Endometriosis

by Betsy McCormick, M.D.

Endometriosis is caused by cells from the lining of the endometrium (endometrial cells), to be misplaced in the pelvis or even other areas of the body.  It affects approximately 5-6 million women in the US.   This leads to inflammation, pain, scar tissue and infertility in 30-50% of endometriosis patients.  Symptoms are frequently menstrual pain (dysmenorrhea), painful intercourse (dyspareunia), abdominal pain with bowel movements or urination, and chronic back and leg pain. There are multiple theories on the causes of endometriosis ranging from retrograde menstrual blood into the pelvis, dislocation of primitive endometrial cells, lymphatic or vascular spread of cells, and abnormal transformation of endometrial cells called metaplasia.  Endometriosis is most commonly seen on the ovaries, and also seen on the fallopian tubes, pelvic cul de sac, intestines, and bladder.  Individuals who may be more likely to develop endometriosis are those who do not have children, family history of endometriosis, short interval between menses, longer days of bleeding with periods, and medical conditions which stop the normal path of menstrual blood.

Endometriosis is suspected by patient history of pain, pelvic examination which reveals immobile uterus or enlarged ovaries, pelvic ultrasound showing cysts suggestive of endometriomas (collection of endometriosis fluid on the ovary).  However, the only definitive way to make the diagnosis is by surgical evaluation of the pelvis, usually performed by laparoscopy.  Laparoscopy involves small incisions on the abdomen to inspect for lesions of endometriosis which can be dark brown, blue, red or even white.  Additionally, scar tissue called adhesions may be seen, and the endometriomas can be removed.  At the time of surgery the endometriosis is treated and staged based on the extent of disease.  Interestingly, the extent of disease seen at the surgery does not always correlate with the pain.

Medical management of endometriosis may involve nonsteroidal  anti-inflammatory drugs (NSAIDS) or various hormones.  The NSAIDS will help with the menstrual pain and bleeding.  The hormones attempt to slow and prevent the new growth of endometriosis.  Oral contraceptive pills, patches, vaginal ring, and IUD are common hormonal options.  Gonadotropin releasing hormone (GnRH) agonist temporarily stop the normal ovarian hormones, which shrinks the endometriosis cells relieving the pain.  The side effects of the medicine can be significant resulting in hot flushes, vaginal dryness, and bone loss, thus the medicine cannot be used for prolonged periods continuously, and cannot be used when trying to conceive.  Depo-Provera is a progesterone injection given either monthly or every 3 months to help relieve the pain.  However side effects with the medicine can limit the use including irregular bleeding, hair loss, mood changes and with long term use bone strength is a concern.

Surgery is the definitive way to make the diagnosis and treat the endometriosis seen.   The visible lesions are ablated or burned and scar tissue is removed.  The endometriosis can be recurrent in 40-80% of patients in as little as 2 years from surgery, so expeditious time to conception is often recommended for infertility patients.  In vitro fertilization (IVF) is one option to treat fertility concerns of endometriosis because the pelvic issues are in a sense, bypassed because the egg and sperm are fertilized outside the body where endometriosis is located.  For patients who are not responsive to medical or laparoscopic management, and do not wish to carry a pregnancy or conceive, hysterectomy is the definitive treatment.