endometriosis

What is endometriosis?
Endometriosis is the abnormal growth of cells (endometrial cells) similar to those that form the inside of the uterus, but in a location outside of the uterus.. The cells of endometriosis attach themselves to tissue outside the uterus and are called endometriosis implants. These implants are most commonly found on ovaries, Fallopian tubes outer surfaces of the uterus or intestines surface lining of the pelvic cavity. They can also be found in the vagina, cervix, and bladder, although less commonly than other locations in the pelvis. Rarely, endometriosis implants can occur outside the pelvis, on the liver, in old surgery scars, and even in or around the lung or brain. Endometrial implants, while they can cause problems, are benign (not cancerous).

Who is affected by endometriosis?

Endometriosis affects women in their reproductive years. Endometriosis is estimated to affect over one million women (estimates range from 3% to 18% of women) in the United States. It is one of the leading causes of pelvic pain and reasons for laparoscopic surgery and hysterectomy in this country. Estimates suggest that between 20% to 50% of women being treated for infertility have endometriosis, and up to 80% of women with chronic pelvic pain may be affected.

Who Is at Risk?
Endometriosis is more common in women who: Are in their 30s and 40s Have not had children Have periods longer than 7 days Have cycles shorter than 28 days Started their period before age 12 Have a mother or sister who had endometriosis

What causes endometriosis?

The cause of endometriosis is unknown. One theory is that the endometrial tissue is deposited in unusual locations by the backing up of menstrual flow into the Fallopian tubes and the pelvic and abdominal cavity during menstruation (termed retrograde menstruation). The cause of retrograde menstruation is not clearly understood. But retrograde menstruation cannot be the sole cause of endometriosis. Many women have retrograde menstruation in varying degrees, yet not all of them develop endometriosis. Another possibility is that areas lining the pelvic organs possess primitive cells that are able to grow into other forms of tissue, such as endometrial cells. (This process is termed coelomic metaplasia.)

 It is also likely that direct transfer of endometrial tissues during surgery may be responsible for the endometriosis implants sometimes seen in surgical scars (for example, episiotomy or Cesarean section scars). Transfer of endometrial cells via the bloodstream or lymphatic system is the most likely explanation for the rare cases of endometriosis that develop in the brain and other organs distant from the pelvis. Finally, some studies have shown alternations in the immune response in women with endometriosis, which may affect the body's natural ability to recognize and destroy any misdirected growth of endometrial tissue.

What are endometriosis symptoms?

Most women who have endometriosis, in fact, do not have symptoms. Of those who do experience symptoms, the common symptoms are pain (usually pelvic) and infertility. Pelvic pain usually occurs during or just before menstruation and lessens after menstruation. Some women experience painful sexual intercourse (dyspareunia) or cramping during intercourse, and or/pain during bowel movements and/or urination. Even pelvic examination by a doctor can be painful. The pain intensity can change from month to month, and vary greatly among women. Some women experience progressive worsening of symptoms, while others can have resolution of pain without treatment.

 Pelvic pain in women with endometriosis depends partly on where the implants of endometriosis are located. Deeper implants and implants in areas with many pain-sensing nerves may be more likely to produce pain. The implants may also produce substances that circulate in the bloodstream and cause pain. Lastly, pain can result when endometriosis implants form scars. There is no relationship between severity of pain and how widespread the endometriosis is (the "stage" of endometriosis).

 Endometriosis can be one of the reasons for infertility for otherwise healthy couples. When laparoscopic examinations are performed for infertility evaluations, endometrial implants can be found in some of these patients, The reasons for a decrease in fertility are not completely understood, but might be due to both anatomic and hormonal factors. The presence of endometriosis may involve masses of tissue or scarring (adhesions) within the pelvis that may distort normal anatomical structures, such as Fallopian tubes, which transport the eggs from the ovaries. Alternatively, endometriosis may affect fertility through the production of hormones and other substances that have a negative effect on ovulation, fertilization of the egg, and/or implantation of the embryo.

Other symptoms related to endometriosis include: lower abdominal pain, diarrhea and/or constipation, low back pain, irregular or heavy menstrual bleeding, or blood in the urine. Rare symptoms of endometriosis include chest pain or coughing blood due to endometriosis in the lungs and headache and/or seizures due to endometriosis in the brain.

Endometriosis and cancer risk

Women with endometriosis seem to have a mildly increased risk for development of certain types of cancer of the ovary, known as epithelial ovarian cancer (EOC), according to some research studies. This risk seems to be highest in women with endometriosis and primary infertility (those who have never borne a child), but the use of oral contraceptive pills (OCPs), which are sometimes used in the treatment of endometriosis, appears to significantly reduce this risk. The reasons for the association between endometriosis and ovarian epithelial cancer are not clearly understood. One theory is that the endometriosis implants themselves undergo transformation to cancer. Another possibility is that the presence of endometriosis may be related to other genetic or environmental factors that also increase a women's risk of developing ovarian cancer.

How is endometriosis diagnosed?

Unfortunately, neither the symptoms nor the physical examinations can be relied upon to conclusively establish the diagnosis of endometriosis. Imaging studies, such as ultrasound, can be helpful in ruling out other pelvic diseases and may suggest the presence of endometriosis in the vaginal and bladder areas, but still cannot definitively diagnose endometriosis. For an accurate diagnosis, a direct visual inspection inside of the pelvis and abdomen, as well as tissue biopsy of the implants are necessary.

As a result, the only accurate way of diagnosing endometriosis is at the time of surgery, either by opening the belly with large-incision laparotomy or small-incision laparoscopy. During laparoscopy, biopsies (removal of tiny tissue samples for examination under a microscope) can also be performed for a diagnosis. Sometimes biopsies obtained during laparoscopy show endometriosis even though no endometrial implants are seen during laparoscopy.

Medical treatment of endometriosis

Nonsteroidal anti-inflammatory drugs or NSAIDs (such as ibuprofen or naproxen sodium) are commonly prescribed to help relieve pelvic pain and menstrual cramping. These medications have no effect on the endometrial implants. Gonadotropin-releasing hormone analogs (GnRH analogs) have been effectively used to relieve pain and reduce the size of endometriosis implants. These drugs suppress estrogen production by the ovaries. As a result, menstrual periods stop, mimicking menopause. Nasal and injection forms of GnRH agonists are available.

 Oral contraceptive pills (estrogen and progesterone in combination) are also sometimes used to treat endometriosis. The most common combination used is in the form of the oral contraceptive pill (OCP). Sometimes women who have severe menstrual pain are asked to take the OCP continuously, meaning skipping the placebo (sugar pill) portion of the cycle. Continuous use in this manner will free a woman of having any menstrual periods at all. Occasionally, weight gain, breast tenderness, nausea, and irregular bleeding are mild side effects. Oral contraceptive pills are usually well-tolerated in women with endometriosis.

Progestins Progestins [for example, medroxyprogesterone acetate (Provera, Cycrin, Amen), norethindrone acetate, norgestrel acetate (Ovrette)] are more potent 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: breast tenderness, bloating, weight gain, irregular uterine bleeding, and depression. Since the absence of menstruation (amenorrhea) induced by high doses of progestins can last many months after cessation of therapy, these drugs are not recommended for women planning pregnancy.

 Danazol (Danocrine) Danazol (Danocrine) is a synthetic drug that creates a high androgen (male type hormone) and low estrogen hormonal environment by interfering with ovulation and ovarian production of estrogen. Eighty percent of women who take this drug will have pain relief and shrinkage of endometriosis implants, but up to 75% of women develop side effects from the drug. Side effects can 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.

 Aromatase inhibitors A newer approach to the treatment of endometriosis has involved the administration of drugs known as aromatase inhibitors [for example, anastrozole (Arimidex) and letrozole (Femara)]. These drugs act by interrupting local estrogen formation within the endometriosis implants themselves. They also inhibit estrogen production in the ovary, brain, and other sources, such as adipose tissue. Research is still ongoing to characterize the effectiveness of aromatase inhibitors in the management of endometriosis. Aromatase inhibitors cause significant bone loss with prolonged use and cannot be used alone without other medications in premenopausal women because they stimulate development of multiple follicles at ovulation.

Surgical treatment of endometriosis

Surgical treatment for endometriosis can be useful when the symptoms of endometriosis are severe or when there has been an inadequate response to medical treatment. Surgery is the preferred treatment when there is anatomic distortion of the pelvic organs or obstruction of the bowel or urinary tract. Surgical therapies for endometriosis may be either classified as conservative, in which the uterus and ovarian tissue is preserved, or definitive, which involves hysterectomy (removal of the uterus), with or without removal of the ovaries. While surgical treatments can be very effective in the reduction of pain, the recurrence rate of endometriosis following surgical treatment has been estimated to be as high as 40%.