Endometriosis is most commonly diagnosed in women in their 30’s and 40’s. It occurs in about 1 out of 10 women of reproductive age.
Endometriosis explained simply is a condition when tissue or blood deposits that are normally found in the lining of the uterus, called the endometrium, are found outside of the uterus. Areas of endometrial tissue may be found on the peritoneum, ovaries, fallopian tubes, bladder, ureters, intestines and the rectum. There are many conflicting theories regarding the origin of endometriosis. There is some evidence that retrograde menstruation ( the blood passing backwards through the tubes instead of all of it coming down and out through the uterus and cervix).
The most common symptoms that occur with endometriosis are chronic pelvic pain. The pain may be dull or sharp shooting pain located in the lower abdomen or lower back. The periodic pain is most common before and during menses. Painful sex may be presenting feature as well. Women may also experience a black-brown discharge before menses. In some cases of severe Endometriosis, the endometrial or blood deposits may also be present on the bowel. This can lead to severe bowel symptoms like painful bowel movements, constipation and constant bloating etc.
The endometrial tissue responds to changes in estrogen in the body. The deposits grow and bleed similarly to how the uterine lining does during the menstrual cycle. This may irritate the tissue, causing it to become inflamed and swollen. When this occurs every month, it can cause formation of scar tissue. The bleeding, inflammation and scarring can cause severe pain, especially before and during periods.
The diagnosis of Endometriosis is not easy. It is based on clinical symptoms as described previously. The gynecologist will perform a pelvic exam which may be painful and give your doctor an indication of endometriosis. Further evaluation may include pelvic sonogram ( ultrasound) to check for any ovarian cysts ( also called chocolate cysts). The only way to accurately diagnose endometriosis is through a procedure called a laparoscopy where a small camera in inserted through your abdomen to look for tissue around your organs. A biopsy, or a small sample of the tissue, may also be taken at that time.
About 40% of women who have endometriosis may experience difficulty in getting pregnant. Inflammation from endometriosis may or interfere with the movement through the fallopian tubes and/or affect implantation in the uterus leading to infertility. Family history of endometriosis may play a role. Women with first degree relatives who have endometriosis are at a 7-10 times increased risk of developing the condition.
The treatment of endometriosis depends on symptoms and desire to have children. Medications such as anti-inflammatory drugs ( Ibuprofen/ Advil etc) and birth control pills are first line treatment options. Birth control pills help prevent new endometrial tissue from forming but are unable to destroy the already existing patches of the endometriosis. More advanced anti-hormonal treatments may include Lupron, Depo-Provera or progesterone releasing hormonal IUDs.
Surgery for endometriosis should be reserved as the last option in case of failure of response to the previously described medical measures. Many women who have surgery to remove endometriotic implants may experience pain again within 2 years after the surgery. These women may need birth control pills after the surgery to help prevent new tissue from forming. For severe endometriosis in women who have completed child bearing or do not desire to have children, a total hysterectomy (removal of uterus, tubes and ovaries) may be performed.
Endometriosis can be lifelong and debilitating condition. It does not always lead to severe problems like infertility or hysterectomy. The diagnosis should be made with care. Compassionate care in management of endometriosis goes a long way.
Adeeti Gupta MD, FACOG