Endometriosis

Are you a woman who suffers from chronic pain in the pelvic area (the area between the hips in the lower part of the trunk)? Is the pain a severe cramping that occurs on both sides, radiates to the lower back and rectal area, and even down the legs? You could be one of 5 million American women and 176 million women worldwide affected by endometriosis.

Endometriosis is a common gynecological condition called the "Invisible Illness" that affects women during the reproductive years (usually between the ages of 15 and 49). It is one of the most treatable, but least treated illnesses and has severe consequences. Endometriosis is one of the top three causes of female infertility. It occurs when the endometrium (the tissue lining the uterine cavity) attaches to organs other than the uterus (for example the ovaries, fallopian tubes, bowel, bladder, or rectum) within the pelvis, and begins to grow. These tissue growths or implants are usually benign (not cancerous). Endometriosis is not cancer, but this displaced uterine tissue causes irritation in the pelvis that leads to pain, heavy periods, and infertility. Endometriosis on the ovaries may occur in the form of small bags of fluid called cysts or endometriomas. Endometriosis implants can be a variety of shapes, sizes, and colors from pea-sized to grapefruit-sized and from colorless to red or dark brown. Symptoms associated with endometriosis are related to a woman's monthly menstrual cycle and its associated hormonal changes. The lining of the uterus thickens and gets ready for pregnancy each month when ovulation occurs and the egg is released from the ovary. If pregnancy does not occur, the uterus sheds it thickened lining and menstrual bleeding occurs, dispelling the thickened uterine lining through the vagina. If endometriosis is present, these implants or growths of uterine tissue outside the uterus also thicken and then bleed during the menstrual period, but the blood has no way of leaving the body, leading to inflammation and scar tissue formation, which in turns leads to pain.

Cause

The cause of endometriosis remains a mystery. Normally during menstrual periods, the uterine lining is shed through the cervix into the vagina. One line of thought is retrograde menstruation, i.e. if some of the uterine tissue enters into the fallopian tubes and thereby into the pelvic and abdominal cavity, women may develop endometriosis implants. A second line of thought is that endometriosis may be familial or hereditary and comes from a genetic predisposition. A third line of thought is that women who develop endometriosis have an impaired immune system that does not detect and destroy uterine tissue growing outside the uterus. Many studies have shown that women who begin their menstrual cycle at a significantly younger age are more predisposed to developing endometriosis. Interestingly, endometriosis is more prevalent in women who have regular menstrual cycles, a shorter interval between their periods, heavy periods, and longer periods. Multiparity (bearing many children) and oral contraceptives have a protective effect.

Common Symptoms

The two most common symptoms of endometriosis are pain and difficulty getting pregnant. The pain occurs mostly in the abdomen, lower back, and pelvic area. The timing of the pain usually correlates with the woman's menstrual period, but may also occur during intercourse or when emptying the bowels or urinating. The severity of pain is unpredictable and ranges from a dull ache to severe pain. The severity of pain is also not directly linked to the amount of endometriosis. Some women with endometriosis may have no symptoms of pain at all and are incidentally diagnosed during investigation for infertility. Endometriosis appears in the form of small patches or nodules sprinkled on the abdominal and pelvic organ surfaces. If the endometriosis irritates the surrounding tissue, it can produce scar tissue called adhesions which bind pelvic organs together. Implants of endometriosis on the ovaries may prevent release of the egg, and implants on the fallopian tubes may prevent passage of the egg released from the ovary during ovulation, leading to infertility.

In general, the most common symptoms of endometriosis include:

• Painful and disabling menstrual cramps.
• Chronic lower abdominal and pelvic pain.
• Pain during intercourse.
• Painful bowel movements or painful urination especially during menstrual periods.
• Heavy menstrual periods.
• Infertility or inability to get pregnant.
• Fatigue.
• Inflammatory bowel disease like symptoms.

Diagnosis

Diagnosis is difficult because the symptoms of endometriosis are so varied and unpredictable. Some women with endometriosis may have no symptoms at all and some women with only a few flecks of endometriosis may suffer from severe symptoms. To further confuse the issue, many unrelated problems like urinary tract infections, appendicitis, and inflammatory bowel disease can mimic symptoms of endometriosis. There is no single or simple test for endometriosis.

• A physician may suspect endometriosis based on a woman's history, symptoms, and pelvic exam (looking for tender masses or nodules).
• A physician will need to perform a procedure called laparoscopy to come to a definitive diagnosis of endometriosis. Laparoscopy is an outpatient surgical procedure which enables the physician to see the pelvic and abdominal organs by inserting a camera into the body.
• A physician may advise a non-invasive imaging test such as a transvaginal ultrasound scan which may be useful to make or exclude the diagnosis of an ovarian endometrioma.

Management

The good news is that medical treatment helps reduce symptoms in 80-90% of women. The type of treatment depends on the severity of symptoms and future fertility goals and concerns. Mild symptoms may warrant only lifestyle changes. If the pain is severe enough to interfere with work, family, and daily activities, hormonal therapy may be advised. Large ovarian endometriomas may require surgery, and surgery may also be suggested if conservative treatment and medical treatment have been unsuccessful or other medical conditions prohibit the use of hormones.

Treatment of pain

• Lifestyle modifications: Exercise and relaxation techniques have been found to be helpful by some women, and if pain is not severe and pregnancy is not desired, then watchful waiting and lifestyle modification may be the way to go.
• Over-the-counter nonsteroidal anti-inflammatory pain medications like ibuprofen and naproxen can reduce discomfort from painful menstrual cramps.
• Changing positions can relieve pain caused by deep penetration during intercourse.
• Hormonal treatments (birth control pills, GnRH agonists, Danazol (male hormone), and progestins) can be highly effective in managing endometriosis-induced pain and they often reduce menstrual cramping and pelvic pain by suppressing ovarian function. These, like all drugs, come laden with side effects which can be distressing, and these drugs should be discussed with a physician to weigh the pros and cons.
• Surgery for severe intractable pain usually consists of laparoscopy as the first line of treatment (conservative) to remove endometriosis nodules and adhesions by ablation. After surgery, medical therapy may be needed to control symptoms which may return.
• Hysterectomy (removal of the uterus with removal of the ovaries) is a radical approach that provides relief for more than 90% of women. If the ovaries are left in place, the chances of recurrence of pain are higher.
• Endometriosis often recedes during pregnancy due to the hormonal environment in the body, but pregnancy as a treatment for endometriosis must be very carefully considered because endometriosis often returns post pregnancy.
• A multidisciplinary approach may become necessary including a team of pain physicians, mental health specialists, counselors, and physical therapists in addition to a gynecologist for especially severe cases.

Treatment of infertility

Various factors like the woman's age, duration of infertility, and severity of pain play a role in determining the course of treatment for infertility caused by endometriosis.

• Laparoscopy may be advised before or after starting fertility-enhancing treatments.
• Surgery has been found on clinical studies to be associated with an improvement in pregnancy rates when compared to women who were diagnosed with endometriosis but not treated with laparoscopy.
• Surgery versus an expectant "watch and wait" approach is a complex decision and the latter is usually not an option for women aged 35 and older as fertility is already on the decline due to advanced maternal age.
• Fertility-enhancing treatments of ovarian stimulation and intrauterine insemination may be necessary for women unable to attain spontaneous pregnancy due to endometriosis-related infertility.
• IVF (in vitro fertilization or test tube baby) is often appropriate treatment if there are other coexisting causes of infertility.

Conclusion

Endometriosis is lifestyle impairing, but treatable condition affecting millions of women worldwide that requires medical attention especially if pain is disabling or fertility is affected. Since endometriosis can be a lifelong problem, it has the potential to disrupt a woman's quality of life and cause significant emotional distress. A qualified specialist who is familiar with the latest developments in treatment of endometriosis can help in formulating an effective pain and infertility management plan based on the woman's age and her duration and severity of symptoms.