| What is endometriosis? |
Endometriosis is a common and often painful disorder of the female reproductive system. In this condition, a specialized type of tissue that normally lines the inside of your uterus (the endometrium) becomes implanted outside your uterus, most commonly on your fallopian tubes, ovaries or the tissue lining your pelvis. Rarely, endometrial tissue may spread beyond the pelvic region.
During your menstrual cycle, hormones signal the lining of your uterus to thicken to prepare for possible pregnancy. If a pregnancy doesn't occur, your hormone levels decrease, causing the thickened lining of your uterus to shed. This results in bleeding that exits your body through the vagina — your monthly period.
When endometrial tissue is located in other parts of your body, it continues to act in its normal way: it thickens, breaks down and bleeds each month as your hormone levels rise and fall. However, because there's nowhere for the blood from this mislocated tissue to exit your body, it becomes trapped, and surrounding tissue can become irritated.
Trapped blood may lead to the growth of cysts. Cysts, in turn, may form scar tissue and adhesions — abnormal tissue that binds organs together. This process can cause pain in the area of this misplaced tissue, usually the pelvis, especially during your period. Endometriosis can also cause fertility problems. In fact, scars and adhesions on ovaries or fallopian tubes can prevent pregnancy.
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Experts estimate that 10 percent to 15 percent of American women of childbearing age have endometriosis. The condition is most likely to occur in women who haven't had children and are between the ages of 25 and 40. In rare cases, endometriosis may be hereditary. Endometriosis can be mild, moderate or severe, and it tends to get worse over time without treatment.
Endometriosis isn't the only cause of pelvic pain. Functional ovarian cysts, pelvic infections and nongynecologic diseases also may cause pelvic pain. Although ovarian cancer doesn't usually cause pelvic pain in its early stages, it's a possibility your doctor should consider. It's important to see your doctor for an accurate diagnosis and to target treatment.
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| Signs and symptoms |
Some women with endometriosis have no symptoms at all, and the disease is discovered only during an unrelated operation, such as a tubal ligation. Others may experience one or more of the following signs and symptoms:
- Painful periods (dysmenorrhea). Pelvic pain and cramping may begin before and extend several days
into your period and may include lower back and abdominal pain.
- Occasional heavy periods or bleeding between periods (menometrorrhagia).
- Pelvic pain during ovulation.
- Sharp pain deep in the pelvis during intercourse.
- Pain during bowel movements or urination.
- Infertility. Endometriosis is first diagnosed in some women who are seeking treatment for infertility.
Pain is a common symptom of endometriosis. However, severity of pain isn't necessarily a reliable indicator of the extent of the condition. Some women with mild endometriosis have extensive pain, while others with more-severe scarring may have little pain or no pain at all.
Endometriosis is sometimes mistaken for other conditions that can cause pelvic pain, such as pelvic inflammatory disease (PID) or ovarian cysts. It may be confused with irritable bowel syndrome (IBS), a condition that causes bouts of diarrhea, constipation and abdominal cramping. IBS can accompany endometriosis, which can complicate a diagnosis.
See your physician if you have significant symptoms of endometriosis. The cause of chronic or severe pelvic pain may be difficult to pinpoint. But discovering the problem early may help you avoid unnecessary complications and pain.
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| Causes |
The cause of endometriosis remains mysterious. Scientists are studying the roles that hormones and the immune system play in the condition. Several suggestions as to how endometrial tissue ends up outside the uterus have been made.
One theory holds that menstrual blood containing endometrial cells flows back through the fallopian tubes, takes root and grows. Another hypothesis proposes that the bloodstream carries endometrial cells to other sites in the body. Still another theory speculates that a predisposition toward endometriosis may be carried in the genes of certain families.
Other researchers believe that certain cells present within the abdomen in some women retain their ability to specialize into endometrial cells. These same cells were responsible for the growth of the women's reproductive organs when she was an embryo. It's believed that genetic or environmental influences in later life allow these cells to give rise to endometrial tissue outside the uterus.
| Risk factors |
Some women may have an inherited tendency to develop endometriosis. A woman whose mother, sister or daughter has endometriosis is 10 times more likely to have endometriosis than a woman without an affected relative. Rarely, a woman may be at increased risk because of a medical problem that prevents the normal passage of menstrual flow. In addition, some evidence suggests that damage to cells that line the pelvis — caused by a previous infection — can lead to endometriosis.
Endometriosis can affect menstruating women of any age or race and usually takes several years after the onset of menstruation (menarche) to develop. When menstruation ends permanently with menopause or temporarily with pregnancy, symptoms of endometriosis stop. They can begin again after pregnancy when menstruation resumes. Very rarely, hormone replacement therapy after menopause can reactivate the disorder.
| Screening and diagnosis |
To diagnose endometriosis and other conditions that can cause pelvic pain, your doctor will ask you to describe your symptoms, including the location of your pain and when you notice it. Your doctor will perform a pelvic exam to check for any abnormalities, such as cysts on your reproductive organs or scars behind your uterus. Often it's not possible to feel small areas of endometrial implantation unless they've caused a cyst to form.
Other tests to check for physical clues of endometriosis include vaginal or pelvic ultrasound. During a vaginal ultrasound, a wand-shaped scanner (transducer) is inserted into your vagina. In a pelvic ultrasound, a small scanner is moved across your abdomen. Both tests use sound waves to provide a video image of your reproductive organs.
Endometrial implants often cannot be felt or clearly seen in these or other tests. The only way a doctor can make a definitive diagnosis of endometriosis is through a minor surgical procedure called laparoscopy.
A general anesthetic is given before the procedure begins. Using a special needle, the abdomen is expanded (distended) with carbon dioxide gas so that reproductive organs are easier to see. A tiny incision is made near the bellybutton, and a slender viewing instrument (laparoscope) is inserted. By moving the laparoscope around, the 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.
A blood test to diagnose endometriosis may someday be available. One test currently under study looks for a protein that's commonly found in the blood of women with endometriosis. Until such a test is shown to be dependable and becomes widely available, however, laparoscopy is necessary to diagnose endometriosis.
| Complications |
The main complication of endometriosis is impaired fertility. In fact, about 10 percent of infertile women have endometriosis, compared with only about 5 percent of fertile women.
For pregnancy to occur, an egg must be released from an ovary and travel through the fallopian tube to the uterus (womb), where it can be fertilized by a man's sperm and then attach to the uterine wall to begin development. Endometriosis can produce adhesions that can trap the egg near the ovary. It may inhibit the mobility of the fallopian tube and impair its ability to pick up the egg. In most cases, however, endometriosis probably interferes with conception in more-complex ways.
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Despite these possible complications, many women with endometriosis are still able to conceive. It may take them a little longer to get pregnant, but overall about 90 percent of women with mild to moderate endometriosis will become pregnant within a 5-year period. During pregnancy, most women have no symptoms of endometriosis.
A woman with endometriosis is sometimes advised not to delay having children, because endometriosis tends to worsen with time. The longer you have endometriosis, the greater is your chance of becoming infertile.
Although cancerous changes may occur in endometrial implants, the rate of cancer in this tissue hasn't been shown to be higher than that in other tissue. Having endometriosis does not increase a woman's risk of uterine or ovarian cancer.
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| Treatment |
Endometriosis can be treated with medications or surgery. The approach you and your doctor choose will depend on the severity of your symptoms and whether you're hoping to become pregnant.
Pain medications
Your doctor may recommend that you take an over-the-counter pain reliever, such as ibuprofen, to help ease painful menstrual cramps. However, if you find that you require the maximum dose without full relief, it may be a sign that you need to try another treatment approach to manage your symptoms.
Hormone therapy
Supplemental hormones are 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. In fact, if hormonal therapy has little to no effect on your symptoms, consider questioning the diagnosis of endometriosis or its relationship to your symptoms.
Hormonal therapies used to treat endometriosis include:
- Oral contraceptives. Birth control pills help control the hormones responsible for the
buildup of endometrial tissue each month. Taking the pill long-term can reduce or eliminate the pain
of endometriosis. Most women also have lighter and shorter menstrual flow when they're taking the
pill. Women older than 35 who smoke shouldn't take the pill because of an increased risk of blood
clots.
- 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.
- Danazol (Danocrine). This drug blocks the production of ovarian-stimulating hormones,
preventing menstruation and the symptoms of endometriosis. It also 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 symptoms of endometriosis. Its side effects can include weight gain and depressed mood.
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Conservative surgery
Although hormone therapies are effective in reducing or eliminating symptoms of endometriosis, they prevent pregnancy. If you have endometriosis and are trying to become pregnant, surgery to remove 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 bellybutton. The laparoscope is equipped with a laser, a cautery — an instrument that destroys tissue with heat — or small surgical instruments. Assisted reproductive technologies (ARTs) are sometimes preferable to conservative surgery and are often suggested if conservative surgery is ineffective.
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Hysterectomy
In severe cases of endometriosis, a total hysterectomy and the removal of both ovaries may be the best treatment. Hysterectomy alone is also very effective, but removing the ovaries ensures that endometriosis will not return. Either type of surgery is typically considered a last resort, especially for women still in their reproductive years. You can't get pregnant after a hysterectomy.
Although no single treatment option is ideal for everyone, most women who seek help for endometriosis find some, if not complete, relief from their symptoms. If your pain persists or if finding a treatment that works takes some time, you can try measures at home to relieve your discomfort. Warm baths and a heating pad can help relax pelvic muscles, reducing cramping and pain.
Finding a doctor with whom you feel comfortable is crucial in managing and treating endometriosis. You may also want to get a second opinion before starting any treatment regimen to be sure you know all of your options and the possible outcomes.
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| Prevention |
Because the causes of endometriosis remain elusive, no definite techniques to manage the risk of endometriosis have been developed. Yet, it appears that women who have given birth are less likely to develop endometriosis than women who have not.
| Coping skills |
Left undiagnosed or untreated, endometriosis can be a frustrating condition. Painful periods can cause you to miss work or school and can strain relationships. Recurring pain can lead to depression, irritability, anxiety, anger and feelings of helplessness. Infertility linked to endometriosis also can cause emotional distress.
That's why it's important to seek treatment if you suspect you may have endometriosis. Keeping a record of your symptoms can aid your doctor in your diagnosis.
If you're dealing with endometriosis or its complications, you may want to consider joining a support group for women with endometriosis or fertility problems. Sometimes it helps simply to talk to other women who can relate to your feelings and experiences.
— November 6, 2002 —
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