, such as bone loss and follicular cysts, aromatase inhibitors must be taken in combination with a Gn-RH agonist or an oral estrogen-progestin contraceptive.
Hormonal therapies aren't a permanent fix for endometriosis. It's possible that you could experience a recurrence of your symptoms after stopping treatment.
If you have endometriosis and are trying to become pregnant, surgery to remove endometrial implants may increase your chances of success. If you have severe pain from endometriosis, you may also benefit from surgery.
Conservative surgery removes endometrial growths, scar tissue, and adhesions without removing your reproductive organs. Your doctor may do this procedure laparoscopically or through traditional abdominal surgery in more extensive cases. In laparoscopic surgery, a slender viewing instrument (laparoscope) is inserted through a small incision near your navel. Guided by the laparoscope, your doctor inserts other instruments through another small incision to remove endometrial implants. Such instruments might include a laser, small surgical instruments or a cautery — an instrument that destroys tissue with heat.
Assisted reproductive technologies to help you become pregnant are sometimes preferable to conservative surgery, and doctors often suggest these approaches if conservative surgery is ineffective.
In severe cases of endometriosis, surgery to remove the uterus and cervix (total hysterectomy) as well as both ovaries may be the best treatment. Hysterectomy alone is not effective — the estrogen your ovaries produce can stimulate any remaining endometriosis and cause pain to persist. Surgery is typically considered a last resort, especially for women still in their reproductive years. You can't get pregnant after a hysterectomy.