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Endometriosis

Endometriosis is an often painful disorder in which tissue that normally lines the inside of your uterus — the endometrium — grows outside your uterus (endometrial implant).

Endometriosis most commonly involves your ovaries, bowel or the tissue lining your pelvis. Rarely, endometrial tissue may spread beyond your pelvic region.

Endometriosis affects women in their reproductive years.

The exact prevalence of endometriosis is not known, since many women may have the condition and have no symptoms.

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 20% to 50% of women being treated for infertility have endometriosis, and up to 80% of women with chronic pelvic pain may be affected.

Common signs and symptoms of Endometriosis may include:

Painful periods (dysmenorrhea). Pelvic pain and cramping may begin before and extend several days into your period and may include lower back and abdominal pain.

Pain with intercourse. Pain during or after sex is common with endometriosis.

Pain with bowel movements or urination. You’re most likely to experience these symptoms during your period.

Excessive bleeding. You may experience occasional heavy periods (menorrhagia) or bleeding between periods (menometrorrhagia).

Infertility. Endometriosis is first diagnosed in some women who are seeking treatment for infertility.

Other symptoms. You may also experience fatigue, diarrhea, constipation, bloating or nausea, especially during menstrual periods.

The severity of your pain isn’t necessarily a reliable indicator of the extent of the condition.
Some women with mild endometriosis have extensive pain, while others with advanced endometriosis may have little pain or even no pain at all.

Endometriosis is sometimes mistaken for other conditions that can cause pelvic pain, such as pelvic inflammatory disease (PID) or ovarian cysts.

It may be confused with irritable bowel syndrome (IBS), a condition that causes bouts of diarrhea, constipation and abdominal cramping.

IBS can accompany endometriosis, which can complicate the diagnosis.

To diagnose endometriosis and other conditions that can cause pelvic pain, your doctor will ask you to describe your symptoms, including the location of your pain and when it occurs.

Tests to check for physical clues of endometriosis include:

Pelvic exam. During a pelvic exam, your doctor manually feels (palpates) areas in your pelvis for abnormalities, such as cysts on your reproductive organs or scars behind your uterus. Often it’s not possible to feel small areas of endometriosis, unless they’ve caused a cyst to form.

Ultrasound. This test uses high-frequency sound waves to create images of the inside of your body. To capture the images, a device called a transducer is either pressed against your abdominal skin or inserted into your vagina (transvaginal ultrasound). Both types of ultrasound may be done to get the best view of your reproductive organs. Ultrasound imaging won’t definitively tell your doctor whether you have endometriosis, but it can identify cysts associated with endometriosis (endometriomas).

Laparoscopy. Medical management is usually tried first. But to be certain you have endometriosis, your doctor may refer you to a surgeon to look inside your abdomen for signs of endometriosis using a surgical procedure called laparoscopy. While you’re under general anesthesia, your surgeon makes a tiny incision near your navel and inserts a slender viewing instrument (laparoscope), looking for endometrial tissue outside the uterus. He or she may take samples of tissue (biopsy). Laparoscopy can provide information about the location, extent and size of the endometrial implants to help determine the best treatment options.

Treatment for endometriosis is usually with medications or surgery. The approach you and your doctor choose will depend on the severity of your signs and symptoms and whether you hope to become pregnant.

Pain medications

Your doctor may recommend that you take an over-the-counter pain reliever, such as the nonsteroidal anti-inflammatory drugs (NSAIDs) ibuprofen (Advil, Motrin IB, others) or naproxen (Aleve, others), to help ease painful menstrual cramps. However, if you find that taking the maximum dose doesn’t provide full relief, you may need to try another approach to manage your signs and symptoms.

Hormone therapy

Supplemental hormones are sometimes effective in reducing or eliminating the pain of endometriosis. That’s because the rise and fall of hormones during the menstrual cycle causes endometrial implants to thicken, break down and bleed. Hormone medication may slow the growth and prevent new implants of endometrial tissue.

However, hormonal therapy isn’t a permanent fix for endometriosis. It’s possible that you could experience a recurrence of your symptoms after stopping treatment.

Hormonal therapies used to treat endometriosis include:

Hormonal contraceptives. Birth control pills, patches and vaginal rings help control the hormones responsible for the buildup of endometrial tissue each month. Most women have lighter and shorter menstrual flow when they’re using a hormonal contraceptive. Using hormonal contraceptives — especially continuous cycle regimens — may reduce or eliminate the pain of mild to moderate endometriosis.

Gonadotropin-releasing hormone (Gn-RH) agonists and antagonists. These drugs block the production of ovarian-stimulating hormones, lowering estrogen levels and preventing menstruation. This causes endometrial tissue to shrink. Gn-RH agonists and antagonists can force endometriosis into remission during the time of treatment and sometimes for months or years afterward. Because these drugs create an artificial menopause, taking a low dose of estrogen or progestin along with Gn-RH agonists and antagonists may decrease menopausal side effects, such as hot flashes, vaginal dryness and bone loss. Your periods and the ability to get pregnant return when the medication is stopped.

Medroxyprogesterone (Depo-Provera). This injectable drug is effective in halting menstruation and the growth of endometrial implants, thereby relieving the signs and symptoms of endometriosis. Its side effects can include weight gain, decreased bone production and depressed mood, among others.

Danazol. This drug suppresses the growth of the endometrium by blocking the production of ovarian-stimulating hormones, preventing menstruation and the symptoms of endometriosis. However, danazol may not be the first choice because it can cause serious side effects and can be harmful to the baby if you become pregnant while taking this medication.

Conservative surgery

If you have endometriosis and are trying to become pregnant, surgery to remove as much endometriosis as possible while preserving your uterus and ovaries (conservative surgery) may increase your chances of success. If you have severe pain from endometriosis, you may also benefit from surgery — however, endometriosis and pain may return.

Your doctor may do this procedure laparoscopically or through traditional abdominal surgery in more extensive cases. In laparoscopic surgery, your surgeon inserts a slender viewing instrument (laparoscope) through a small incision near your navel and inserts instruments to remove endometrial tissue through another small incision.

Assisted reproductive technologies

Assisted reproductive technologies, such as in vitro fertilization, to help you become pregnant are sometimes preferable to conservative surgery. Doctors often suggest one of these approaches if conservative surgery is ineffective.

Hysterectomy

In severe cases of endometriosis, surgery to remove the uterus and cervix (total hysterectomy) as well as both ovaries may be the best treatment. Hysterectomy alone is not effective — the estrogen your ovaries produce can stimulate any remaining endometriosis and cause pain to persist. Hysterectomy is typically considered a last resort, especially for women still in their reproductive years. You can’t get pregnant after a hysterectomy.

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