Endometriosis

Written by Abdul Wadood Mohamed and Matthew Solan | Published on July 25, 2012
Medically Reviewed by George Krucik, MD

Overview

Endometriosis is a disorder in which the endometrium grows outside your uterine cavity. The endometrium is the tissue which makes up the inside surface of your uterus.

Endometriosis occurs when this lining grows on the ovaries, bowel, and tissues lining your pelvis. It is unusual (but not impossible) for endometrial tissue to spread beyond the pelvic region.

The misplaced endometrial tissue follows the menstrual cycle under the influence of hormonal changes. This means the tissue will grow, thicken, and break down. Over time it will have nowhere to exit and become trapped.

This causes irritation, scar formation, or adhesions (binding of organs by abnormal tissue) with the surrounding tissues. It may lead to severe pain during your periods and possible fertility problems

Causes of Endometriosis

During a regular menstruation, your body sheds the lining of your uterus. This enables menstrual blood to flow from your uterus through the small opening in the cervix and out through your vagina.

Endometriosis often occurs due to a process called retrograde menstruation. This happens when menstrual blood flows back through the fallopian tubes into the pelvic cavity instead of the body.

The displaced endometrial cells then stick to your pelvic walls and surfaces of pelvic organs. They then continue to grow, thicken, and bleed over the course of your menstrual cycle.

Doctors believe the condition may also occur if areas of the abdomen convert into endometrial tissue. This may happen because cells in the abdomen arise from embryonic cells, which can change shape and act like endometrial cells. Why this occurs is unknown.

Stages (“Types”) of Endometriosis

Based on the stages of evolution of the disease, there are four main types: subtle, typical, cystic ovarian, and deep endometriosis.

Subtle

Often the beginning stage, subtle types look like a small sac or cyst. These cysts range in size from 1 to 3 mm. Subtle growths are not serious, but may mimic ovarian cancer.

Typical

This type appears as black spots over a white fibrous area and varies in size from 1 to 2 cm in diameter. These spots are found in and around your pelvis and/or your diaphragm.

Cystic Ovarian

This stage involves cysts larger than 4 to 5 cm, growing as large as 15 cm, and covering the ovary. They may form adhesions with the wall of your pelvis or other organs within the pelvis.

Deep

The last stage, it results in solid tumors up to 5 or 6 cm in diameter. These tumors will mostly be found in the space between the back wall of your uterus and the rectum.

Risk Factors for Endometriosis

Age

Women of all ages are at risk for endometriosis. Typically, it affects women from age 25 to 40.

Family History

If you have a family member who had endometriosis, consult your doctor. You may have a higher risk of developing the disease.

Nulliparous

Pregnancy seems to protect women against endometriosis. Childless women run a greater risk, however, endometriosis can still occur in women who have had children.

Menstrual History

If you have problems regarding your menses, such as shorter cycles, heavier and longer periods, or you began menstruating at younger than average age, consult your doctor. This may place you at higher risk.

Recognizing the Symptoms of Endometriosis

Pain is the most common symptom Specifically, this may include:

  • painful periods
  • pain in the lower abdomen before and during menstruation
  • cramps one or two weeks around menstruation
  • pain following sexual intercourse
  • discomfort with bowel movements
  • pelvic or lower back pain that may occur at any time during your menstrual cycle

Some patients experience no symptoms. The severity of pain does not indicate the degree or stage of the disease. For example, mild endometriosis can have extensive pain, whereas advanced endometriosis may have little or no pain.

It is recommended you maintain yearly gynecological exams so your gynecologist can monitor for changes, especially if you suffer from two or more symptoms.

Potential Complications of Endometriosis

Impaired fertility is the most serious complication. According to the Mayo Clinic, about one-third to one-half of patients with endometriosis have trouble getting pregnant. (Mayo) Still, women with milder forms are still able to conceive and carry their baby to term.

If you are a woman who has been diagnosed with endometriosis, you should make a decision about having children right away. The symptoms may get worse over time.

Testing for and Diagnosing Endometriosis

To diagnose endometriosis, your doctor or gynecologist will perform one or more of the following tests or procedures.

Detailed Patient History

Your doctor will note your symptoms and personal and family history of endometriosis. A general health assessment may also be performed to determine if any other signs of a long-term disorder are present.

Physical Exam

During a pelvic exam, your doctor will manually feel your abdomen for cysts or scars behind the uterus.

Ultrasound

There are two types: a vaginal ultrasound, where a transducer is inserted into the vagina, and an abdominal ultrasound. Both provide images of your reproductive organs. They can identify cysts, but are not effective in ruling out the disease.

Laparoscopy

The only certain method for identifying endometriosis is by directly viewing it. This is done by a minor surgical procedure known as laparoscopy.

Endometriosis Treatment Options

Medical and surgical options are both available depending on the extent of the disease. Your doctor may attempt conservative treatments first, and opt for surgery as a last resort. Here is a summary:

Pain Medications

Many types of pain medication can be recommended, but they are not effective in all cases.

Hormonal Therapy

Taking supplemental hormones can sometimes relieve pain. These help your body to regulate the monthly changes in hormones that promote the growth in endometriosis.

Hormonal Contraceptives

Hormonal contraceptives decrease fertility by preventing the monthly growth and buildup of endometrial tissue. Birth control pills, patches, and vaginal rings can reduce (or eliminate) the pain in less severe endometriosis.

Gonadotropin-Releasing Hormone (GnRH) Agonist and Antagonist

Women take GnRH agonists and antagonists to block the production of estrogens that stimulate the ovary. As a result, your menstruation is prevented, which creates an artificial menopause. This therapy has side effects like vaginal dryness and hot flashes. Taking small doses of estrogen and progesterone at the same time can help to limit or prevent these symptoms.

Danazol

Danazol is another medication used to stop menstruation and reduce symptoms. Unfortunately, it has harsh side effects, such as hirsutism (unwanted hair growth) and acne.

Depo-Provera (Methoxyprogesterone)

Depo-Provera is also effective in halting menstruation. Upon injection it stops the growth of endometrial implants. Although it relieves pain and other symptoms, it also decreases bone production, causes weight gain, and may lead to depression.

Conservative Surgery

Conservative surgery is for women who want to get pregnant or suffer from severe pain. It strives to remove or destroy the endometrial growths without damaging your reproductive organs.

This can be done through traditional open surgery, where the endometrial growths are removed through a wide incision. Laparoscopy, a less invasive surgery, is another option. The surgeon will make a number of small incisions in your abdomen to remove the growths.

Radical Surgery (Hysterectomy)

A hysterectomy involves the removal of the uterus and cervix. Because endometrial growths grow under the influence of estrogen, the ovaries also must be removed for long-lasting relief.

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