Endometriosis is a benign chronic condition where cells that resemble the tissue lining the uterus are found in other areas of the body. This tissue also functions in a similar way to the lining of the uterus, swelling and bleeding in a predictable manner with the menstrual cycle. The condition may be very minor and found only incidentally at surgery for other things, or can be much more serious and associated with scarring, infertility and pain. Although first found primarily in women of reproductive age groups, it can also be found in adolescents and may continue into menopause, and may be stimulated after menopause by some hormone therapies. The incidence of endometriosis is difficult to determine because the way it is manifest varies from woman to woman. Each woman afflicted with endometriosis has a particular set of symptoms with varying degrees of disability, including days off work or school, inability to engage in intercourse etc. It has been reported to be present in up to 14% of women of childbearing age and has been seen in as many as 40% of women suffering from infertility with no other apparent cause. It is felt to be the second most common cause of infertility in women who have normal regular menses and ovulation. It is now well recognized that a genetic susceptibility appears probable as well, meaning that endometriosis tends to run in families. Where does it come from?: A number of theories exist to explain the etiology, or cause, of endometriosis. One theory is that retrograde menstruation occurs, or that blood and tissue during the menstrual cycle escape from the uterine cavity and out through the fallopian tubes into the pelvis, where the tissue may land and become established and functional. It responds to estrogen the same way the lining of the uterus responds in its new location. It is most often found on the ovaries (55%) or diffusely scattered over the surface of the uterus or tubes and on the uterosacral ligaments which are the most inferior part of the uterus support system (10-33%) and is increasingly rarer the greater distance from the uterus and tubes. |
| Endometriosis |
| Brenda L. Kehoe, M.D. |
A recent genetic study found that there is a link between endometriosis and a particular location on a chromosome, possibly explaining in part why endometriosis runs in families. A recent study found that women whose sisters have endometriosis are nearly six times as likely to have endometriosis as a control group of women. Chronic pelvic pain. When pelvic pain has increased over time to the extent described above, a woman may fall into a chronic pain category. Endometriosis is difficult to distinguish from other causes of pelvic pain, including bladder, bowel, or pelvic muscle sources. Painful intercourse. Dyspareunia (painful intercourse) is a difficult issue for many women to discuss and for physicians to address because there are multiple potential causes and no easy answers. Pain may be caused by endometriosis implants, nodules, or scarring, by the inability of closely placed organs to move independently, by rigidity of the lining of the pelvis, and by anatomic deformity caused by the disease. Pain with bowel movements Pain with urination in the absence of infection Infertility Ovarian cysts (see below) Menstrual diarrhea Nausea and vomiting with menses Other rare symptoms include nosebleeds or bloody cough with menses Diagnosis: Endometriosis may be suspected on the basis of history. It can be difficult to diagnose. Diagnostic laparoscopy is the most reliable method of diagnosis, but can be associated with false positives (believing the disease to be the cause of symptoms when it is not) and false negatives (believing the disease to be absent when it is present). In many cases, one option is to treat medically on the basis of a very strong suspicion after a thorough history and physical examination and imaging studies where indicated. There are problems with trying to diagnose endometriosis. One problem is that the primary symptom for which women seek care is pain, and pain is entirely subjective. In addition, there may be a difference between how much endometriosis is present and how much subjective pain is felt; some women with small areas of endometriosis have severe pain, and some women with severe endometriosis don’t feel a thing. This is a well-known conundrum in gynecology. Severe pain may be present without apparent disease, and and forms of endometriosis exist that are painless. In addition, pain can come from any source in the pelvis, including the bowel, bladder, appendix, bony structures, muscles, as well as from infection, inflammation, or scarring or other diseases involving the uterus, tubes, or ovaries. No good and reliable blood tests or chemical markers exist for endometriosis. The most well known, CA-125, is actually used more frequently as a chemical marker for a particular type of ovarian cancer, and is very nonspecific, meaning there are false positives and false negatives. Imaging studies, including ultrasound and MRIs, are useful for some types of endometriosis but not others. Endometriosis involving the ovary may result in the formation of a closed cavity on the ovary that fills with blood and becomes an endometrioma, or chocolate cyst. They can vary from small dark spots on the ovary to masses greater than 10 centimeters. The larger the cyst, the more likely it will be felt on physical exam or identified by ultrasound. Ultimately, the gold standard for diagnosis is laparoscopy. Laparoscopy is not itself without pitfalls. Endometriosis has a number of different appearances, including classic powder-burn spots, scattered red spots, adhesions, localized scarring, anatomical distortion or thickened peritoneum, white spots, red flames, nodules, etc. Adenomyosis Adenomyosis is a specialized type of endometriosis. Instead of being outside the uterus, adenomyosis is a condition where the endometrial lining has extended from its usual place as a thin sheet covering the inner surface of the endometrial cavity (the inner open space of the uterus) into the thick muscular layers of the uterus. The symptoms are similar to endometriosis with progressive cyclic menstrual pain and heavy bleeding. It is even more difficult to diagnose in the absence of tissue to send to a pathologist, but can be suspected on the basis of the previously described symptoms in the presence of a globular, slightly enlarged, soft uterus (often described as “mushy”) on physical exam. Treatment The treatment for endometriosis varies depending on the needs and desires of the woman who has it. Primarily, treatment focuses on relief of pain, including painful menses, painful intercourse, and relief of symptoms associated with urination and bowel movements. Treatment also may be useful in the management of infertility. Medical management therapies currently in use include combination oral contraceptives or birth control pills, danazol, medications that simulate menopause and turn off or down- regulate the ovaries such as GnRH analogues, and hormonal management aimed at direct anti-estrogenic effects such as progestins. Lesions become inactive and undergo regression during the time of treatment. In some cases, the best treatment is a staged process, in which the least invasive and best-tolerated treatments are attempted first with an aim toward attaining pain relief, maintaining fertility if desired, and achieving a balance between efficacy and safety. Evaluation and treatment with laparoscopy is the gold standard, despite the pitfalls described above. The procedure usually involves a general anesthetic and a one-day hospital stay. Laparoscopic treatment is dependent on a number of variables, including extent or spread of the disease, identification of the disease in all its appearances, location, presence of adhesions or scar tissue, involvement of the bowel, bladder, or ureters, anatomic distortion caused by thickened peritoneum or scarring, depth of infiltration of the disease, and other variables. Surgical intervention may include laser vaporization of endometriosis, electrocautery as a tool in removal, complete excision or cutting out of deeper nodules, removal of ovarian cysts or removal of an ovary, cutting scar tissue, freeing up tubes and ovaries to allow normal mobility, and using newer techniques and adhesion barriers to prevent scar tissue formation. Findings at laparoscopy may prompt other surgical interventions as well, depending on the severity of a woman’s symptoms and her personal desires. A combination approach may be beneficial, starting with laparoscopy and adding ovary down-regulation for a period of time (3-12 months) afterwards, although there is some question of whether post-surgical treatment is useful. Ultimately, any treatment must be individualized to a woman’s symptoms, needs, and intent with regard to fertility in a conversation between the woman and her doctor. The Psychology of Endometriosis Endometriosis is a chronic condition. Despite optimal management, both surgical and medical, this may mean that a woman will experience some level of her symptoms and associated problems life-long. Women who suffer from endometriosis may also describe depression and anxiety reactions, vaginal muscle spasm, relationship issues, or an inability to cope with daily activities of home, work, family, etc. It is a disservice to disregard this very important part of dealing with endometriosis. Several very good organizations exist to provide information and support for sufferers of endometriosis and I encourage their use. References: On request |
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