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Endometriosis
What Is It?...Endometriosis is a condition in which endometrial tissue, the tissue lining the inside of the uterus, grows in places outside of the uterine cavity. Although endometriosis can develop in many different locations, the most common sites are in the areas of the pelvis and abdomen, including the ovaries, the outside surface of the uterus, the membranes and ligaments of the pelvis and lower abdomen, the fallopian tubes, and the spaces between the bladder, uterus and rectum. Less commonly, patches of endometriosis may grow within the wall of the rectum, bladder, intestines or appendix. Rarely, deposits of endometriosis may be found in areas very far from the reproductive tract, such as the lung, arm, thigh and skin. Areas of endometriosis tend to behave like the normal endometrium (uterine lining); therefore they can respond to the normal cyclic rise and fall of female hormones. They may even ooze blood at the time of menstruation, sometimes causing cyclic episodes of pelvic or abdominal pain. As they grow, areas of endometriosis may also interfere with a woman's fertility by covering or growing into the ovaries. These deposits can directly block the fallopian tubes, or indirectly block them by producing scarred tissue and adhesions (bands of fibrous tissue) that distort the normal anatomy of the reproductive tract. Islands of endometriosis on the ovaries may coalesce to form large fluid-filled cysts called endometriomas. Endometriomas are sometimes called "chocolate cysts" because they typically contain a thick, brownish mixture of blood and sloughed tissue that looks like chocolate.
Researchers have several different theories about the cause of endometriosis. According to one explanation, the condition develops when a retrograde (backward) flow of menstrual fluid carries bits of uterine tissue upward through the fallopian tubes into the pelvis, instead of flowing downward toward the vagina. This seems to be a reasonable explanation for areas of endometriosis that develop very close to the uterus, within the pelvis.
The retrograde flow explanation does not easily explain why endometriosis sometimes grows in distant sites such as the lung or skin. Migration of endometrial cells directly through the bloodstream or lymph channels may explain endometriosis found in sites distant from the pelvis. An alternative explanation is that certain special types of cells found throughout the body may actually transform themselves spontaneously into endometrial cells and then join together to form large deposits of endometriosis.
Whatever the underlying cause of endometriosis, however, faulty immune defenses play some role in its development. The immune system apparently fails to identify and destroy the islands of endometrial tissue that are growing where they do not belong, and may even promote growth and proliferation of endometrial deposits. There is active research directed towards understanding the relationship between the immune system and occurrence of endometriosis.
Currently in the United States, endometriosis affects an estimated 10 percent to 20 percent of women of childbearing age. The average patient with endometriosis is diagnosed at age 27, although the symptoms of the condition may have existed for two to five years before the diagnosis is confirmed. The diagnosis is confirmed by viewing areas of endometriosis during pelvic surgery, or by removing a suspicious area of growth for examination.
In general, a woman probably has a higher than average risk of endometriosis if any of the following is true:
...She has a heavy menstrual flow.
...She has a short menstrual cycle (27 days or less).
...She has a close female relative (mother, sister, daughter) with endometriosis.
A woman's risk is probably lower than average if any of the following applies to her:
...She is slightly underweight.
...She exercises regularly.
...She has had multiple pregnancies.
...She has used oral contraceptives (birth control pills).
Symptoms...Many women with endometriosis have no symptoms of the condition. Those who do have symptoms may experience any of the following:
...Severe menstrual discomfort, usually with heavy menstrual flow
...Periodic pain in the pelvis or abdomen, usually either just before or during menstruation
...Backache
...Pain during or immediately after sexual intercourse
...Vaginal spotting before menstruation begins
...Bowel symptoms, such as painful bowel movements, diarrhea, constipation or (rarely) blood in the stool
...Painful urination, or (rarely) blood in the urine
...Infertility or repeated miscarriages
In general, the severity of symptoms depends on the location of a woman's endometriosis rather than its size. A woman who has only a few small patches of endometriosis may suffer from severe pelvic pain, while a woman with larger areas of endometriosis may feel no symptoms at all.
Expected Duration...Without treatment, endometriosis is a chronic problem that usually persists until menopause. At that time, areas of endometriosis tend to decrease in size and volume as levels of female hormones decrease. Women who elect to take estrogen replacement therapy may experience persistent problems with their endometriosis due to the influence of the estrogen replacement therapy. This important issue should be discussed with your gynecologist.
Prevention...Although there is no effective way to prevent endometriosis, the condition may stop progressing (temporarily) if you use oral contraceptives or become pregnant.
Treatment...Several different treatment options are available:
...Pain management alone - If you have mild pelvic or abdominal pain due to endometriosis, your doctor may suggest that you try a nonprescription pain medication, such as ibuprofen. If this is not effective, your doctor may prescribe a stronger medication that contains a mild narcotic, such as codeine. The use of narcotics is limited by the risk of drug dependence and potential for addiction.
...Pain management combined with control of hormone levels - These treatments decrease the pain of endometriosis by either limiting or eliminating the effects of female hormones on areas of endometrial tissue. These medications include: oral contraceptives, progestins, danazol and the gonadotropin-releasing hormone agonists such as: nafarelin acetate and leuprolide acetate. The gonadotropin-releasing hormone agonists act at the level of the pituitary gland to dramatically decrease levels of female hormones. This creates a reversible "fake menopause", or psuedomenopause that allows time for the endometriosis to fade away.
...Conservative surgical treatments (laparoscopy and laparotomy) - During laparoscopy, your doctor will either burn away small areas of endometriosis or use a laser to vaporize them. Your doctor will also trim away any problem spots of adhesions or scarred tissues that might be twisting your pelvic organs out of their normal position. These procedures can often be done during the same laparoscopy session that is used to diagnose endometriosis. If you have more extensive areas of endometriosis, your doctor may perform a regular laparotomy (traditional abdominal surgery through a larger incision) instead. The larger incision will give the doctor more room to reach and treat all areas of endometriosis inside your pelvis and abdomen.
...Hysterectomy (removal of the uterus) - In women who no longer wish to become pregnant, and in women with severe disabling pain, the doctor may treat endometriosis by removing the uterus, together with the ovaries and fallopian tubes.
The treatment option that is best for you depends on several factors, including the severity of your symptoms and your plans for pregnancy. For example, if you have painful endometriosis and are also troubled by infertility, your doctor may recommend that you have conservative surgical treatment with laparoscopy. This option may not only improve your symptoms, but also increase the chances that you will conceive. On the other hand, if you wish to postpone pregnancy, your doctor may suggest that you take oral contraceptives for a few months to see if this relieves your symptoms.
When To Call A Professional...Call your family doctor or gynecologist if you have pelvic or abdominal pain, abnormally heavy menstrual periods, vaginal spotting or any other symptom of endometriosis. Also contact your doctor if you are trying to conceive a child, and you have not become pregnant after one year of unprotected intercourse.
Prognosis...Overall, the prognosis is good, especially when the condition is diagnosed and treated early. Current medical and surgical treatments can relieve the pain of endometriosis in about 90 percent of women who suffer from this condition.
Even without treatment, three out of four women with mild endometriosis can eventually become pregnant. Of those who choose to have laparoscopic surgery to improve their fertility, about 40 percent become pregnant after the procedure.
Additional Info...For more information about endometriosis, you can contact:
Endometriosis Association
http://www.endometriosisassn.org/
Last updated February 15, 2001