Endometriosis

The information provided by Advanced Healthcare for Women and E. Daniel Biggerstaff, III, M.D. is for informational purposes only. As each woman is unique, do not rely on this information for diagnosis and treatment. We cannot guarantee the accuracy of the content and advise that you see a qualified Health Care Professional for individual needs and care.

What is endometriosis?

The tissue that normally lines the inside of the uterus is called the endometrium. In some women endometrium-like tissue grows in the pelvis or abdomen outside the uterus. When this happens a woman has a condition called endometriosis. The most common areas for this growth of endometrium are the reproductive organs (ovaries, fallopian tubes, uterus) and the thin, Saran Wrap-like lining of the abdominal cavity called the peritoneum. Endometrium may also grow on the intestines or bladder and rarely in distant sites.

The following image shows classic endometriosis as a dark spot in the center.  The dark spot is surrounded by subtle endometriosis, seen as orange discoloration of th eperitoneum.

This image shows a normal appearing uterus, fallopian tubes, and ovaries.  An area of dark endometriosis is seen on the posterior aspect of the cervix.

This misplaced tissue responds to the hormones of the menstrual cycle and can bleed each month in the same way the lining of the uterus responds to hormones. However, if the tissue is not in the uterus, the blood shed from the tissue has no way to leave the body. When the tissue bleeds, this causes irritation and inflammation; and cysts, adhesions, and scar tissue can form, and the area around the endometriosis thickens.

How does it occur?

Why some women develop endometriosis is not known. There are many theories, but none of them explains all cases. One theory suggests that in some women part of the endometrial tissue flows backwards during menstrual flow into the fallopian tubes and abdomen where it attaches and grows. Still another theory states that either the presence or absence of unknown substances may stimulate the growth of endometriosis from multi-potential cells (cells in the body that can become many different types of tissue). One final theory is that endometrial tissue may travel to areas outside the uterus through blood vessels or the lymph system. In recent years, researchers have found certain chemicals present in higher amounts in women with endometriosis than in women who do not have endometriosis.

What are the symptoms of endometriosis?

Some women have no symptoms. If symptoms occur they may include:

• abnormal or heavy menstrual flow
• pelvic, back or flank pain before or during menstrual period
• very painful menstrual cramps
• painful intercourse
• painful bowel movements, diarrhea, constipation or other intestinal upsets during menses
• painful urination or feeling the need to urinate often during the menstrual cycle
• difficulty becoming pregnant

How is endometriosis diagnosed?

Before treatment can begin, a definite diagnosis is required. First, the doctor may do a physical exam, feeling for cysts or nodules or any abnormal tenderness or thickening in your pelvis. Unfortunately, endometriosis cannot be diagnosed with ultrasound, CT, or MRI. Usually, an outpatient surgical procedure called a laparoscopy is required (see Laparoscopy under Surgery). You are given general anesthesia so you will not feel any pain during the procedure. A small incision is then made near the navel and your abdomen is filled with a gas (carbon dioxide). Your surgeon inserts an instrument called a laparoscope through the incision and into the abdomen to look at the organs and the pelvic cavity. With laparoscopy, the size, location, and number of endometrial growths can be seen. If endometriosis is seen or suspected, the tissue is removed to confirm the diagnosis and to treat the condition.

How is it treated?

There is no cure for endometriosis. It is a disease that gets more severe as you grow older. However, there are many ways to lessen the symptoms and complications. The treatment depends on the severity of the symptoms, the location and degree of endometriosis, your age, and your plans for childbearing. If the only symptom is mild premenstrual pain, the only treatment necessary may be a medication such as aspirin or ibuprofen to relieve the pain.

If you have a diagnostic laparoscopy, your doctor may use a laser to remove the diseased tissue at the time of the laparoscopy. Additionally, if you have severe cramping in the midline of your lower abdomen (as opposed to the sides), your physician may discuss the possibility of a procedure called a presacral neurectomy (see Presacral Neurectomy in Surgical Procedures). This procedure is used to interrupt the nerves going to the uterus in the case that endometriosis may be in the muscular wall of the uterus resulting in pain. Fortunately presacral neurectomy can now be performed through a laparoscope.

Your doctor may prescribe birth control pills, progesterone pills, or other drugs to control your hormones. The purpose of these medicines is to stop heavy menstrual periods from occurring and may help to a degree with your menstrual cramps. These hormones are usually prescribed for at least 6 months, but the length of time varies with individual circumstances.

Some of the drugs (so-called GNRH analogues) used for treatment of endometriosis are very expensive and can cause significant side effects. While on the medication, the patient is frequently pain free, but the pain usually returns within 6 to 12 months after stopping the drug. These drugs are used only in special situations, and the use of these drugs should be discussed by your physician.

Another possible treatment is to surgically remove the organs containing the growths (such as the fallopian tubes, uterus, or the ovaries). If your uterus is removed, you can never become pregnant.

Different physicians treat endometriosis in different ways.  There is a significant difference in the way physicians treat endometriosis, and as a result, a significant difference in the chance that all of the endometriosis will be removed.  Most physicians vaporize or coagulate endometriosis using a laser or electrical cautery.  When endometriosis is superficial, this method is effective.  But when endometriosis invades into the surrounding tissues, the superficial ablation technique frequently leaves endometriosis behind, along with its associated pain.  In 1989, a physician in Memphis, Dan Martin, demonstrated that simple destruction of endometriosis would frequently result in incomplete removal of the disease.  He demonstrated that 61% of patients had endometriosis penetrating greater than 2mm, 43% had endometriosis penetrating greater than 3mm, and 25% had endometriosis penetrating greater than 5mm.  Coagulation would have missed the full depth of the endometriosis in 61% and vaporization in 25% of the patients.  So, what is the best technique to have the best chance of getting rid of endometriosis? 

Excision of extensive endometriosis has been shown to be the best technique for treatment of the disease.  Few physicians use this technique because of the extensive training and practice that is necessary to become proficient.  The excision can be accomplished using a laser or laparoscopic scissors.   When  using a laser, the instrument is used like a knife or scissors to remove the endometriosis.  Endometriosis may attach intself to the bladder, intestine, ureters, or major blood vessels.  Unfortunately, the amount, location, and depth of penetration of endometriosis can only be determined at the time of laparoscopy.  Dr. Biggerstaff routinely treats patients with extensive endometriosis using the laser excision technique; other physicians refer patients to him for excision of extensive endometriosis.

How long will the effects of treatment last?

No treatment has been found yet that is 100 percent effective. Current therapy offers at least some relief from the symptoms, but it is not a cure. Endometriosis may recur or progress after hormone therapy or surgery. If conservative surgical therapy (at least one ovary is left in place) is chosen, the recurrence rate appears to be around 30%. But another way to look at surgery short of total hysterectomy is that up to 70% of patients will get good long-term relief of symptoms. If total hysterectomy is performed, the rate of recurrence is less than 2%.

How can I take care of myself?

Keep a careful record of your symptoms. The easiest way to do this is to assign a number to each of the symptoms you have and record them by number on your calendar for 3 months. Record all symptoms, including any time lost from work and leisure activities. Report the symptoms to your doctor. Take your calendar with you to your appointment. If you have not yet been diagnosed with endometriosis, your doctor may not suspect endometriosis without this information.

Try the following recommendations for easing your pain:

• Take warm baths.

• Rest.

• Wear loosely fitting clothing.

• Use a hot water bottle or heating pad on your abdomen.

• Avoid constipation by increasing the fiber in your diet.

• Do relaxation exercises.

• Take pain medication as recommended by your doctor (the pain medication works much better if you can predict the onset of your next episode of pain and begin the medication 12-24 hours before the onset of pain)

What can be done to help prevent endometriosis?

There is currently no prevention for endometriosis and no guarantee of cure in all cases. Much research is being conducted in an effort to find a solution.

Further information on endometriosis can be obtained from the Endometriosis Association (endometriosisassn.org).\

E. Daniel Biggerstaff, III, MD     November 22, 2003