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EndometriosisPlease Login to watch the video...
DEFINITIONS — The normal tissue that lines the uterus and bleeds during menstruation is called the endometrium. Endometriosis is a noncancerous disorder in which tissue similar in appearance and function to endometrium develops outside of the uterus. Typically this occurs in the pelvis, but may occur in virtually any part of the body. The most common locations for endometriosis, in decreasing order of frequency, are: the outer surface of the ovaries, peritoneum (the tissue that lines the abdomen) and peritoneal structures (eg, cul-de-sac [the area behind the uterus] and the various ligaments that hold the uterus in place), uterus, fallopian tubes, bowel, and bladder. Most women have endometriosis in more than one location. Some other terms that you should be familiar with are: An endometrioma, which is an area of endometriosis that is large enough to be considered a mass or tumor. WHO DEVELOPS ENDOMETRIOSIS? — The exact incidence of endometriosis is not known because the disease can only be diagnosed by visualization during surgery. Therefore, many women will not know they have endometriosis if they have no symptoms and if their pelvis has not been examined at surgery. Studies in small groups of women have shown that endometriosis is present in at least 1 percent of all women of reproductive age and in: 1 percent of women having gynecologic surgery for any reason Endometriosis does not usually occur prior to menarche (the first menstrual period of a woman's life) or after menopause (the last menstrual period of a woman's life), since the growth and function of endometriosis depends upon stimulation from estrogen and progesterone produced by normally cycling ovaries. The average age when the disease is first diagnosed is 27. Risk factors for developing endometriosis include: A family history of the disease in your mother (7 percent chance) Conditions that decrease menstruation are associated with a lower risk of endometriosis. Some examples are amenorrhea (absent menstrual periods), pregnancy, and prolonged use of birth control pills. One study suggested that women who exercise regularly for several hours a week are at lower risk for developing the disease. CAUSE OF ENDOMETRIOSIS — The cause of endometriosis is not known, but several theories have been suggested. Retrograde menstruation is the passage of menstrual blood and tissue backwards from the uterus, through the fallopian tubes and into the pelvis. This theory was proposed since women with partial or complete obstruction to normal flow are more likely to have endometriosis, presumably because obstructed menses are more likely to flow backwards. Further supporting this theory are the facts that retrograde menstruation has been observed during surgery and the endometrial tissue shed in menstrual fluid is able to grow when "planted" in the pelvis. SYMPTOMS AND SIGNS — The diagnosis of endometriosis is most commonly made when a woman develops pelvic pain, problems with fertility, or a mass noted on pelvic examination or ultrasound. The disease may be asymptomatic (having no symptoms) and the intensity of the symptoms frequently does not correlate with the severity or amount of endometriosis. Pelvic pain usually occurs just before or during menses or during intercourse. Other symptoms include pain during bowel movements, premenstrual spotting, frequent or heavy periods, pain during urination, and bloody urine. Painful periods are characterized by mild to severe discomfort (often cramps) in the lower abdomen that becomes worse over time. Some women have constant pelvic soreness or pain in the lower back and legs that is aggravated during menses or intercourse. Pelvic pain is probably the result of bleeding into areas of endometriosis and release of substances that cause pain (eg, prostaglandins). Endometriosis responds to cyclic hormonal changes during the menstrual cycle in a similar way to normal endometrium; that is, at the end of a cycle, small amounts of endometrial tissue are shed and bleeding occurs. On pelvic examination, your physician may feel thickening of, or nodules on, pelvic structures, an adnexal mass (a mass in the area of the ovary), or fixed or distorted pelvic organs, which suggests the presence of endometriosis. However, since these signs and symptoms are present in a variety of disorders, the diagnosis and stage (severity) of endometriosis can only be made with certainty by visualizing the implants (small areas of endometriosis) at surgery, with either laparoscopy or laparotomy. There are no blood tests or x-ray examinations that can make a definitive diagnosis, but a mildly elevated CA-125 blood level or adnexal mass on ultrasonography may suggest the disease. At surgery, endometriosis appears as small (< 1/4 inch) blue, purple, or red implants in typical areas. Scar tissue (adhesions) and/or an ovarian mass may also be noted. A biopsy (removal of a small piece of tissue) can be done to confirm the diagnosis. Surgery is also helpful for staging (determining the volume and location of disease) and treating the disorder. To stage the disease, the surgeon assigns points based upon size, depth, and location of implants. Endometriosis is classified as minimal (stage I, 1 to 5 points) if there are isolated superficial implants; mild (stage ll, 6 to 15 points) if there are several small, superficial implants and no more than a few small adhesions; moderate (stage lll, 16 to 40 points) if the implants are superficial and deep with prominent adhesions; and severe (stage lV, over 40 points) when there are multiple superficial and deep implants with large endometriomas and prominent adhesions. PROGNOSIS — Endometriosis progresses slowly, over years, and resolves after menopause. Most women with endometriosis will get relief of pain from taking medication, after a pregnancy, or after menopause; some women will be helped only by surgery. In women who have completed their families, hysterectomy with removal of the ovaries almost always provides excellent pain relief. Some women with endometriosis will have difficulty becoming pregnant, especially those who have severe disease and extensive adhesions. However, most women can achieve pregnancy after medical or surgical therapy or with fertility enhancing drugs or procedures (eg, in vitro fertilization). Rarely does endometriosis causes problems such as bowel or urinary obstruction or disease in the chest. PREVENTION — There is no proven way to prevent endometriosis. Reducing the number and volume of menstrual cycles, such as by using birth control pills for several years or having several pregnancies, may reduce the risk. TREATMENT — There are several treatment options for women with endometriosis: No therapy The treatment strategy depends upon whether the woman's major concern is pain, infertility, or a pelvic mass. No treatment is an option for women with minimal disease or women who are near menopause and have no troubling symptoms. Asymptomatic young women with minimal disease may consider taking birth control pills to protect against unplanned pregnancy and to prevent progression of disease. Near menopause, endometriosis is treated naturally since low levels of ovarian estrogen production result in regression of implants. Pelvic pain — When a laparoscopy is performed for diagnosis of endometriosis, surgical excision of endometrial implants and scar tissue should be performed and may relieve pain temporarily, but the disease and pain tend to recur unless the uterus and ovaries are removed. Recurrent or persistent pain after surgery is usually treated with medication. Studies have not determined the best medical therapy for treating pelvic pain, and no medical therapy has been proven to affect future fertility. The advantages of medical therapy are that the risks associated with surgery (eg, damage to pelvic organs, adhesion formation, anesthesia) are avoided and implants not visualized by the surgeon will still be treated. However, medical therapy does not eliminate existing adhesions or endometriomas, has side effects, does not permit simultaneous attempts at pregnancy (if drugs suppressing ovulation are used), and pain often recurs when therapy is stopped. The medications used to treat pain include nonsteroidal antiinflammatory drugs and hormonal therpies. The use of hormonal therapies is based upon the belief that estrogen has a major stimulatory effect on the growth and function of endometrial tissue, including endometriosis, and that androgens (male hormones) inhibit endometrial growth. Hormonal therapy can shrink endometrial implants and reduce pain, but there is no effect on scar tissue or endometriomas. Nonsteroidal antiinflammatory drugs (NSAIDs) — The first-line of therapy for relief of pain are NSAIDs (eg, ibuprofen, naproxen sodium). These drugs reduce menstrual bleeding, inhibit prostaglandins, and reduce inflammation (one of the body's responses to disease). A common dose is ibuprofen 600 mg by mouth four times per day taken when pain starts or is expected. Serious side effects from NSAIDs, although uncommon, include gastrointestinal pain and bleeding, kidney problems, and worsening high blood pressure. NSAIDs do not shrink or prevent the growth of implants, and pain often returns when medication is stopped. Oral contraceptive pills (birth control pills) — These are synthetic hormones that inhibit ovulation and create an inactive endometrium. They are less effective than GnRH agonists and danazol (see sections on these drugs below) for women with moderate or severe disease, but are a good choice for women with minimal or mild symptoms, since they provide contraception and have a low rate of side effects. Birth control pills contain both estrogen and a progestin, thus providing some estrogen and utilizing a lower dose of progestin than found in progestin-only regimens. Birth control pills work by reducing the number of menstrual cycles and volume of bleeding. For most patients with only mild pain, this results in less painful periods and may also slow progression of disease. The side effects of these pills include nausea, weight gain, breast tenderness, changes in libido, and mood changes. Serious side effects (eg, blood clots, stroke, heart attack) are rare in women who do not smoke and have no underlying vascular disease. Gonadotropin releasing hormone (GnRH) agonists — These drugs (eg, nafarelin, leuprolide, goserelin) are synthetic, more potent copies of natural GnRH hormone (the hormone signal from the brain that indirectly stimulates the ovary to make estrogen and progesterone). Paradoxically, they work by turning off ovarian production of estrogen, thereby creating a menopause-like environment that shrinks implants and reduces pain in over 80 percent of patients. The drugs may be given as a nasal spray, implant, or injection. The usual duration of therapy is six months. Side effects of GnRH agonists are headaches in 20 percent of women, especially in patients with a history of migraine, and the signs and symptoms of menopause: amenorrhea, hot flashes, vaginal dryness, decreased libido, insomnia, and loss of bone density (on average a 2 to 7 percent loss). Bone strength recovers substantially after the drug is stopped. Many of these side effects can be minimized by add-back therapy, that is, giving estrogen or a bone strengthening drug along with the GnRH agonist. Five years after completing GnRH agonist treatment, many women will again have pain (37 of women with mild disease and 74 percent of women with severe disease). Danazol — Danazol is a synthetic drug that creates a high androgen (male type hormone) and low estrogen hormonal environment. This results in amenorrhea by inhibiting ovulation and ovarian production of estrogen and by shrinking the endometrium. The drug is given orally at a dose of 200 to 400 mg two to four times per day for 6 months or more. Eighty percent of patients will get good pain relief and shrinkage of implants. However, there is a high (75 percent) incidence of one or more side effects, which include: weight gain, edema, decreased breast size, acne, oily skin, hirsutism (male pattern hair growth), deepening of the voice, headache, hot flashes, changes in libido, and mood changes. All of these changes are reversible, except for voice changes; however, return to normal may take many months. Danazol should not be taken by women with certain types of liver, kidney, and heart disease because these disorders may worsen. Progestins — Progestins (eg, medroxyprogesterone acetate, norethindrone acetate, norgestrel acetate) are more powerful than birth control pills and are recommended for women who do not obtain pain relief from or cannot take a birth control pill. Side effects are more common and include: bloating, weight gain, irregular uterine bleeding, and aggravation of depression. Amenorrhea induced by high doses of progestins can last many months after cessation of therapy. Therefore, this drug is not recommended for women planning pregnancy. Surgery — Surgery is an option when pain has failed to improve with medication and for severe disease (scarring, endometriomas, involvement of the bowel or bladder) that is unlikely to respond to drugs alone. The goal of conservative surgery, usually performed through a laparoscope, is to eliminate as many implants and adhesions as possible. Pain relief is achieved in 80 to 90 percent of women, but the risk of recurrent pain within 10 years is 40 percent. Surgical therapy avoids the side effects of medication and can improve fertility, although there are risks from anesthesia, damage to pelvic organs may occur, and new adhesions can form from surgical manipulation. Definitive surgery consists of removal of the uterus, ovaries, and endometrial implants to eliminate as much of the disease as possible and create a low estrogen state. It is indicated in women who are not planning pregnancy when severe symptoms remain despite medical and conservative surgical therapies. Low dose hormone replacement therapy to prevent menopausal symptoms after surgery usually does not provoke recurrent pain. Pelvic mass — A pelvic mass in a woman with endometriosis may be an endometrioma, chocolate cyst, conglomeration of scarring and normal pelvic organs, or a mass unrelated to the disease. Surgery is the best way to make a definite diagnosis and remove the mass. Medical therapy is not effective. Infertility — Endometriosis does not completely prevent conception, but may reduce the probability of conceiving in any given month. Reduced fertility may be the result of distortion of the normal anatomy between the ovaries and fallopian tubes and from the production of substances that may impair normal ovulation, fertilization, and implantation. However, as many as 70 percent of women with minimal or mild endometriosis and infertility will conceive within three years without any therapy. If pregnancy occurs, endometriosis will often regress or resolve. Most physicians feel that pregnancy rates are better after surgery than after hormonal therapy in infertile women with endometriosis. As an example, in one study pregnancy rates after surgery in women with moderate or severe disease were 50 and 39 percent, respectively, compared to 25 and 5 percent, respectively, after medical therapy. Once pregnancy is achieved, women with endometriosis are not at higher risk for pregnancy complications. The ideal time for surgical ablation (burning, cutting, or excising endometriosis implants) is when the diagnosis of endometriosis is first confirmed surgically. Other effective treatments for infertility include drugs that enhance ovulation combined with intrauterine insemination of sperm and in vitro fertilization (IVF). IVF is the best approach for women with severe disease and extensive scarring. WHERE TO GET MORE INFORMATION — Your doctor is the best resource for finding out important information related to your particular case. Not all patients with endometriosis are alike, and it is important that your situation is evaluated by someone who knows you as a whole person. A number of other sites on the internet have information about endometriosis. Information provided by the National Institutes of Health, national medical societies, and some other well-established organizations are often reliable sources of information, although the frequency with which their information is updated is variable. National Library of Medicine (http://www.nlm.nih.gov/medlineplus) American College of Obstetricians and Gynecologists (http://www.acog.org/) The Hormone Foundation (http://www.hormone.org) The Endometriosis Association (http://www.endo-online.org/)  |
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