Understanding Endometriosis: Diagnosis, Treatment and Management

To Your Health -- CHRC Newsletter

Winter 2008

Joanne Seitz, MSN, RNC, NP, CHCQM, PAMF Palomares Obstetrics & Gynecology

While it is not unusual for a woman to experience mild discomfort associated with the monthly menstrual cycle, many women are affected by more severe symptoms. Endometriosis is one of the most common gynecological disorders. Its symptoms cause many women to seek the help of a practitioner experienced in providing relief for the discomfort experienced. Endometriosis can affect women at any time during their childbearing years although it is more common for women in their 20s and 30s to have this disease. In fact, over 5.5 million women in the United States suffer from this disease. If you are one of these women, you are not alone.

What is Endometriosis?

Endometriosis occurs when the endometrium, the same tissue that lines the uterus, is found outside the uterus. Endometriosis can occur almost anywhere in the body. The most commonly affected sites include the ovaries, fallopian tubes, ligaments supporting the uterus, the area between the vagina and rectum, the outer surface of the uterus and the lining of the pelvic cavity. Other sites that can be affected with endometrial growths include the bladder, bowel, vagina, cervix, vulva, and in abdominal surgical scars. Less commonly these growths can be found in the lung, arm and thigh.

Once outside the uterus, the endometrial tissue can form nodules or growths. Because the tissue in these growths resembles the tissue lining the uterus, it responds to the hormones of the woman’s menstrual cycle. Therefore, each month the tissue builds up, breaks down, and bleeds during monthly menstruation. Unlike the lining of the uterus, the endometrial tissue outside of the uterus is unable to leave the body which results in internal bleeding and degeneration of this blood and tissue. The resulting inflammation in the surrounding areas can lead to chronic pelvic pain, infertility, formation of scar tissue and bowel problems. Depending on the location of the lesions, other complications such as rupture of growths can result in the spread of endometriosis to new areas. Intestinal bleeding or obstruction can occur when the growths are near the intestines, also interference with bladder function when growths are on or in the bladder. Symptoms may worsen with time, although cycles of remission and reoccurrence are the pattern in many cases.

Causes

The exact causes of endometriosis are uncertain although many theories have been suggested. The most common and widely accepted theory is that of retrograde menstruation. This theory suggests that during menstruation some of the menstrual tissue backs up through the fallopian tubes, implants in the abdomen, and grows. Some experts believe that all women experience some menstrual tissue backup, but that women with endometriosis have an immune system problem or a hormonal problem resulting in growth of the endometrial implants. However, this does not explain endometriosis in areas such as the lung and in scars. Another widespread theory suggests that endometrial tissue is circulated from the uterus to other parts of the body through the lymph or blood system. Various alternative theories have been suggested including surgical transplantation when endometriosis is found in abdominal surgical scars. There may be a genetic predisposition for developing endometriosis. The possibility of a woman developing endometriosis when her female relatives have this disease has been recognized for some time.

Signs and Symptoms

Many women with endometriosis are entirely without symptoms. The severity of involvement does not always correlate with severity of symptoms. The most common symptoms include:
  • Pain before and during periods that is worse than typical menstrual cramps
  • Pain with intercourse
  • Painful urination during periods
  • Painful bowel movements during periods
  • GI upset: diarrhea/constipation, nausea
  • Fatigue
  • Infertility

Diagnosis and Testing

The diagnosis of endometriosis is often based on symptoms a woman reports to her practitioner. Often there are no abnormal findings on examination in women with endometriosis. Currently, there are no reliable laboratory tests available for diagnosis.

Ultrasound, a noninvasive test that utilizes sound waves to identify soft tissue lesions inside the body, is rarely helpful in diagnosing endometriosis. It lacks adequate resolution for visualizing adhesions unless the disease has caused a large enough growth on organs, such as the ovaries, to be visualized.

Diagnosis of endometriosis is by direct visualization of the growths by laparoscopy, a minimally invasive surgical procedure done under anesthesia. Laparoscopy allows the physician to pinpoint the location and extent of disease. Often, the physician can destroy these growths during this procedure to preserve fertility. Recurrences are common.

Treatments: Medical, Surgical or Both

Treatment for endometriosis has varied over the years but at this time, there is no definitive cure. NSAIDS (non-steroidal anti-inflammatory drugs) like ibuprofen are generally the initial treatment for symptoms. Medical treatment with oral contraceptives containing estrogen and/or progesterone are often utilized to prevent ovulation and can sometimes force the endometriosis into remission for months and even years after discontinuation of treatment. A testosterone derivative, Danazol, has been used but is often associated with bothersome side effects.

Leuprolide acetate, a medication given by injection, has shown promising results for temporary relief of symptoms although the side effects, similar to menopause, are often bothersome. Using low dosages of progesterone or combination estrogen and progesterone can alleviate many of these symptoms. Pregnancy often provides a temporary relief in symptoms. Although it is thought that infertility is more common the longer endometriosis is present and women are often counseled not to delay pregnancy. This is an important decision involving critical elements and should not be based solely on symptom relief.

Hysterectomy with removal of the ovaries has been considered a definitive cure and is often the last resort for women suffering from endometriosis who have had no symptom relief from other therapies. Menopause typically ends the activity of certain stages of endometriosis. However, with the use of hormone replacement therapy, some evidence suggests that severe cases of endometriosis may possibly be reactivated.

Conclusion

The timely diagnosis of endometriosis will assist you and your practitioner make decisions to treat your symptoms, preserve fertility and long-term health. Despite available treatments, the pain can recur. The symptoms of endometriosis and the potential for infertility can significantly impact one’s life. If you or someone you know is experiencing symptoms associated with endometriosis, see your practitioner to discuss your symptoms and treatment options.

For More Information

American College of Obstetricians & Gynecologists, 202-638-5577
www.acog.org

EndoFacts
www.endofacts.com

The Endometriosis Association, 800 992-3636
www.endometriosisassn.org