What is Endometriosis?
Endometriosis is a common and often painful disorder of the female reproductive system. In this condition, a specialized type of tissue that normally lines the inside of your uterus (the endometrium) becomes implanted outside your uterus, most commonly on your fallopian tubes, ovaries or the tissue lining your pelvis. Rarely, endometrial tissue may spread beyond your pelvic region.
During your menstrual cycle, hormones signal the lining of your uterus to thicken to prepare for possible pregnancy. If a pregnancy doesn't occur, your hormone levels decrease, causing the thickened lining of your uterus to shed. This produces bleeding that exits your body through the vagina — your monthly period.
When endometrial tissue is located in other parts of your body, it continues to act in its normal way: It thickens, breaks down and bleeds each month as your hormone levels rise and fall. However, because there's nowhere for the blood from this mislocated tissue to exit your body, it becomes trapped, and surrounding tissue can become irritated.
Trapped blood may lead to the growth of cysts. Cysts, in turn, may form scar tissue and adhesions — abnormal tissue that binds organs together. This process can cause pain in the area of this misplaced tissue, usually the pelvis, especially during your period. Endometriosis can also cause fertility problems. In fact, scars and adhesions on ovaries or fallopian tubes can prevent pregnancy.
Endometriosis isn't the only cause of pelvic pain. Functional ovarian cysts, pelvic infections and nongynecologic diseases also may cause pelvic pain. Although ovarian cancer doesn't usually cause pelvic pain in its early stages, it's a possibility your doctor should consider. See your doctor for an accurate diagnosis and to target treatment.
Signs and symptoms of Endometriosis
Endometriosis can be mild, moderate or severe, and it tends to get worse over time without treatment. Some women with endometriosis have no signs and symptoms at all, and the disease is discovered only during an unrelated operation, such as a tubal ligation. Others may experience one or more of the following signs and symptoms:
- Painful periods (dysmenorrhea). Pelvic pain and cramping may begin before and extend several days into your period and may include lower back and abdominal pain.
- Pain at other times. You may experience pelvic pain during ovulation, a sharp pain deep in the pelvis during intercourse, or pain during bowel movements or urination.
- Excessive bleeding. You may experience occasional heavy periods (menorrhagia) or bleeding between periods (menometrorrhagia).
- Infertility. Endometriosis is first diagnosed in some women who are seeking treatment for infertility.
Some cramping during your period isn't abnormal. But women with endometriosis typically describe menstrual pain that's far worse than normal. They also tend to report that the pain has increased over time.
Pain is a common symptom of endometriosis. However, severity of pain isn't necessarily a reliable indicator of the extent of the condition. Some women with mild endometriosis have extensive pain, while others with more severe scarring may have little pain or no pain at all.
Endometriosis is sometimes mistaken for other conditions that can cause pelvic pain, such as pelvic inflammatory disease (PID) or ovarian cysts. It may be confused with irritable bowel syndrome (IBS), a condition that causes bouts of diarrhea, constipation and abdominal cramping. IBS can accompany endometriosis, which can complicate the diagnosis.
See your doctor if you have signs and symptoms that may indicate endometriosis. The cause of chronic or severe pelvic pain may be difficult to pinpoint. But discovering the problem early may help you avoid unnecessary complications and pain.
Causes of Endometriosis
The cause of endometriosis remains mysterious. Scientists are studying the roles that hormones and the immune system play in this condition.
One theory holds that menstrual blood containing endometrial cells flows back through the fallopian tubes, takes root and grows. Another hypothesis proposes that the bloodstream carries endometrial cells to other sites in the body. Still another theory speculates that a predisposition toward endometriosis may be carried in the genes of certain families.
Other researchers believe that certain cells present within the abdomen in some women retain their ability to specialize into endometrial cells. These same cells were responsible for the growth of the women's reproductive organs when she was an embryo. It's believed that genetic or environmental influences in later life allow these cells to give rise to endometrial tissue outside the uterus.
Risk factors for Endometriosis
Experts estimate that up to one in 10 American women of childbearing age have endometriosis. The condition is most likely to occur in women who haven't had children. Some women may have an inherited tendency to develop endometriosis.
Rarely, a woman may be at increased risk because of a medical problem that prevents the normal passage of menstrual flow. In addition, there's some thinking that damage to cells that line the pelvis — caused by a previous infection — can lead to endometriosis.
Endometriosis can affect menstruating women of any age or race and usually takes several years after the onset of menstruation (menarche) to develop. When menstruation ends permanently with menopause or temporarily with pregnancy, the signs and symptoms of endometriosis stop. They can begin again after pregnancy when menstruation resumes. Rarely, hormone replacement therapy after menopause can reactivate the disorder.
To diagnose endometriosis and other conditions that can cause pelvic pain, your doctor will ask you to describe your symptoms, including the location of your pain and when it occurs. Your doctor will perform a pelvic exam to check for any abnormalities, such as cysts on your reproductive organs or scars behind your uterus. Often it's not possible to feel small areas of endometrial implantation, unless they've caused a cyst to form.
Other tests to check for physical clues of endometriosis include:
- Ultrasound. During a vaginal ultrasound, a wand-shaped scanner (transducer) is inserted into your vagina. In an ultrasound of the pelvis via the abdomen, a small scanner is moved across your abdomen. Both tests use sound waves to provide a video image of your reproductive organs.
- Laparoscopy. Because endometrial implants often cannot be felt or clearly seen in some tests, the only way a doctor can make a definitive diagnosis of endometriosis is through a minor surgical procedure called laparoscopy.
You receive a general anesthetic before the procedure begins. Using a special needle, your abdomen is expanded (distended) with carbon dioxide gas so that reproductive organs are easier to see. A tiny incision is made near you navel, and a slender viewing instrument (laparoscope) is inserted. By moving the laparoscope around, the surgeon can view the pelvic and other abdominal organs, looking for signs of endometrial tissue outside the uterus. If you have endometriosis, laparoscopy will provide you and your doctor with information about the location, extent and size of the endometrial implants. This information will help your doctor guide you through treatment options.
- Blood test. CA-125 is a blood test used to detect a certain protein that's commonly found in the blood of women with endometriosis. Although CA-125 commonly reveals an elevation in such blood protein in women with advanced endometriosis, it's not as sensitive to less advanced disease. CA-125 doesn't always perform well as a screening test for endometriosis.
Treatment for endometriosis is with medications or surgery. The approach you and your doctor choose will depend on the severity of your signs and symptoms and whether you hope to become pregnant.
Your doctor may recommend that you take an over-the-counter pain reliever, such as ibuprofen, to help ease painful menstrual cramps. However, if you find that taking the maximum dose doesn't provide full relief, you may need to try another treatment approach to manage your symptoms.
Supplemental hormones are effective in reducing or eliminating the pain of endometriosis. That's because the rise and fall of hormones during a woman's menstrual cycle causes endometrial implants to thicken, break down and bleed. In fact, if hormonal therapy has little to no effect on your symptoms, consider questioning the diagnosis of endometriosis or its relationship to your symptoms.
Hormonal therapies used to treat endometriosis include:
- Oral contraceptives. Birth control pills help control the hormones responsible for the buildup of endometrial tissue each month. Taking the pill long term can reduce or eliminate the pain of endometriosis. Most women also have lighter and shorter menstrual flow when they're taking the pill.
- Gonadotropin-releasing hormone (Gn-RH) agonists and antagonists. These drugs block the production of ovarian-stimulating hormones. This action prevents menstruation and dramatically lowers estrogen levels, causing endometrial implants to shrink. Gn-RH agonists and antagonists can force endometriosis into remission during the time of treatment and sometimes for months or years afterward. These drugs create an artificial menopause that can sometimes lead to troublesome side effects, such as hot flashes and vaginal dryness. A low dose of estrogen may be taken along with these drugs to decrease such side effects.
- Danazol (Danocrine). This drug blocks the production of ovarian-stimulating hormones, preventing menstruation and the symptoms of endometriosis. It also suppresses the growth of the endometrium. However, danazol may not be the first choice because it can cause unwanted side effects, such as acne and facial hair.
- Medroxyprogesterone (Depo-Provera). This injectable drug is effective in halting menstruation and the growth of endometrial implants, thereby relieving the signs and symptoms of endometriosis. Its side effects can include weight gain and depressed mood.
Although hormone therapies are effective in reducing or eliminating symptoms of endometriosis, they prevent pregnancy. If you have endometriosis and are trying to become pregnant, surgery to remove implants may increase your chances of success. If you have severe pain from endometriosis, you may also benefit from surgery.
Conservative surgery removes endometrial growths, scar tissue and adhesions without removing your reproductive organs. Your doctor may do this procedure laparoscopically or through traditional abdominal surgery in more extensive cases. In laparoscopic surgery, a slender viewing instrument (laparoscope) is inserted through a small incision near your navel. The laparoscope is equipped with a laser, a cautery - an instrument that destroys tissue with heat - or small surgical instruments. Assisted reproductive technologies are sometimes preferable to conservative surgery, and doctors often suggest these approaches if conservative surgery is ineffective.
In severe cases of endometriosis, a total hysterectomy and the removal of both ovaries may be the best treatment. Hysterectomy alone is also effective, but removing the ovaries ensures that endometriosis will not return. Either type of surgery is typically considered a last resort, especially for women still in their reproductive years. You can't get pregnant after a hysterectomy.
Although no single treatment option is ideal for everyone, most women who seek help for endometriosis find some, if not complete, relief from their symptoms. If your pain persists or if finding a treatment that works takes some time, you can try measures at home to relieve your discomfort. Warm baths and a heating pad can help relax pelvic muscles, reducing cramping and pain.
Finding a doctor with whom you feel comfortable is crucial in managing and treating endometriosis. You may also want to get a second opinion before starting any treatment regimen to be sure you know all of your options and the possible outcomes.