This is a common often painful female reproductive health disorder that occurs when tissues linning the uterus (the endometrium) develops outside the uterus leading to chronic pelvic pain. Endometrial tissues usually grow in the pelvic area or abdominal cavity and may attach itself to the ovaries, intestines or other abdominal organs. In rare cases these tissues may spread beyond the pelvis into the lungs or brain. Endometriosis may also develop from scars after undergoing surgery on the pelvic organ. In addition to severe pain endometriosis can also cause irregular periods and infertility.
CAUSES AND RISK FACTORS
During menstruation, the ovaries produces hormones that signal the inner lining of the uterus – the endometrium - to be shed. In some cases endometrial tissues shed during menstruation travel backward though the fallopian tubes into the pelvis, where they implant and grow. This process is called retrograde menstruation. These endometrial tissues usually grow on ovaries, bladder, rectum, colon and the lining of the pelvic area. They may also travel to distant organs like the lungs, brain, legs and arms. It should be noted that unlike endometrial cells of the uterus, implantations that occur outside the uterus stay in place and grow with subsequent menstruations. They may sometimes bleed a little. This process may cause severe pain and other symptoms of endometriosis. Retrograde menstruation is the most likely cause of endometriosis, however other factors like flactuations in hormonal levels may be involved. Hormone levels that affect endometriosis are directly related to menstruation therefore it is rare for women to develop endometriosis before menstruation or after menopause. Endometriosis is less severe when hormone levels are constant or there is no menstruation like during pregnancy. Determination of the exact number of women who have this disease is unknown because most women do not develop symptoms and those who get symptoms do not go for proper diagnosis. However, it is estimated that over 5.5 million American women will experience this problem. Endometriosis is more common in Caucasian women than African American or Asian women. It is most commonly diagnosed between the ages of 23 – 35 years. Reasearch shows that it is more commom in taller thinner women with low Body Mass Index (BMI).
Women at high risk of endometriosis include those who have:
- Never had children
- Painful periods
- Pelvic infection
- Pain with bowel movement
- Pain duing or after sex
- Family member with the disease
- A condition that prevents menstruation
- Shorter menstrual cycle (less than 27 days) and bleeding that lasts more than 8 days
- Cramping a week or two before menstruation and during menstruation
- Pelvic or lower back pain during menstruation
SYMPTOMS
Most people with endometriosis do not expereince any symptoms at all. In some cases, women may expereince symptoms with the most common complaint being pelvic pain that worsen before menstruation and improves at the end of menstruation. Severity of symptoms depend on the women and the timimg of the menstraul cycle.
Other common signs and symptoms include:
- Painful periods (dysmenorrhea)
- Pain with sexual intercourse (dyspareunia)
- Infertility
- Excessive bleeding – Occasional heavy periods (menorrhagia) or bleeding between periods (menometrorrhagia)
- Pain with bowel movements or urination
- Lower abdominal pain before and during menstruation
- Lower back or pelvic pain during menstruation
Other symptoms may include fatigue, constipation, diarrhea, nausea and bloating during menstruation.
TESTS AND DIAGNOSIS
Your doctor will first of all ask you to describe the pain, it’s intensity and location. Then he will go ahead to do other physical examinations. These include:
Pelvic exam – Your doctor will feel areas around your pelvis for abnormalities as cysts on your reproductive organs or scars behind the uterus. A pelvic exam is however not enough because small areas of endometriosis are hard to find unless they form a cyst.
Transvaginal ultrasound – This is not a definite test for endometriosis but it helps locate cysts associated with the disease. Sound waves are used to produce video images of the reproductive organs by doing an ultrasound of the vagina or pelvis.
Pelvic laproscopy – This is a definite test for endometriosis. This is a minor surgical procedure where your doctors directly visualizes the inside of your abdomen for signs of endometrial implants. This test will also provide information about the location, size and stage of the endometrial implants.
STAGES
A system has been developed for staging endometriosis. The stage of the disease is not directly related to the severity of the disease but it is helpful in predicting a woman’s chances of fertility. Endometriosis is classified from minimal to severe depending on the laproscopy results.
Minimal – isolated implants, no significant adhesion
Mild – superficial implants less that 5 cm in aggregate without significant adhesion
Moderate – multiple implants and scarring (adhesions) around ovaries and tubes
Severe – multiple implants including large ovarian endometriomas, thick adhesions
TREATMENTS
Endometriosis is usually treated with surgery or medication. Treatment options depend on age, severity of disease and symptoms and whether you want to have children in the future. Doctors usually recommend having surgery to be the last resort.
Medications – Your doctor will recommend taking over-the-counter pain medications like motrin, advil etc to ease menstrual cramping. However if this does not work then other treatment options may be considered to manage the signs and symptoms.
Hormone therapy – Inconsistencies in a women’s hormone during menstruation causes endometrial implants to thicken, break down and bleed causing pain. Supplemental hormones may be given to reduce or completely remove this pain. Hormonal therapies used include:
Hormonal contraceptives – Most women experience lighter and shorter periods when on hormonal contraceptives. A continuous cycle regimen of hormonal contraceptives can reduce or eliminate the pain of mild to moderate endometriosis.
Gonadotropin – releasing hormone (Gn-RH) agonists and antagonist – These drugs prevent menstruation by blocking the release of ovarian stimulating hormones. This dramtic decrease in estrogen shrinks endometrial implants. These are administered either as nasal sprays or intramascular injections. This artificial menopause causes serious side effects like irregular vaginal bleeding, hot flashes, fatigue, mood changes and osteoporosis. These side effects can be minimized by administering small doses of estrogen and progesterone in a pill form.
Progestins – These are potent birth control pills used to halt menstruation and growth of implants thereby relieving symptoms. Examples include medroxyprogesterone acetate (Provera) and norethindrone acetate (Camila, Errin)
Androgens – Danazol stimulates high levels of androgens and low levels of estrogen and blocks the production of ovarian stimulating hormones. This as a result prevents menstruation and eliminate endometriosis signs and symptoms by shrinking implants. Note however that it has high incidence of side effects like edema, weight gain, decreased breast size, deepening of voice, hot flashes, oily skin, acne, changes in libido and mood changes. All of these side effects except changes in voice are reversible although it could take several months. Women with certain liver, kidney and heart conditions should not take Danazol.
Aromatase inhibitors - These block the conversion of hormones such as androstenedione and testosterone into estrogen. They also block the production of estrogen from endometrial implants themselves. Examples include anastrozole (Arimidex) and letrozole (Femara). If used for a long time they may cause bone loss.
Hormonal therapies are not a permanent fix for endometriosis. Symptoms may come back if discontinued.
Surgery – If medication does not work surgery is the next step. Your doctor may perform conservative surgery to remove the implants if you are trying to get pregnant or have severe pain from the disease. The doctor removes implants, scar tissues and adhesions without removing the reproductive organ. It can be done laproscopically or throw traditional abdominal surgery in severe cases.
Hysterectomy – Surgery may also be done to remove the uterus and cervix (total hysterectomy) as well as both ovaries in very severe cases. Hysterectomy alone is ineffective as the hormones produced by the ovaries can still stimulate any remaining endometriosis to cause pain. It should be the last resort for women in their reproductive age. You cannot become pregnant after a hysterectomy.
LIFE STYLE AND HOME REMEDIES
If pain persist you can relieve symptoms at home with warm baths and heating pad to reduce cramping and relax the pelvic muscle. Increase in physical activities may also reduce the pain.
COMPLICATIONS
The main complication of endometriosis is infertility. Doctors usually advice women with endometriosis not to delay in having children because the condition may worsen.
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