Endometriosis

Endometriosis is a condition in tissues that lines of the uterus and sheds and bleeds each month (called the "endometrium") finds a new home OUTSIDE of the uterus, and embeds itself into tissue outside the uterus, and proliferates and bleeds there, just as if it were inside the uterus. The most common places for it to implant are the lining of the back of the lower abdomen, near the top of the vagina, the ovaries, the outside surface of the bladder, the outside surface of the bowel, the ovaries, the fallopian tubes, and the surface of the uterus.

Symptoms of Endometriosis

This leads to PAIN and/or INFERTILITY. Typically, the pain associated with endometriosis occurs in the lower abdomen with radiation to the lower back, begins a few days prior to the onset of menses, is relieved by menses. If endometriosis has developed in the lower abdomen near the top of the vagina, it can lead to dyspareunia, or pain with intercourse. Endometriosis can also result in pelvic floor spasm, which can further exacerbate pain symptoms.

Other people don’t experience pain at all, and endometriosis, often extensive, is noted at the time of laparoscopy done to further explore infertility. The substances produced by endometriosis are toxic to sperm, slow down egg movement along the fallopian tube, and can cause scarring (adhesions) inside the pelvis that results in anatomical distortions that make it difficult to achieve pregnancy.

What Causes Endometriosis

No one knows for sure. Most people believe it occurs as a result of back bleeding during menses. Back bleeding, which occurs in 95% of women during menses, refers to a small amount of blood flowing backwards through the tubes, and landing in the abdomen, instead of exiting through the cervix and vagina, and onto a feminine protection device of some sort. In most women, this tissue disintegrates and dissolves, but for some reason, in a small percentage of women, it stays live and reimplants itself on the surface where it lands. This theory explains the "gravitational" distribution of where endometriosis is found, and why women with particularly heavy, frequent menses, have endometriosis more commonly, and why having a constriction in the outflow tract (such as a constriction in the cervix or vagina) puts women at higher risk for this condition. Others feel that endometriosis spreads through the blood and lymph channels (which explains it sometimes being seen in distant sites such as the lungs, and still others think it can develop from the lining of the peritoneum under certain circumstances (which explains why sometimes, rarely, it has been seen in men, and in children who have not yet menstruated). Possibly, all three theories are true.

Regardless of what causes it, one thing is certain. Unopposed estrogen makes it grow and proliferate. Many people with endometriosis tend to have high levels of estrogen and relatively low levels of natural progesterone.

Adenomyosis

Adenomyosis is a "reverse" form of endometriosis occurring when the endometrium invades deeply into the muscle of the uterus, then sheds and bleeds deep inside the muscle, causing painful periods, and sometimes painful sexual relations.

Endometrioma—the “chocolate cyst”

These are large collections of endometriosis inside the ovary that occur when endometriosis burroughs deep into the ovary and is sealed over by the ovary. The menstrual blood has nowhere to go, so it accumulates inside the ovary, creating a cyst. The disintegrating blood has a thick dark brown consistency, hence the name “chocolate cyst.”

How is endometriosis diagnosed?

First, it is suspected, based on symptoms and physical exam. Ultrasound can detect endometriomas and sometimes adenomyosis, and rule out other causes of pain. It can NOT, however, rule out endometriosis, since most endometriosis implants can not be seen on ultrasound, they are too small. Laparoscopy is the mainstay of diagnosis. It is also a very useful way to treat endometriosis implants and destroy them, although this treatment does not get at the root of why it occurred to begin with, nor does it prevent it from coming back in the future.

There seems to be no correlation between the visible extent of endometriosis and its symptoms. Often people with very mild symptoms have severe endometriosis when viewed surgically, and sometimes people with classic and severe symptoms have only a few lesions, yet get enormous relief when these few lesions are treated.

How is endometriosis treated?

Endometriosis can be treated surgically, usually by laparoscopy. Laparoscopic destruction of endometriosis improves fertility for approximately a year, at any stage or severity. Laparoscopy can also be used to remove scar tissue that is distorting the anatomy of the pelvis.

Once the diagnosis is made, treatment is usually hormonal adjustment. This may consist of the oral contraceptive pill (which, although it contains estrogen, also contains some powerful and potent synthetic progestins, which tend to be dominant), or progestins by themselves. Alternatively a functional medical approach can be used, with supplements that compete with an bring down estrogen levels, and dilute the effect of estradiol, as well as natural progesterone. A potent medication called Lupron can be used to treat endometriosis, although it can’t be used for long periods of time - it creates a false (and temporary) state of menopause in that it completely shuts down ovarian production of both estrogen and progesterone. This can relieve pain in the short term, but of course, can create some other problems and side effects, so is not a good long term solution.

None of these hormonal manipulations, except possibly supplementation with natural progesterone, is compatible with attempting to become pregnant. Once pregnancy is achieved, pregnancy and subsequent breastfeeding seem to suppress endometriosis for up to a few years afterward.

Hysterectomy, especially laparoscopic supracervical hysterectomy, which allows the surgeon to also look for and remove lesions, in addition to removing the source of the endometriosis, the uterine body, may be a solution for those who have completed childbearing and are having unrelenting symptoms.

More information about endometriosis can be found by clicking here.

Debra Ravasia, updated 2017