Endometriosis

Definition

Endometriosis is a condition in which the endometrial tissue normally found in the uterus grows in other areas.

Description

The endometrium, a type of tissue that nourishes fertilized eggs, normally grows each month within the uterus and, if no egg is implanted, is shed through menstruation.

Endometriosis occurs at menstruation when normal endometrial tissue backs up with menstrual blood through the fallopian tubes and then implants and grows in other places such as:

• Ovaries

• Fallopian tubes

• Outer surface of the uterus

• Outer surfaces of the bowel

• Other pelvic structures

• Other body tissues located anywhere in the abdomen

These tissues respond to the cycle of changes brought on by the female hormones just as the endometrium normally responds in the uterus. Thus, at the end of every cycle, when the hormones cause the uterus to shed its endometrial lining, endometrial tissue growing outside the uterus will break apart and bleed.

Unlike menstrual fluid from the uterus, which is discharged freely out of the body during menstruation, blood from the abnormal tissue has no place to go. Body tissues respond to this menstrual-type bleeding by:

• Surrounding it with inflammation (tissue that becomes red, swollen, and painful around the area)

• Trying to absorb it back into the circulatory (blood) system

This monthly inflammation subsides when the bleeding ends (at the same time normal menstrual bleeding ends), and scar tissue is produced around the area. This pattern occurs in the same cycle as the menstrual cycle, occurring month after month, ultimately creating scar tissue and sometimes adhesions - abnormal tissue growth that bind organs together.

Sometimes a patch of endometriosis is surrounded by enough scar tissue to cut off its blood supply and the tissue can no longer respond completely to the hormones. Other patches may rupture, or burst, during menstruation and spread their contents to other pelvic areas, causing new spots of endometriosis to develop. Thus, the condition may become gradually worse with time, although symptoms may come and go.

Stages

Doctors use stages to describe the severity of endometriosis. The four (4) stages are minimal, mild, moderate and severe.

• Minimal endometriosis is when the growths are small and not widespread.

• Mild endometriosis is the same as minimal endometriosis except the growths are deeper in the tissue and more numerous.

• Moderate endometriosis means that larger growths or scar tissue are present.

• Severe endometriosis is used to describe large growths and extensive scar tissue.

Causes and Risk Factors

The cause of endometriosis is still unknown. One theory is that during menstruation some of the menstrual tissue backs up through the fallopian tubes into the abdomen, where it implants and grows.

Another theory suggests that endometriosis may be a genetic process or that certain families may have predisposing factors.

Symptoms

The symptoms of endometriosis are:

• Pain before and during menstrual periods

• Pain during or after sexual activity

• Heavy or irregular bleeding

• Fatigue

• Pain with bowel movements at the time of the period

Diagnosis

Diagnosis of endometriosis requires confirmation by a laparoscopy. This is a relatively minor surgical procedure done under anesthesia.

A laparoscope (a thin tube with a light in it) is inserted into an incision made in the patient's abdomen. The laparoscope is moved around the abdomen, which has been distended with carbon dioxide gas to make the organs easier to see. The surgeon can then check the condition of the abdominal organs and see the location, extent and size of the endometrial growths.

Treatment

There is no certain cure for endometriosis. The goal of the treatment is to keep the disease and its symptoms in check. Based on the disease stage, the severity of symptoms, and the patient's age, desire to have children, circumstances and preferences, the doctor will recommend one of three approaches - pharmaceutical intervention (medication), surgery or a combination of the two.

Medication

All drugs used in treating endometriosis are directed at disrupting the hormones that govern the menstrual cycle.

The oldest such medical treatment is continuous use of an oral contraceptive, which supplies a steady dose of estrogen and progesterone and signals the brain to shut down its production of gonadotropin-releasing hormone (GnRH). GnRH stimulates the pituitary, which in turn stimulates the ovary to release an egg.

This drug treatment usually brings only temporary relief and most women who have taken it experience a return of pain within months of discontinuing therapy. Newer medications have had longer lasting effects.

The synthetic male hormone danazol (danocrine), one of the most frequently prescribed drugs used for endometriosis, inhibits the monthly surge of luteinizing hormone (LHG), reduces estrogen production, and influences the way estrogen affects endometriosis. Its side effects include weight gain, acne, oily skin, a reduction in breast size, deepening of the voice, and growth of hair on the face and chest. It may also adversely affect lipid metabolism and raise blood pressure.

Synthetic forms of progesterone, most commonly Depo-Provera (medroxyprogesterone), are also used to treat the condition by causing endometrial tissue to break down and atrophy. Depo-Provera is as effective as danazol in relieving pain and its benefits last longer, but it too has side effects, which include abnormal uterine bleeding, nausea, breast tenderness, fluid retention, and depression. However, these usually clear up as soon as treatment ends.

The newest drugs are GnRH analogs, such as Lupron, Suprefact, Synarel and Zoladex which displace the natural hormone and in doing so disrupt the menstrual cycle. These medications, which act on the pituitary to shut down the ovaries, are as effective as danazol in relieving pain. Their side effects are considerable, including hot flashes, headaches, vaginal dryness, and a reduction in bone mass.

Surgery

Surgery is a common treatment for the pain of endometriosis. There are two surgical procedures available - laparoscopic electrical cauterization of endometrial growths, and total abdominal hysterectomy with bilateral oophorectomy.

Laparoscopic electrical cauterization or laser removal of endometrial growths is performed during the diagnostic phase of the disease. While doing a laparoscopy the doctor will either use a cauterizer or a laser to remove the endometrial growth(s).

Total abdominal hysterectomy with bilateral oophorectomy is the removal of the uterus and ovaries. This surgery is suggested in women who have advanced disease and severe pain and who do not wish to have children.

For most women, the symptoms of endometriosis disappear after menopause. For the very few whose symptoms may persist, estrogen replacement therapy could theoretically exacerbate the condition. Thus, postmenopausal women with endometriosis should thoroughly explore the risks and benefits of hormone replacement therapy with their physicians.

Questions to Ask Your Doctor

What tests need to be done to diagnose endometriosis or to rule out some other disease?

Will a laparoscopy be recommended?

What is the procedure?

Are there any risks?

What is the cause of the condition?

What treatment will you be recommending?

Will you be prescribing any medication? What are the side effects?

How effective is this medication in treating endometriosis?

What are the chances that surgery may be needed to correct the condition?

How will this affect my chances of getting pregnant and of having a successful pregnancy?