For Our Patients

Endometriosis

Robert Yelverton
Raymond Ke, MD

What is Endometriosis?

Endometriosis is a common gynecological condition. It occurs when the cells of the mucous membrane lining the uterus (endometrium) form implants that attach, grow, and function in locations outside of the uterus, usually in the pelvic region.

Endometrial cells respond to the hormones estrogen and progesterone. These hormones function to promote uterine lining growth and thickening, and levels of these hormones fluctuate throughout your menstrual cycle. With endometriosis, endometrial cells are abnormally implanted in structures outside the uterus, where these hormonal activities continue to occur, causing bleeding and scarring.

The process of endometriosis mimics menstruation at various stages. Every month, the endometrial implants respond to the monthly cycle just as they would in the uterus (fill with blood, thicken, break down, and bleed). Products of the endometrial process cannot shed through the vagina as menstrual blood and debris does. Instead, the implants develop into collections of blood that form cysts, spots, and patches. These lesions may grow as the cycle continues. The lesions are not cancerous, but they often develop to the point that they cause obstruction or adhesions (web-like scar tissue) that attach to nearby organs, causing pain, inflammation, and sometimes infertility.

The most common locations of endometrial implants are on or next to the ovaries, as well as in the peritoneum – the smooth lining that covers the wall of the abdomen and folds over the inner organs in the pelvic area. Implants may also be found in the area between the uterus and the rectum, the tissue that supports the uterus, the fallopian tubes, the vagina, the urinary tract, and the gastrointestinal tract. Very rarely, implants may be found in locations far from the pelvis.

What are the symptoms?

Many patients experience no physical symptoms. However, since pelvic pain during menstruation is the most common symptom with endometriosis, many women fail to associate it with a medical condition. This pain is often a severe cramping that occurs on one or both sides of the pelvis and may radiate to the back, rectal area, and occasionally legs. Keep in mind that while endometrial pain most often occurs at the time of menstruation, many women report endometriosis pain at other times of the month or possibly during intercourse. It is important to understand that the severity of pain varies widely between patients and does not appear to be related to the extent of the endometriosis itself. A woman can have a few very small implants and have severe pain while another woman with extensive endometriosis may have very few signs of the disorder.

Other symptoms associated with endometriosis include joint and muscle aches, fatigue, bloating, nausea, dizziness, heavy menstrual bleeding, headaches, depression, and sleep difficulties.

Endometriosis and Infertility

Endometriosis may be found in as many as 40% of infertility patients. Some evidence suggests that between 30% and 50% of women with endometriosis are infertile. Endometriosis may directly contribute to infertility in a number of ways:

  • Implants in the fallopian tubes may block the passage of eggs
  • Implants in the ovaries may prevent release of the egg
  • Severe endometriosis may form adhesions between the uterus, ovaries, and fallopian tubes, preventing the transfer of egg to the tube.

New research suggests that the immune system may play a significant role in infertility associated with endometriosis. Even in early stages of endometriosis, researchers have observed increased immune system activity. It is thought that the body perceives the endometrial implants as hostile and launches an attack. This attack can create a toxic environment for both egg and sperm, leading to decreased fertility.

How do we treat Endometriosis?

Currently there is no perfect way to treat endometriosis. There are basically three approaches to therapy:

  • Watchful waiting  (Treatment involves relieving symptoms only)
  • Hormonal therapy (Aimed at reducing endometrial implants)
  • Surgery (Aimed at reducing endometrial implants and restoring fertility)

The choice of treatment depends on the patient’s symptoms, her age, her desire to have children, and the severity of the disease. Watchful waiting is a good initial choice for women with mild disease and no desire to become pregnant, however most women with moderate to severe symptoms or a desire to become pregnant need more proactive treatment.

Hormonal therapies are used to mimic states in which ovulation does not occur (such as pregnancy or menopause) or to directly block ovulation. Common agents include oral contraceptives, progestins and GnRH agonists, while danazol is less commonly used. These can be very effective in reducing the symptoms of endometriosis. However there are downsides associated with hormonal therapy:

  • Hormonal agents do not cure endometriosis. Symptoms recur in about half of patients within 5 years of treatment.
  • They no do not improve fertility rates and will delay conception in women who use them.

Surgery is an option for women with severe symptoms that don’t respond to hormonal therapies, and for women who wish to become pregnant. The most common surgical approach to endometriosis in women desiring pregnancy involves using laparoscopy (insertion of a camera and instruments through two small incisions in the abdomen) to remove endometrial implants without removing any reproductive organs. This is called conservative surgery.  The goal of the procedure is to remove as many endometrial implants and cysts as possible without causing surgical scarring and subsequent adhesions that could increase fertility problems.  Conservative surgery has been shown to improve rates in women with moderate to severe endometriosis. Surgery has also been shown to have a positive effect on fertility in women with mild endometriosis although the improvement in fertility may be small. Therefore, most doctors recommend surgery even in early-stage endometriosis because of the progressive nature of the disorder and evidence that it improves fertility.

Surgery has been shown to reduce pain associated with endometriosis in 60% of women. Conservative surgery, however, can miss microscopic implants that may continue to cause pain and other symptoms after the procedure. Even with very successful surgery, endometriosis usually recurs within a period of two months to several years. The risk of recurrence appears to be highest in women with severe endometriosis. The use of GnRH agonists (one of the hormonal therapies) after surgery may delay recurrence without affecting fertility.

You and your doctor will decide which treatment is best for you based on your age, your symptoms, the severity of your disease, and whether you wish to become pregnant.  More information may be found at the following websites: