Endometriosis

Introduction

Endometriosis is the abnormal growth of uterine-lining tissue outside of the uterus. Endometriosis frequently develops on the outside of the uterus, fallopian tubes, ovaries, or pelvic lining. It is a common problem that needs monitoring and treatment because complications may lead to pain and infertility. Treatment for endometriosis involves medication or surgery.

Anatomy

The internal female reproductive system includes the ovaries, fallopian tubes, uterus, cervix, and vagina. The ovaries are two small organs that produce eggs (ova) and hormones. An ovary typically releases one mature egg each month. Two fallopian tubes extend from near the ovaries to the uterus. The fallopian tubes transport the mature eggs to the uterus.

The uterus is a pear-shaped organ where a baby grows in during pregnancy. The lining of the uterus undergoes cyclic changes to facilitate and maintain pregnancy. Each month the uterine lining thickens as it builds up extra blood and tissue in preparation for a potential fertilized egg. An egg that is fertilized by a sperm cell may implant itself in the nourishing uterine lining and develop into a baby. An unfertilized egg or a fertilized egg that does not implant in the uterus passes through the reproductive system. During menstruation the uterine lining sheds and the blood leaves the body through the vagina. The uterus is joined to the vagina by the cervix. The vagina is a muscular passageway that extends from the cervix to the external female genitalia.

Causes

The exact cause of endometriosis is unknown. Researchers suspect that hormones and the immune system may somehow contribute to the development of endometriosis. Endometriosis occurs when the tissue that normally lines the uterus grows outside of the uterus. Common sites for endometriosis include the outside of the uterus, fallopian tubes, ovaries, bowel, rectum, bladder, and tissue lining the pelvic region. In response to monthly hormonal changes, the endometrial cells may bleed and cause pain or form cysts. Overtime, this can lead to adhesion and scar tissue formation. Endometriosis in the fallopian tubes and ovaries can cause infertility.

Symptoms

Endometriosis may or may not cause symptoms. Symptoms include lower abdominal pain or cramps that may begin a week or two before your period starts. Pelvic or back pain may continue during your period. Y our periods may become increasingly painful. The pain may feel dull or quite severe. You may experience pain during or after sexual intercourse or bowel movements. You may spot blood before your period begins. You may bleed quite heavily during your period or bleed between periods. You may experience infertility, the inability to become pregnant after a year of trying. Symptoms of endometriosis go away during pregnancy and after menopause.

Diagnosis

You should contact your doctor if you have the signs and symptoms of endometriosis. Your doctor will review your medical history and conduct a pelvic examination. An ultrasound may be performed to create images of your reproductive organs. A laparoscopy may be used to confirm the diagnosis and determine the extent of your condition. A laparoscopy is a minimally invasive surgical procedure that uses a laparoscope to view the reproductive organs. A laparoscope is a thin tube with a light and viewing instrument that is inserted through a small incision in your abdomen. Images from the laparoscope are sent to a video monitor.

Treatment

Treatment for endometriosis depends on several factors, including the extent of your condition and your desire to have children in the future. Mild endometriosis may be monitored with regular examinations. Your doctor may prescribe or recommend medication for pain relief. You may find it helpful to use a heating pad or warm baths. This can relax muscles and relieve pain.

Birth control pills may be used to stop menstruation and prevent the condition from getting worse. Hormonal therapy may be used to prevent symptoms and the growth of endometriosis. However, certain types of hormone medications may prevent pregnancy. If you desire to get pregnant or have severe symptoms, you may consider surgical treatment.

Surgical treatment for endometriosis involves traditional or laparoscopic surgery to remove growth, scar tissue, or adhesions. Laparoscopic surgery is minimally invasive and associated with short recovery times. I n severe cases of endometriosis, a total hysterectomy is performed to remove the uterus, both fallopian tubes, and both ovaries. In some cases, just the uterus may be removed. You will not be able to become pregnant after a hysterectomy.

Prevention

There is no proven way to prevent endometriosis. Birth control pills may help to prevent the onset or slow the growth of the condition.

Am I at Risk

Endometriosis is a common condition. Women with a family history of endometriosis have a higher risk of developing it. Women that did not give birth to children may have a higher risk. Women with periods that last longer than seven days or had their first period at an early age may be at risk for endometriosis.

Complications

Endometriosis may cause infertility in some women. Endometriosis may come back after surgical treatment, including hysterectomy. Endometrial growths on the bladder or bowel may cause blockages or incontinence.

Endometriosis

The lining tissue of the uterus is called the endometrium. Each month (except during pregnancy) this lining is shed through the cervix and into the vagina during the menstrual period. However, some of the blood and lining cells may exit the uterus in the wrong direction, flowing up through the fallopian tubes and into the abdominal cavity. This is sometimes called retrograde bleeding. It is a fairly common occurrence, but usually the body’s immune system recognizes that these cells are in the wrong place and eliminates them.

For unknown reasons, in some women these uterine lining cells may grow outside the uterus. They may grow in or on the ovaries, in the fallopian tubes, on the outer surface of the uterus, or on other areas of the membrane that lines the abdominal cavity. The cells still behave like uterine lining cells, however – growing full of blood and nutrients in preparation to receive an egg and bleeding afterwards as in normal menstruation. This condition is called endometriosis. The blood and other biochemicals released by the endometriosis cells begin to irritate the surrounding tissues, causing pelvic pain. Eventually the body may form scar tissue around these injuries, which can lead to more pain.

Prevalence
Endometriosis is a common gynecological condition among American women of all ages, races and backgrounds. It is more common in women in their 20’s and 30’s, but even adolescents can develop endometriosis. Because endometriosis responds to the monthly release of female hormones (estrogen and progesterone), it decreases and eventually disappears with menopause.

Although the exact cause or causes are not understood, there seems to be a genetic component. A woman whose mother or sister has had surgically proven endometriosis has a sevenfold higher risk of developing the condition than women in the general population.

Consequences
In addition to causing pelvic pain, endometriosis can affect fertility. Mild cases can reduce the chance of getting pregnant from the normal 25% per month to around 7% per month, for a healthy woman in her 20s. More extensive endometriosis that involves scarring, blocking of the fallopian tubes or large cysts in the ovaries (endometriomas) reduce these chances further.

Diagnosis
When a woman complains of chronic pelvic pain, pain with sex, low back pain, painful bowel movements or sudden, knifelike pelvic pain, her physician may suspect endometriosis. Sometimes it can be felt during the rectal part of a pelvic examination as tender, thickened areas near the uterus. A sonogram can reveal the presence of an ovarian cyst and may show patterns characteristic of endometriosis. However, the only way to obtain a definite diagnosis is with visual inspection of the organs, which is done by laparoscopy.

Both medical and surgical approaches are available to treat endometriosis, and both have had good success rates at reducing pain and improving fertility. If surgery is required, endometriosis can usually be treated with laparoscopic surgery.

References

American College of Obstetricians and Gynecologists. Gynecological Problems: Endometriosis. 2001. www.acog.org/publications/patient_education.pdf/bp013.cfm.
American Society for Reproductive Medicine. Pelvic Pain: A Guide for Patients. Patient Information Series 1997. www.asrm.org/patients/patientbooklets/pelvicpain.pdf.
Parker WH. A Gynecologist’s Second Opinion. (c)2003; A Plume Book; Published by the Penguin Group, New York, NY.
Society of Laparoendoscopic Surgeons. Endometriosis. Patients>Information on Laparoscopic and Endoscopic Procedures. 2004 http://www.sls.org/ | http://www.laparoscopy.org/