A Woman’s Guide to Endometriosis

Mary is an active working mother with one child and a husband she loves and feels an equal partner to in their marriage. But lately, she has had difficulty coping with her daily routine because of severe abdominal pain. When she rises in the morning, the cramping starts and doubles her over. At times it subsides to a dull ache, and she has described it to her doctor has “Having a bad case of PMS-all the time.” She would like to have another child, but is having trouble conceiving.

Mary has endometriosis.

If you are a woman with endometriosis, you may have one or more of the symptoms described above, or others, which include:

* Severe cramps during menstrual periods and ovulation
* Bleeding between periods
* Backache
* Pain during intercourse or orgasm
* Pain/cramping during bowel movements
* Painful/frequent urination

The pain a person with endometriosis feels is not linked to how severe the disorder is, and a woman with advanced endometriosis may have no symptoms, while another with mild disease experiences severe pain.

If you have endometriosis, you also have a 30 to 40 % chance of infertility and may need treatment for it.

What is endometriosis?
Endometriosis is caused when tissues that are normally found in the uterus are found outside it in the abdomen. This tissue may stick to areas such as the bladder, the rectum, the area behind the uterus (the cul-de-sac), the fallopian tubes and uterine ligaments, the colon or the abdominal wall.

This tissue that escapes the uterus responds to hormones just as the uterus does, and “bleeds” during the monthly cycle, causing irritation and inflammation. Vesicles, or fluid filled sacs, become filled with blood early in the disease process. As time goes on, these vesicles may turn dark in color, and eventually fill with scar tissue. At this point they no longer respond to hormone influences.

What Causes It?
There are several theories about the causes of endometriosis. Dr. John Sampson proposed in the 1920s that during menstruation, uterine tissue escapes through the fallopian tubes into the abdominal cavity. This is called retrograde menstruation, and occurs in 70% to 80% of women. The escaping cells are believed to implant in a certain area, and to grow into an endometrial spot. The problem with this theory is that most women with retrograde menstruation do NOT develop endometriosis, and women after a hysterectomy have developed it. Also, there are reported cases of MEN who developed endometriosis after prostate surgery when undergoing estrogen therapy.

Another theory ties this disorder with genetics, since sisters and first-degree relatives of a woman with endometriosis have a greater chance of developing it.

Some researchers propose that early embryonic tissue that stays undifferentiated into adulthood develops into endometriosis when the tissue is exposed to hormones. Other theories are that uterine cells “migrate” through the bloodstream or lymph system to other areas of the body.

Staging
Endometriosis tends to progress over time, and the American Society for Reproductive Medicine has published a standard for staging endometriosis. It stages endometriosis from Stage I, or minimal, up to stage IV, or severe, where large endometriomas (tumor-like growths) and adhesions (scar tissue) occur.

Diagnosis
Before making a diagnosis, the doctor will do a thorough history and physical exam. If symptoms of endometriosis are present, he may then do a laparoscopy (inserting a small lighted scope into the abdomen) to allow him to directly view the fallopian tubes, ovaries, and abdominal cavity. A biopsy (small amount of tissue extracted) may be done to confirm the diagnosis in a laboratory.

Treatment Options
No treatment:
No treatment other than pain relievers for cramping may be an option, especially if the diagnosis is new, to see if the symptoms will fade without aggressive therapy.

Medications:
Since the tissue implants in endometriosis respond to hormones, medications to treat it are directed towards decreasing the amount of estrogen stimulation of the sites. The thought is that with less estrogen, the activity in the sites will be reduced and the disease will not progress.

These medications include oral contraceptives (low-dose combinations of estrogen and progesterone). The symptoms of menstrual cramping and ovulatory pain may be reduced for women with endometriosis on these medications since ovulation is suppressed and periods are shorter and lighter.

Depo-Provera, a long acting injected form of progesterone, may be given to prevent ovulation and to reduce estrogen levels. Side effects such as irregular bleeding, bloating, weight gain, and permanent suppression of ovulation may occur in some women.

Gonado-tropin releasing hormone (GNRH) analogs are used to suppress ovary function and induce chemical menopause. They are often tried for a period of 6 to 12 months, and frequently bring symptom relief, although they are very expensive. They can also cause side effects that mimic menopause, such as hot flashes, headache, sleep disruption, vaginal dryness, osteoporosis, decreased libido and others. Letting the endometrial sites “rest” during the drug treatment allows them to heal (and stops the inflammation cycle). Normal ovary function and hormone production resumes when the drugs are discontinued.

Surgery
The goals of surgery include removing the endometriosis, pain relief, and attempting to restore fertility in advanced cases.

Surgery by incision may be done to remove large endometriomas, or dark scar-filled vesicles. Laser surgery is also increasing in popularity. The physician will try to remove all of the disease while preserving the organs of the pelvis, and to maintain fertility if possible.

Endometriosis is better understood now than years ago, and research is ongoing to find effective methods of controlling pain, relieving symptoms, and restoring fertility to the woman who deals with this disorder. If you, like Mary, suffer with endometriosis, the treatment options are increasing as time goes on, and the possibility of relief is much greater.

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