Gynecology

What is Endometriosis?

Endometriosis is a painful, chronic disease that affects at least 6.3 million women and girls in the U.S., 1 million in Canada, and millions more worldwide. It occurs when tissue like that which lines the uterus (tissue called the endometrium) is found outside the uterus -- usually in the abdomen on the ovaries, fallopian tubes, and ligaments that support the uterus; the area between the vagina and rectum; the outer surface of the uterus; and the lining of the pelvic cavity. Other sites for these endometrial growths may include the bladder, bowel, vagina, cervix, vulva, and in abdominal surgical scars.


This misplaced tissue develops into growths or lesions which respond to the menstrual cycle in the same way that the tissue of the uterine lining does: 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.

What are the Symptoms of Endometriosis?

  • Pain before and during periods
  • Pain with sex
  • Infertility
  • Fatigue
  • Painful urination during periods
  • Painful bowel movements during periods
  • Other Gastrointestinal upsets such as diarrhea, constipation, nausea. 

Diagnosis


A health history and a physical examination can in many patients lead the physician to suspect endometriosis. Surgery is the gold standard in diagnosis. However, in the United States most insurance plans will not cover surgical diagnosis unless the patient has already attempted to become pregnant and failed. Use of imaging tests may identify endometriotic cysts or larger endometriotic areas. It also may identify free fluid often within the cul-de-sac. The two most common imaging tests are ultrasound and magnetic resonance imaging (MRI). Normal results on these tests do not eliminate the possibility of endometriosis. Areas of endometriosis are often too small to be seen by these tests.

The only way to diagnose endometriosis is by laparoscopy or other types of surgery with lesion biopsy. The diagnosis is based on the characteristic appearance of the disease, and should be corroborated by a biopsy. Surgery for diagnoses also allows for surgical treatment of endometriosis at the same time.

Although doctors can often feel the endometrial growths during a pelvic exam, and these symptoms may be signs of endometriosis, diagnosis cannot be confirmed without performing a laparoscopic procedure. Often the symptoms of ovarian cancer are identical to those of endometriosis. If a misdiagnosis of endometriosis occurs due to failure to confirm diagnosis through laparoscopy, early diagnosis of ovarian cancer, which is crucial for successful treatment, may have been missed.

Treatment


There is no cure for endometriosis, but there are many treatments for the pain and infertility that it causes. Talk with your doctor about what option is best for you. The treatment you choose will depend on your symptoms, age, and plans for getting pregnant.

Pain Medication. For some women with mild symptoms, doctors may suggest taking over-the-counter medicines for pain. These include ibuprofen (Advil and Motrin) or naproxen (Aleve). When these medicines don't help, doctors may prescribe stronger pain relievers.

Hormone Treatment. When pain medicine is not enough, doctors often recommend hormone medicines to treat endometriosis. Only women who do not wish to become pregnant can use these drugs. Hormone treatment is best for women with small growths who do not have bad pain. Hormones come in many forms including pills, shots, and nasal sprays. Common hormones used for endometriosis include:

  • Birth control pills to decrease the amount of menstrual flow and prevent overgrowth of tissue that lines the uterus. Most birth control pills contain two hormones, estrogen and progestin. Once a woman stops taking them, she can get pregnant again. Stopping these pills will cause the symptoms of endometriosis to return.

  • GnRH agonists and antagonists greatly reduce the amount of estrogen in a woman's body, which stops the menstrual cycle. These drugs should not be used alone because they can cause side effects similar to those during menopause, such as hot flashes, bone loss, and vaginal dryness. Taking a low dose of progestin or estrogen along with these drugs can protect against these side effects. When a woman stops taking this medicine, monthly periods and the ability to get pregnant return. She also might stay free of the problems of endometriosis for months or years afterward.
  • Progestins. The hormone progestin can shrink spots of endometriosis by working against the effects of estrogen on the tissue. It will stop a woman’s menstrual periods, but can cause irregular vaginal bleeding. Medroxyprogesterone (muh-DROKS-ee-proh-JESS-tur-ohn) (Depo-Provera) is a common progestin taken as a shot. Side effects of progestin can include weight gain, depressed mood, and decreased bone growth.
  • Danazol (DAY-nuh-zawl) is a weak male hormone that lowers the levels of estrogen and progesterone in a woman's body. This stops a woman's period or makes it come less often. It is not often the first choice for treatment due to its side effects, such as oily skin, weight gain, tiredness, smaller breasts, and facial hair growth. It does not prevent pregnancy and can harm a baby growing in the uterus. It also cannot be used with other hormones, such as birth control pills.

Surgery. Surgery is usually the best choice for women with severe endometriosis — many growths, a great deal of pain, or fertility problems. There are both minor and more complex surgeries that can help. Your doctor might suggest one of the following:

  • Laparoscopy can be used to diagnose and treat endometriosis. During this surgery, doctors remove growths and scar tissue or burn them away. The goal is to treat the endometriosis without harming the healthy tissue around it. . During this procedure, the endometriosis tissue is removed with a laser, heat, or other methods.  Women recover from laparoscopy much faster than from major abdominal surgery
  • Laparotomy (lap-ar-AW-tuh-mee) or major abdominal surgery that involves a much larger cut in the abdomen than with laparoscopy. This allows the doctor to reach and remove growths of endometriosis in the pelvis or abdomen.
  • Hysterectomy (his-tur-EK-toh-mee) is a surgery in which the doctor removes the uterus. Removing the ovaries as well can help ensure that endometriosis will not return. This is done when the endometriosis has severely damaged these organs. A woman cannot get pregnant after this surgery, so it should only be considered as a last resort.

 About Laparoscopic Surgery

Laparoscopy often is done as outpatient surgery. You usually can go home the same day, after you recover from the procedure. More complex procedures, such as laparoscopic hysterectomy, may require an overnight stay in the hospital. Before surgery, you will be given general anesthesia that puts you to sleep and blocks the pain. Local anesthesia instead of general anesthesia may be used. This type of anesthesia numbs the area, but you remain awake.

Your doctor will make a small incision in your navel and insert the laparoscope. During the procedure, the abdomen is filled with a gas (carbon dioxide or nitrous oxide). Filling the abdomen with gas allows the pelvic reproductive organs to be seen more clearly.

The laparoscope shows the pelvic organs on a screen. Other incisions may be made in the abdomen for surgical instruments. These incisions usually are no more than half an inch long. Another instrument, called a uterine manipulator, may be inserted through the cervix and into the uterus. This instrument is used to move the organs into view.

After the procedure, the instruments are removed and the small incisions are closed with stitches or tape. There will be small scars that usually fade over time.

Your Recovery

If you had general anesthesia, you will wake up in the recovery room. You will feel sleepy for a few hours. You may have some nausea from the anesthesia. You must have someone drive you home.

For a few days after the procedure, you may feel tired and have some discomfort. You may be sore around the incisions made in your abdomen and navel. Sometimes, the tube put in your throat to help you breathe during the surgery may give you a sore throat for a few days. If so, try throat lozenges or gargle with warm salt water. You may feel pain in your shoulder or back. This pain is from the gas used during the procedure. It goes away on its own within hours or a day or two. If pain and nausea do not go away after a few days or become worse, you should contact your doctor.

Your doctor will let you know when you can get back to your normal activities. For minor procedures, it is often 1–2 days after the surgery. For more complex procedures, it can take longer. You may be told to avoid heavy activity or exercise.