Endometriosis is a common, poorly misunderstood disease. It occurs equally in women of any socioeconomic class, age, or race. It is estimated that between 10 percent and 20 percent of american women of childbearing age have endometriosis.
While some women with endometriosis may have severe pelvic pain, others who have the condition have no symptoms. Nothing about endometriosis is simple, and there are no absolute cures.
The term endometriosis comes from the word "endometrium", the tissue that lines the inside of the uterus. If a woman is not pregnant, this tissue builds up, and is shed each month. It is discharged as menstrual flow at the end of each cycle.
In endometriosis, tissue that looks and acts like normal endometrial tissue is found outside the uterus, usually in the abdominal cavity.
Endometrial tissue residing outside the uterus responds to the menstrual cycle in a way that is similar to the way endometrium usually responds in the uterus.
At the end of every cycle, when hormones cause the uterus to shed its endometrial lining, endometrial tissue growing outside the uterus will break apart and bleed.
However, unlike menstrual fluid from the uterus, which is discharged from the body during menstruation, blood from this misplaced tissue has no place to go. Tissues surrounding the area of endometriosis may become inflamed or swollen.
The inflamation may produce scar tissue around the area of endometriosis. These endometrial tissue sites may develop into what are called "lesions", "implants", "nodules", or "growths".
Endometriosis is most often found:
1. in the ovaries
2. in the fallopian tubes
3. on the ligaments supporting the uterus
4. in the internal area between the vagina and the rectum
5. on the outer surface of the uterus
6. on the lining of the pelvic cavity
Less frequently endometrial growths are found:
1. on the intestines
2. in the rectum
3. on the bladder
4. on the vagina, cervix and vulva
5. in abdominal surgery scars
Very rarely endometrial growths are found:
1. outside the abdomen
2. in the thigh
3. in the arm
4. in the lung
Phisycians sometimes use stages to describe the severity of endometriosis. Endometrial growths that are small and not widespread are considered minimal or mild endometriosis. Moderate endometriosis means that larger growths or more excessive scar tissue is present. Severe endometriosis is used to describe large implants and excessive scar tissue.
What are the symptoms of endometriosis?
The most common symptom of endometriosis is pain, esspecially excessive menstrual cramps (dysmenorrhea) which may be felt in the abdomen or lower back. Painful menstruation may begin before a woman's period and last several days after.
Other symptoms include:
1. occasional heavy periods
2. sharp pain deep in the pelvis during intercourse (dyspareunia)
3. infertility
4. pain during bowel movements
Most commonly the symptoms of endometriosis start years after the menstrual period begins. Over the years, the symptoms tend to gradually increase as the endometriosis increases in size. After menopause, the abdomen implants shrink away and the symptoms subside.
Infertility occurs in 30 to 40 percent of women with endometriosis. Rarely, the irritation caused by the endometrial implants may progress into infection or abscesses causing pain independant of the menstrual cycle.
Endometrial patches may also be tenderto touch or pressure, and intestinal pain may also result from endometrial patches on the walls of the colon or intestine.
The amount of pain is not always related to the extent of the disease - some women with many large endometrial patches have little or no pain; while others with just a few small growths have incapacitating pain.
Endometrial cancer is very rarely associated with endometriosis, occurring in less than 1 percent of women who have the disease. When it does occur, it is usually found in more advanced patches of endometriosis in older women and the long term outlook in these unusual cases is reasonably good.
Does Endometriosis Prevent Pregnancy?
Severe endometriosis with excessive scarring and organ damage may affect fertility. It is considered one of the three major causes of female infertility. However, unsuspected or mild endometriosis is a common finding among infertile women and how this type of endometriosis affects infertility is still not clear.
While the pregnancy rates of those with endometriosis remain lower than those of the general population, most patients with endometriosis do not experience infertility problems, according to the National Institute of Health and Human Development.
What Causes Endometriosis?
The cause of endometriosis is still unknown. One theory is that during menstruation some of the menstrual fluid backs up through the fallopian tubes into the abdomen, where it implants and grows.
Another theory suggests that endometriosis may be a genetic process or that certain families may have predisposed factors to endometriosis. In the latter view, endometriosis is seen as tissue development gone awry.
Whatever the cause of endometriosis, its progression is influenced by various stimulating factors such as hormones or growth factors. In this regard, NICHD investigators are studying the role of the immune system in activating cells that may secrete factors, which in turn, stimulate endometriosis.
In add ition to these new hypotheses , investigators are continuing to look at previous theories that endometriosis is a disease influenced by delayed childbearing. Since the hormones made by the placenta during pregnancy prevent ovulation, the progress of the endometriosis is slowed or stopped during pregnancy and the total number of lifetime cycles is reduced for a woman who had multiple pregnancies.
How is Endometriosis diagnosed?
Diagnosis of endometriosis begins with an evaluation of the woman's medical history. A complete physical exam, including a pelvic examination, is also done.
Diagnosis of endometriosis, however, is only confirmed when proven by laparascopy, a minor surgical procedure in which a laparascope (a tube with a light in it) is inserted into a small incision in the abdomen.
The laparascope is moved around inside the abdomen, which has been distended with carbon dioxide to make the organs easier to see. The surgeon can then check the condition of the abdominal organs and see the endometrial implants.
The laparascopy will show the locations, extent, and size of the growths and will help the patient and her doctor make better informed decisions about treatment.
Doctors recommend laparascopy to confirm endometriosis because ovarian cancer can produce similar symptoms. The hormones often prescribed to treat endometriosis can make cancer grow faster.
As with all tests and procedures, it is important that a woman question her doctor about all the benefits, risks and costs of diagnostic treatment alternatives.
What Are The Treatment Options For Endometriosis?
Physicians agree that if the symptoms are mild, no treatment other than medication for pain may be recommended. For those women with mild or minimal endometriosis who wish to become pregnant, doctors may suggest that , depending on the age of the individual and the amount of pain associated with the disease, the best course of action is to have a trial period of unprotected intercourse for 6 months to a year. If pregnancy does not occur within that time, then further treatment may be suggested.
For women not seeking a pregnancy, where treatment specific for the management of endometriosis is required and a definitive diagnosis of endometriosis by laparascopy has been made, a physician may suggest hormone suppression treatment.
Since this therapy shuts off ovulation, women being treated for endometriosis will not get pregnant during such therapy, although some may elect to become pregnant shortly after therapy is stopped.
Hormone treatment is most effective when implants are small. The doctor may prescribe a weak synthetic male hormone called Danzanol, a sythetic progestin alone, or a combination of estrogen and progestin such as oral contraceptives.
Danzanol has become a more common treatment choice than either progestin or the birth control pill. Disease symptoms are improved for 80 percent to 90 percent of the patients taking Danzanol, and the size and extent of the implants are also reduced.
Side effects with Danzanol treatment, however, are not uncommon. Among others, the side effects include acne, hot flashes, and fluid retention. Overall, pregnancy rates following this therapy depend on the severity of the disease. However,some studies have shown that with mild to minimal endometriosis, Danzanol alone does not improve pregnancy rates.
It is important to remember that Danzanol treatment is unsafe if there is any chance that a woman is pregnant. a fetus accidentally exposed to this drug may develop abnormally. For this same reason, although pregnancy is not likely while a woman is taking this drug, careful use of a barrier birth control method such as a condom or diaphram is essential during this treatment.