Endometriosis

Endometriosis is a disorder in which bits of tissue from the inner lining of the uterus, called the endometrium, grow inside a woman's body but outside of the uterus. These misplaced bits of endometrial tissue can cause pain and irregular bleeding, and can affect a woman's ability to become pregnant.
Experts believe that between 5 and 15 percent of all women of childbearing age have this disorder.  The true percentage is not known because sometimes no symptoms are present and a woman is not diagnosed until she has another medical problem, such as infertility.

How Endometriosis Occurs

In a normal menstrual cycle, the ovaries produce hormones (the body's chemical messengers) that stimulate the cells of the uterine lining - the endometrial cells - to multiply and prepare for a fertilized egg.  These cells swell and thicken.  If the egg is not fertilized and a pregnancy does not occur, this excess tissue is shed from the uterus and discharged from the body, resulting in a normal menstrual period. 

However, in endometriosis, pieces of misplaced endometrial tissue implant themselves on organs outside of the uterus, such as the ovaries, fallopian tubes, rectum, bowel or bladder.  These cells respond normally to the ovaries' hormonal signals by swelling and thickening, but the other organs do not shed them as the uterus does. The cells stay in place and eventually heal.  When this happens month after month, the process can result in scarring and adhesions, which are web-like tissues that can bind pelvic organs together.

Symptoms

Pain is the most common symptom of endometriosis. Usually the pain is in the abdomen, lower back, and pelvis.  The severity of the pain is not an indicator of how much endometriosis exists.   Some women with large affected areas have almost no pain, while others have severe pain even though they have only a few small growths.

Symptoms of endometriosis include:

• Painful menstrual cramps, usually worsening over time
• Chronic pain in the lower back and pelvis
• Pain during or after sex
• Intestinal pain, painful bowel movements or painful urination, especially during menstrual periods
• Very heavy and/or long menstrual periods, often with spotting or bleeding between periods
• Infertility
• Fatigue
• Diarrhea, constipation or bloating during the menstrual period

Diagnosis

If you have one or more of these symptoms, talk with your healthcare provider.  He or she will discuss your symptoms with you and do a pelvic exam, which will often reveal signs of endometriosis.  The physician or midwife may also use imaging tests to diagnose the source of your pain. The two most common imaging tests are:

• Ultrasound, the use of sound waves to create a picture of the inside of the body
• Magnetic resonance imaging (MRI), which uses magnets and radio waves to do the same

However, the only way to know the real extent of the disease is to have a minor surgical procedure called laparoscopy. In this procedure, a tiny cut is made in your abdomen, and a thin tube with a camera and light is placed inside to see growths from endometriosis. Sometimes the physician can diagnose endometriosis by seeing the growths.  Other times he or she will take a small sample of tissue, or a biopsy, for study under a microscope.

Treatments

There is no cure for endometriosis, but there are several different options for treating the pain and infertility that it causes.  Your healthcare provider can assist you in choosing the best treatment for you based on your age, symptoms, and plans for future pregnancies.

Pain Medication – If only mild symptoms are present, your physician/midwife may suggest taking over-the-counter medicines for pain, such as ibuprofen or naproxen.  If these are not sufficiently strong, you may be prescribed stronger pain relievers.

Hormone Treatment – If medication does not relieve the pain, the healthcare provider may recommend hormone therapy to treat endometriosis. However, this option is only available to women who do not wish to become pregnant. Hormones come in many forms including pills, shots, and nasal sprays. Many hormones are used for endometriosis, including:

• Birth control pills, or oral contraceptives block the effects of natural hormones on endometrial growths and can prevent the monthly cycle of buildup and breakdown of growths.  This can lessen the pain of endometriosis, as well as making a woman’s periods lighter and shorter.
• Progestins or progesterone medicines work much like birth control pills and can be taken by women who can't take estrogen. However, it may have side effects including irregular vaginal bleeding, bloating and weight gain, and mood swings.
• Gonadotropin releasing hormone agonists or GnRH agonists slow the growth of endometriosis and relieve symptoms. They greatly reduce the amount of estrogen in the body, which stops the monthly cycle.  It is usually effective in relieving pain and minimizing the endometriosis.  Side effects may include osteoporosis, headaches, hot flashes and vaginal dryness.   GnRH agonists should not be used alone for more than six months, and they are usually prescribed in conjunction with medication to prevent bone loss as well as the other side effects. 
• Danazol is a weak male hormone that lowers the levels of estrogen and progesterone in a woman's body. This either reduces or stops the monthly cycle, as well as giving pain relief.  Side effects include acne, weight gain, tiredness, smaller breasts, and excess hair on the face, chest and abdomen. 

No medication can completely relieve the symptoms or remove the growths, and when hormonal treatment ends, the monthly cycle returns and so may the symptoms.  Therefore, often the best option for the possibility of long-term relief is surgery.

Surgical Procedures

Surgery is usually the best option when a woman has a fertility problem, a large number of growths, or severe pain.   Your healthcare provider might suggest one of the following:

• Laparoscopy is used to both diagnose and treat endometriosis. The surgeon removes growths and scar tissue, or destroys them with intense heat, treating the endometriosis without affecting the healthy tissue around it.  The recovery period is very short compared to major abdominal surgery.  
• Laparotomy is a major abdominal surgery that is sometimes necessary for severe endometriosis.  The surgeon makes a much larger cut in the abdomen so that she or he can reach and remove large growths and those in the abdomen or pelvis.  Recovery usually takes several weeks. 
• Hysterectomy is only an option for women who do not want to become pregnant in the future.  The uterus is removed, and, if necessary, also the ovaries and fallopian tubes as well.  A women who has had a hysterectomy will no longer have periods or be able to get pregnant.  It is also a major surgery with possible side effects that must be discussed with your physician or midwife.

Remember

If you have any of the symptoms of endometriosis, talk to your healthcare provider.  Your physician or midwife is equipped to diagnose the condition and recommend the best course of treatment for your particular case.  Endometriosis can usually be treated or managed in order to improve the quality of your life.