Nearly one in 10 women in the United States are afflicted with a disease that causes agonizing pelvic pain and the inability to conceive a child. Endometriosis affects women in different ways, with many being so sick that they may vomit on a daily basis or others get incapacitating cramps that can last for weeks.
What is Endometriosis?
This chronic condition affects millions of women throughout the world. It occurs when the lining of the uterus, which is called the endometrium, grows outside of the uterus instead of inside of it. When the endometrium does grow outside of the uterus, it normally attaches to the ovaries, fallopian tubes, and the ligaments that help support the uterus.
Endometrial growths can also be found in the area between the vagina and the rectum, on the outside of the uterus or along the lining of the pelvic cavity. Growths can also occur on bladder, bowel, cervix, and, in rare cases, they can also grow on organs like the lungs or on arms, thighs or in other locations.
The endometrial growths are caused when the lining of the breaks down, as it normally does in the uterus, which results in menstruation. However, since the lining is on the outside of the uterus, there is no where for the broken down lining to go. This can cause cysts, severe cramps, internal bleeding, blood and tissue can breakdown from resulting lesions and it can cause inflammation.
Who does Endometriosis Affect?
Endometriosis usually develops in women during their reproductive years, generally between the ages of 25 to 35. However, it can occur at earlier ages and cases have been found in girls as young as 11 years of age. It is not commonly found in women who are postmenopausal.
This disease is the leading cause for pelvic pain and for laparoscopic surgeries and hysterectomies in the U.S. Endometriosis may be the cause of 20% to 50% of all infertility cases and up to 80% of all chronic pelvic pain cases. For a reason that isn’t known to researchers, endometriosis seems to more common in taller, thin women who have a low body mass index.
The Causes of Endometriosis
While the exact cause of endometriosis is not known, there are several theories about what causes this disease. One of the theories is called retrograde menstruation or transtubal migration. This theory suggests that menstrual tissue backs up into the fallopian tubes of women who have heavy periods or whose uterus has an abnormal structure.
When the tissue back up into their tubes, it implants in the abdomen and grows there. Some researchers believe that most women will have some menstrual backup, they theorize that in women who have a faulty immune system or hormonal issues, endometriosis will develop because the menstrual tissue grows in those women.
Normally, the immune system would detect the tissues and attack them as invaders who don’t belong in other areas of the body. However, if a woman has a dysfunctional immune system, the endometrial tissue may not be detected and they could grow outside of the uterus.
There may be a genetic link to endometriosis as well. The disease sometimes runs in families, so if a relative had endometriosis, you could develop it as well. If a first degree relative, such as the mother or a sister, was afflicted with endometriosis, it can raise the risk of a woman developing this disease.
Some experts surmise that endometrial tissue may be distributed through the lymph system or through the bloodstream to other areas of the body. As it moves through the body, some of the tissue will attach to other places in the body and grow. For instance, they may attach to the organs or grow on the ovaries or other areas within the body.
Surgical transplantation is another possible cause of endometriosis. The transplantation usually occurs accidentally and endometrial cells end up in abdominal scars. The cells then develop into endometriosis.
Research by the Endometriosis Association found a link between the development of endometriosis and dioxin. Dioxin is a highly toxic by-product of several manufacturing processes, including pesticides, bleached paper and pulp products, and municipal and medical waste incineration.
During the research, the association found a colony of Rhesus monkeys that had been exposed to Dioxin and 79% females had developed endometriosis. Their research also determined that the more exposure there is to dioxin, the more severe the cases of endometriosis. Dioxin exposure is also known to cause hormonal disturbances, which could also aid in the development of endometriosis.
Another suggestion for the cause of endometriosis is that left over tissue, particularly abdominal cells, from when the afflicted woman was an embryo, were able to retain their ability to become endometrial cells. These cells can grow anywhere within the body and cause the symptoms associated with endometriosis.
There are a few other possible causes of the disease including waiting until an older age to have a child, never having given birth, an early onset of menses and late menopauses may all be reasons for the development of endometriosis in some women.
The Symptoms of Endometriosis
Not every woman who develops endometriosis experiences symptoms and others may only experience mild symptoms. In fact, most women who do develop endometriosis will not have any symptoms at all. However, the most prevalent symptom of the disease is pain. Some women will experience mild to moderate discomfort while others will experience debilitating pain that can disrupt their normal activities and last for weeks.
The most common source of pain is cramping during the menstruation cycle. The cramps can become worse over time and end up being debilitating for some women. The reason for the pain is internal bleeding caused by the lining being shed inside of the body where is doesn’t belong. This can lead to the formation of scar tissue, along with bowel problems or blocked fallopian tubes.
The pain is often cyclical and, if not diagnosed, a woman will experience cramps like she would during a normal menstruation cycle. However, the cramps will be worse than normal and they can appear before menstruation begins or at the beginning of ovulation. The pain may end when the menstruation cycle does, which is about seven days later, but some women can experience pain for several days after their period has ended.
Women with endometriosis may find it difficult to have sexual intercourse without experiencing pain. The pain associated with intercourse can be a mild to moderate cramping pain or some women experience stronger pains during intercourse. Any pain during intercourse should be checked out by a doctor as normal sexual intercourse should never be painful.
Going to the bathroom can also be a source of discomfort or pain for women who have this disease. Both urination and bowel movements can be painful during the menstruation cycle. The pain may feel like cramps or the pain can feel much worse.
Aside from the menstruation cycle, some women experience pelvic discomfort or aches during the rest of the month. Women may also experience pain during a pelvic examination. Low back ache pain is also a possible symptom of endometriosis, although it can be a symptom for many other ailments.
General digestive disorders can be caused by the disease, as can constipation or diarrhea. Fatigue is also common with endometriosis, as are heavy menstruation cycles and/or infrequent periods can also be caused by endometriosis. It is estimated that about 40% of women with endometriosis will be infertile.
There are general symptoms that are associated with endometriosis as well. These symptoms include:
- Low Grade Fevers
- Low Blood Sugar, Hypoglycemia
During the later stages of endometriosis, adhesions can develop in the pelvic cavity. Adhesions are membranous surfaces that form together because of an injury or inflammation. These adhesions are caused by untreated cysts that can end up “gluing” pelvic organs together. The adhesions can interfere with normal organ functions in the pelvic area, causing digestive problems, bowel obstructions, infertility, urinary issues, problems when adhesions are pulled and even mobility problems.
There are other diseases with similar symptoms of endometriosis, which can make an accurate diagnosis difficult at times. The other diseases include:
- Ectopic Pregnancy
- Ovarian Cysts
- Pelvic Inflammatory Disease
- Irritable Bowel Syndrome
- Colon Cancer
- Fibrous Tumors
The Cancer Risks Associated with Endometriosis
Women who have been diagnosed with endometriosis have an increased risk for an ovarian cancer called epithelial ovarian cancer, or EOC. The risk is greatest for women who have been diagnosed with the disease and primary infertility, meaning those women who never gave birth to a child.
The reason for this connection between endometriosis and EOC is not well known, but one theory suggests that endometriosis implants transform into cancer. Another theory is that the presence of endometriosis can be related to other factors, such as genetics and the environment, that increase women’s risk of developing ovarian cancer.
The risk of ovarian cancer related to endometriosis appears to be greatly reduced by taking oral contraceptive pills that are prescribed to treat the disease.
How Endometriosis is Diagnosed
Endometriosis is often suspected because of symptoms like pelvic pain and other findings during a physical examination at the doctor’s office. The doctor may do a rectovaginal exam, which involves inserting one finger in the vagina and one in the rectum.
During the exam, the doctor may be able to feel nodules, or endometrial implants, along the ligaments attached to the pelvic wall or behind the uterus. Sometimes the doctor will not find any nodules, but the pelvic exam will cause discomfort or pain, which is a common symptom associated with endometriosis.
The physical exam nor the symptoms are conclusive enough to accurately diagnose endometriosis, so imaging studies, such as an ultrasound, are done to rule out any other pelvic diseases. The most accurate way to diagnose the disease is to visually inspect the inside of the pelvis and do a tissue biopsy on any nodules that may be found.
In order to visually inspect the pelvis, surgery must be done to see the inside of the area. The belly can be opened for inspection by doing a large-incision laparotomy or a small-incision laparoscopy. The laparoscopy is the most common surgical procedure used to help diagnose endometriosis.
A laparoscopy is a minor surgery that can be done under general anesthesia or, sometimes, local anesthesia can be used. A laparoscopy is usually done as an outpatient procedure. The procedure involves inflating the abdomen with carbon dioxide by placing a small incision in the navel. The laparoscope, which is a long, thin viewing instrument, is inserted into the naval incision. Once it is inserted, the doctor can visually inspect the area to find endometrial implants.
During the laparoscopic surgery, biopsies on tissue can be performed to help diagnose endometriosis. Sometimes biopsies can determine the presence of endometriosis even though no nodules were found during the procedure. A laparoscopy, along with a pelvic ultrasound, can be used to exclude conditions like ovarian cancer or other malignancies that can mimic the symptoms of endometriosis.
How Endometriosis can be Treated
Treatment of Endometriosis can be done using medications, surgery or both. The goals for any treatment of this disease are to reduce pain and/or increase the chances of fertility and conception.
Medical Endometriosis Treatments
Prescription medications like non-steroidal anti-inflammatory drugs, NSAIDS, are used to help reduce pelvic pain and cramping due to the onset of menstruation. However, these medications do not change the endometrial implants. They can also help reduce the production of prostaglandin, which are known to play a part in producing the sensation of pain.
Since endometriosis can only be accurately diagnosed during surgery, for those women who doctors suspect may have the disease because of pelvic pain symptoms, they will be prescribed NSAIDS like ibuprofen and naproxen to help reduce pain. If they do help control pain, then other procedures and medical treatments are not needed. However, if medical treatments don’t control pain, further examinations and treatments usually take place.
Since endometriosis develops during a woman’s reproductive years, some of the current treatments for the disease depend on interrupting the ovaries’ production of hormones. The medications used to interrupt the hormone cycle include GnRH analogs, oral contraceptives and progestins.
Gonadotropin-releasing Hormone Analogs or GnRH Analogs
Gonadotropin-releasing hormone analogs (GnRH analogs) are drugs that hinder the pituitary gland’s release of regulatory hormones, which suppresses the ovaries’ production of estrogen. They mimic menopause, so the menstruation cycle is stopped. These drugs have been proven effective in helping to reduce pain and shrink the size of endometriosis implants. They are either taken through the nose or in the form of an injection.
Because of the shortage of estrogen in the body, there are side effects to taking GnRH analogs which include:
- Mood changes
- Hot flashes
- Irregular vaginal bleeding
- Vaginal dryness
Side effects can be relieved, however, by taking small doses of progesterone, in the form of a pill, in conjunction with the GnRH analogs.
Contraceptive pills taken orally, which are a combination of progesterone and estrogen, can be used as a treatment for endometriosis. Some women who experience severe pain during menstruation are prescribed the pill for continual use. Using the pill in that manner does have side effects, such as skipping menstruation altogether. Other side effects can be weight gain, tender breasts, irregular bleeding and nausea. Women who suffer from endometriosis tolerate oral contraceptives very well.
Progestins have more potency than oral contraceptive pills and are prescribed when oral contraceptives are not successful in relieving pain, or for women who cannot take them. The most common side effects are:
- Tender breasts
- Weight gain
- Irregular uterine bleeding
The interruption of the menstruation cycle can last for several months after women have stopped taking progestins. Women who are wanting to get pregnant should not take these drugs.
Other Medications Prescribed to Treat Endometriosis
Danazol or Danocrine
This is a synthetic drug that interferes with ovulation and the ovarian production of estrogen. It does this by creating a high androgen (the male oriented hormone) and low estrogen hormonal condition. About 80% of the women who are prescribed Danazol will experience pain relief and it will help to shrink endometriosis implants. However, about 75% of women may suffer side effects due to taking the drug. The side effects include:
- Decreased breast size
- Weight gain
- Oily Skin
- Hot flashes
- Changes in sex drive
- Deepening of the voice
- Changes in mood
All of the changes mentioned are irreversible, expect for voice changes, but it can take several months before the voice returns to normal. This drug should not be taken by women who have certain kidney, heart and liver conditions.
A new option for the treatment of endometriosis is the use of drugs known as aromatase inhibitors. They work by disrupting estrogen formations within the endometrial implants. They also interfere with the production of estrogen in the ovaries, brain and in other sources like the adipose tissue. They must be used along with other drugs in women who have not yet started menopause because of the effects they have on the ovaries. One of the side effects is significant bone loss due to using these drugs for a prolonged period of time.
Surgical Treatments for Endometriosis
When the symptoms of endometriosis are severe or if medical treatment hasn’t worked well, surgical solutions can be useful and may be the only option for women with the disease. Surgery is also the preferred treatment for bowel or urinary obstructions as well as issues with the anatomical structure of the pelvic organs. Conservative surgical treatments involve preservation of the ovaries and the uterus. However, more definitive surgeries involve hysterectomies, with or without the removal of the ovaries.
The conservative surgery option is done by laparoscopy because endometrial implants can be destroyed by using a laser. If the endometriosis is extensive or if there is distortion of the anatomy, a laparotomy, which is opening up of the abdomen with a larger incision, may be necessary.
Although surgery can help reduce pain, there is a high reoccurrence rate when surgery is performed. Almost 40% of women who undergo surgery for endometriosis will have a reoccurrence of the disease. Many doctors will prescribe oral medications to women after they’ve had surgery to help maintain symptom relief.
Treating Infertility Caused by Endometriosis
While endometriosis is common in infertile women, mild to moderate cases do not prevent a woman from conceiving a child. There are estimates that say up to 70% of women with mild to moderate endometriosis will conceive within three years of their diagnosis without any specific treatment.
While the reasons for the decrease in fertility among women with the disease are not totally understood, it is thought that both hormonal changes and anatomy play a role. Endometriosis can cause scarring, or adhesions, within the pelvis that can distort the structures of some parts of the anatomy. The structures such as the fallopian tubes can be affected by the presence of adhesions.
Endometriosis may also affect fertility because of the production of hormones and the presence of other substances that can impact ovulation, fertilization of the egg or the implantation of the embryo in the womb. While women with mild to moderate endometriosis may be able to conceive, infertility is more common in women with more severe cases of the disease.
Although the treatment options for infertility caused by endometriosis vary, surgery intervention is the preferred treatment method, especially when the goal of the treatment is to improve the chances of conception. Using assisted reproduction methods may be appropriate when used in combination with surgical techniques.
It is important for women to know their bodies and to listen to them when they have unusual pain in the pelvic region, especially during a menstruation cycle. That pain could be caused by endometriosis and, as with most disease, have the condition treated as soon as possible can help lessen the symptoms of endometriosis. Women who feel abnormal pelvic pain, no matter their age, should contact a doctor for an examination to get the pain diagnosed and treated.
What is Endometriosis? http://www.endometriosisassn.org/endo.html