Specialities

What is Endometriosis?

Endometriosis is an often painful disorder of the female reproductive system. In endometriosis, a specialized type of tissue that normally lines the inside of your uterus (the endometrium) becomes implanted outside your uterus, most commonly on your fallopian tubes, ovaries or the tissue lining your pelvis. Rarely, endometrial tissue may spread beyond your pelvic region. Other sites for these endometrial growths may include the bladder, bowel, vagina, cervix, vulva, and in abdominal surgical scars. Less commonly they are found in the lung, arm, thigh, and other locations.

During your menstrual cycle, hormones signal the lining of your uterus to thicken to prepare for possible pregnancy. If a pregnancy doesn't occur, hormone levels decrease, causing the thickened lining of your uterus to shed. This produces bleeding that exits your body through the vagina — your monthly period.

When endometrial tissue is located elsewhere in your body, it continues to act in its normal way: It thickens, breaks down and bleeds each month as your hormone levels rise and fall. Each month the tissue builds up, breaks down, and sheds. Menstrual blood flows from the uterus and out of the body through the vagina, but the blood and tissue shed from endometrial growths has no way of leaving the body. This results in internal bleeding, breakdown of the blood and tissue from the lesions, and inflammation -- and can cause pain, infertility, scar tissue formation, adhesions, and bowel problems.

Trapped blood may lead to the growth of cysts. Cysts, in turn, may form scar tissue and adhesions — abnormal tissue that binds organs together. This process can cause pain in the area of misplaced tissue, often the pelvis, especially during your period. Scars and adhesions related to endometriosis also can cause fertility problems.

Endometriosis isn't the only cause of pelvic pain. If you're experiencing pelvic pain, see your doctor to determine whether endometriosis or another condition is the cause, and to target appropriate treatment.

What are the Symptoms of Endometriosis?

Endometriosis can be mild, moderate or severe, and it tends to get worse over time without treatment. Some women with endometriosis have no signs and symptoms at all, and the disease is discovered only during an unrelated operation, such as a tubal ligation. Other women may experience one or more of the following signs and symptoms:

• Pain before and during periods. Some cramping during your period is normal. But women with endometriosis typically describe menstrual pain that's far worse than usual. They also tend to report that the pain has increased over time.
  
  Pain is a common symptom of endometriosis. However, severity of pain isn't necessarily a reliable indicator of the extent of the condition. Some women with mild endometriosis have extensive pain, while others with more severe scarring may have little pain or even no pain at all.
   

• Pain while having sex
   

• Infertility
   

• Fatigue
   

• Painful urination during periods
   

• Painful bowel movements during periods
   

• Other Gastrointestinal upsets such as diarrhea, constipation, nausea.

What causes Endometriosis?

The cause is really not known but some theories have been put forward

• The retrograde menstruation theory (transtubal migration theory) suggests that during menstruation some of the menstrual tissue backs up through the fallopian tubes, implants in the abdomen, and grows. Some experts believe that all women experience some menstrual tissue backup and that an immune system problem or a hormonal problem allows this tissue to grow in the women who develop endometriosis.

• Another theory suggests that endometrial tissue is distributed from the uterus to other parts of the body through the lymph system or through the blood system.

• A genetic theory suggests that it may be carried in the genes in certain families or that some families may have predisposing factors to endometriosis.

• Another theory suggests that remnants of tissue from when the woman was an embryo may later develop into endometriosis, or that some adult tissues retain the ability they had in the embryo stage to transform reproductive tissue in certain circumstances.

Endometriosis is most likely to occur in women who haven't had children. Some women may have an inherited tendency to develop endometriosis. Endometriosis can affect menstruating women of any age or race, and it usually takes several years after the onset of menstruation (menarche) to develop. When menstruation ends permanently with menopause or temporarily with pregnancy, the signs and symptoms of endometriosis stop. They can begin again after pregnancy when menstruation resumes. Rarely, hormone replacement therapy after menopause can reactivate the disorder.

How is Endometriosis diagnosed?

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. Your doctor will perform a pelvic exam to check for any abnormalities, such as cysts on your reproductive organs or scars behind your uterus. Often it's not possible to feel small areas of endometrial implantation, unless they've caused a cyst to form.

Other tests to check for physical clues of endometriosis include:

* Ultrasound. During a vaginal ultrasound, a wand-shaped scanner (transducer) is inserted into your vagina. In an ultrasound of the pelvis via the abdomen, a small scanner is moved across your abdomen. Both tests use sound waves to provide a video image of your reproductive organs.

*Laparoscopy. Because endometrial implants often cannot be felt or clearly seen in some tests, a common way a doctor can make a definitive diagnosis of endometriosis is through a minor surgical procedure called laparoscopy.

You receive a general anesthetic before the procedure begins. Using a special needle, your abdomen is expanded (distended) with carbon dioxide gas so that the reproductive organs are easier to see. A tiny incision is made near your navel, and a slender viewing instrument (laparoscope) is inserted. By moving the laparoscope around, the surgeon can view the pelvic and other abdominal organs, looking for signs of endometrial tissue outside the uterus.

Laparoscopic view of an endometriotic cyst	Cyst wall being peeled of laparoscopically

If you have endometriosis, laparoscopy will provide you and your doctor with information about the location, extent and size of the endometrial implants. This information will help your doctor guide you through treatment options. Sometimes, symptoms and signs are obvious enough that a laparoscopy isn't necessary.

* Blood test. Cancer antigen 125 (CA 125) is a blood test often used to detect tumor markers for certain cancers, but it's also used to detect a certain protein found in the blood of women with endometriosis. Although CA 125 commonly reveals an elevation in such blood protein in women with advanced endometriosis, it's not as sensitive to mild or moderate disease. As with cancer, CA 125 doesn't perform well as a screening test for endometriosis because it's least sensitive when the disease is in its earliest stages.

Complications of Endometriosis

The main complication of endometriosis is impaired fertility. Approximately one-third to one-half of women who have difficulty becoming pregnant have endometriosis.

For pregnancy to occur, an egg must be released from an ovary and travel through the fallopian tube to the uterus (womb), where it can be fertilized by a male's sperm and then attach to the uterine wall to begin development. Endometriosis can produce adhesions that can trap the egg near the ovary. It may inhibit the mobility of the fallopian tube and impair its ability to pick up the egg. In most cases, however, endometriosis probably interferes with conception in more complex ways.

Despite these possible complications, many women with endometriosis are still able to conceive. It may take them a little longer to get pregnant, but most women with mild to moderate endometriosis can become pregnant. During pregnancy, most women have no signs or symptoms of endometriosis.

Doctors sometimes advise women with endometriosis not to delay having children because endometriosis tends to worsen with time. The longer you have endometriosis, the greater your chance of becoming infertile.

Although cancerous changes may occur in endometrial implants, the rate of cancer in this tissue hasn't been shown to be higher than that in other tissues. Having endometriosis doesn't increase your risk of uterine cancer or ovarian cancer.

What are your treatment options if you have Endometriosis?

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 ibuprofen, mefanamic acid etc, 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 treatment approach to manage your signs and symptoms.

Hormone therapy
Supplemental hormones are effective in reducing or eliminating the pain of endometriosis. That's because the rise and fall of hormones during a woman's menstrual cycle causes endometrial implants to thicken, break down and bleed. In fact, if hormonal therapy has little to no effect on your symptoms, consider questioning the diagnosis of endometriosis or its relationship to your symptoms.

Hormonal therapies used to treat endometriosis include:

* Oral contraceptives. Birth control pills help control the hormones responsible for the buildup of endometrial tissue each month. Taking the pill long term can reduce or eliminate the pain of endometriosis. Most women also have lighter and shorter menstrual flow when they're taking the pill.
* Gonadotropin-releasing hormone (Gn-RH) agonists and antagonists. These drugs block the production of ovarian-stimulating hormones. This action prevents menstruation and dramatically lowers estrogen levels, causing endometrial implants to shrink. Gn-RH agonists and antagonists can force endometriosis into remission during the time of treatment and sometimes for months or years afterward. These drugs create an artificial menopause that can sometimes lead to troublesome side effects, such as hot flashes and vaginal dryness. A low dose of estrogen may be taken along with these drugs to decrease such side effects.
* Danazol (Danocrine). Another drug that blocks the production of ovarian-stimulating hormones, preventing menstruation and the symptoms of endometriosis, is danazol. In addition, it suppresses the growth of the endometrium. However, danazol may not be the first choice because it can cause unwanted side effects, such as acne and facial hair.
* Progesterone. This 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 and depressed mood. However it is one of the most cost effective treatments available.

Conservative surgery
Although hormone therapies are effective in reducing or eliminating symptoms of endometriosis, they prevent pregnancy. If you have endometriosis and are trying to become pregnant, surgery to remove implants may increase your chances of success. If you have severe pain from endometriosis, you may also benefit from surgery.

Conservative surgery removes endometrial growths, scar tissue and adhesions without removing your reproductive organs. Your doctor may do this procedure laparoscopically, or through traditional abdominal surgery in more extensive cases. In laparoscopic surgery, a slender viewing instrument (laparoscope) is inserted through a small incision near your navel. The laparoscope is equipped with a laser, a cautery — an instrument that destroys tissue with heat — or small surgical instruments.

Assisted reproductive technologies to help you become pregnant are sometimes preferable to conservative surgery, and doctors often suggest these approaches if conservative surgery is ineffective.

Hysterectomy
In severe cases of endometriosis, a total hysterectomy and the removal of both ovaries may be the best treatment. Hysterectomy alone is also effective, but removing the ovaries ensures that endometriosis will not return. Either type of surgery is typically considered a last resort, especially for women still in their reproductive years. You can't get pregnant after a hysterectomy.

Although no single treatment option is ideal for everyone, most women who seek help for endometriosis find some, if not complete, relief from their symptoms. If your pain persists or if finding a treatment that works takes some time, you can try measures at home to relieve your discomfort. Warm baths and a heating pad can help relax pelvic muscles, reducing cramping and pain.

"Uterine Endometriosis" or Adenomyosis