Endometriosis

Endometriosis is one of the most common women’s gynecologic disorders. It is estimated that one in seven women of reproductive age in the United States is affected by the disease.

What is endometriosis?
What causes endometriosis?
Who is most likely to develop endometriosis?
What are the symptoms of endometriosis?
How do female hormones affect endometrial growth?
How is a diagnosis made?
What kind of treatment is available?
What is the objective of the treatment?

What is endometriosis?

Endometriosis is a condition which occurs when endometrial tissue, the tissue that lines the uterus and is shed during menstruation, grows outside the uterus. Once outside the uterus, endometrial tissue can develop into painful growths. Common sites for endometrial growths or endometriosis include the ovaries, the fallopian tubes and the ligaments that support the uterus. Other possible sites for endometriosis include the bladder, bowel, and vagina.

What causes endometriosis?

Endometriosis is one of the most puzzling conditions that affect women. The exact cause of the disease remains unclear. The most common theory is referred to as “retrograde menstruation.” According to this theory, a portion of the menstrual fluid flows backward into the fallopian tubes, rather than into the vagina. Endometrial cells contained in the menstrual fluid may then attach themselves to various locations in the pelvic cavity, as discussed earlier.

Who is most likely to develop endometriosis?

It is estimated that about 15% of all women develop some degree of endometriosis before reaching menopause. Although the disease more commonly occurs in childless women between the ages of 25 and 40, endometriosis can affect women, including those with children, at any time during the childbearing years.

What are the symptoms of endometriosis?

The most common symptoms of endometriosis are pain before and during menstrual periods, pain during sexual intercourse and heavy or irregular bleeding. In more serious cases, scar tissue may form on the fallopian tube and/or on the ovary, blocking the release of the egg and its passage through the tube toward the uterus. This, in turn, will inhibit a woman’s ability to conceive.

However, some women with endometriosis may experience no symptoms. What’s more, the amount of pain is not related to the extent of a patient’s endometrial growths. Some women with numerous growths have no pain while others with minimal endometriosis experience severe pain.

How do female hormones affect endometrial growth?

During menstruation, endometrial growth can bleed, just like the uterine lining bleeds in response to the hormones of the menstrual cycle. However, unlike the lining of the uterus, products of the endometrial growths have no way of leaving the body. This can result in irritation of the surrounding tissues. In reaction to this irritation, the body may surround this area with adhesions or scar tissue which can cause a woman severe pain.

In other words, as long as a woman’s monthly menstrual cycle takes place, the endometrial tissue will be simulated. This, in turn, can cause women to experience severe menstrual cramps, chronic pelvic pain or pressure, pain during sexual intercourse and/or bowel and bladder problems.

If a woman becomes pregnant or enters menopause, the endometrial growths shrink and much of the pain is eliminated. However, scar tissue that has developed during the course of the disease remains. This remaining tissue may continue to cause pain even though the menstrual cycle has ceased.

How is a diagnosis made?

If a physician suspects endometriosis, an accurate diagnosis of the disease can be made through a procedure called laparoscopy. During this minor surgical procedure, a slender light-transmitting microscope, the laparoscope, is inserted through a tiny incision made in the abdomen. This procedure enables the physician to examine the condition of the abdominal organs and check the size and extent of the endometrial growths. This method also allows the physician to rule out other conditions with similar symptoms, such as ovarian cancer.

What kind of treatment is available?

Management of endometriosis is directed at suppressing a woman’s levels of estrogen and progesterone, which stimulate the endometrial growths. Possible treatment options range from essentially no treatment in cases of minimal or even mild endometriosis to major surgery. In general, patients have two broad choices: surgical treatment and drug therapy. For some women, a combination of the two may be required.

What is the objective of the treatment?

In choosing a treatment option for patients with endometriosis, physicians are concerned about
(a) relieving pain and other symptoms
(b) halting the progression of future lesions
(c) restoring fertility to those patients who have lost the ability to become pregnant
(d) preserving reproductive function for future childbearing

Treatment Options - Surgery

Surgery

Surgical treatment falls into two categories: conservative and nonconservative management.

Conservative Surgery

Conservative surgical treatment is designed to preserve the ability of a woman to become pregnant and bear children in the future. This form of treatment focuses on removing individual areas of endometriosis. The surgeon often can accomplish this through the use of a laparoscope.

Superficial growths can be cut or destroyed by electrical current or through the use of a laser.

Nonconservative Surgery

Nonconservative surgery comes the closest to providing sustained relief for endometriosis. However, such measures are undertaken only to relieve a woman of severe pain after all other options have failed. Nonconservative methods include total hysterectomy (removal of the uterus and both ovaries); oophorectomy (removal of the ovaries alone); or bilateral salpingooophorectomy (removal of both ovaries and fallopian tubes). These methods may prevent the recurrence of endometriosis, but they also leave the patient unable to bear children and in a permanent state of menopause.

Treatment Options - Drug Therapy

Drug Therapy

The traditional medical treatments for endometriosis have included oral contraceptives, progesterones and male hormone derivatives.

Oral Contraceptives

The use of oral contraceptives to treat endometriosis is designed to temporarily halt a woman’s ovulation and menstrual cycle. Oral contraceptives are most effective in treating mild cases of endometriosis. The use of oral contraceptives may help halt the spread and pain caused by endometriosis, but it is not proven effective in eliminating endometrial growths. It is sometimes used as a follow-up therapy to surgical removal of the endometrial growths, as a means of minimizing their recurrence.

The side effects associated with oral contraceptives, used at the dosage required to treat endometriosis, include nausea, water retention and irregular vaginal bleeding. More serious complications, such as stroke, vascular problems and heart disease are rare but have been reported.

Progesterones

High doses of progesterones (female hormones) interrupt normal ovarian function cycle and also reduce the stimulating effect of estrogen on endometrial growths. Progestersones may be administered either orally or through an injection. Like oral contraceptives, progesterones are most effective in cases of minimal or mild endometriosis. Once therapy is discontinued, an unpredicted period of infertility may follow. Side effects associated with progesterones include menstrual-like spotting between periods, fluid retention, breast tenderness and adverse effects on lipid levels.

Male Hormone Derivative

A derivative of the male hormone testosterone, taken orally, is used to suppress the body’s production of estrogen. This, in turn, interrupts the menstrual cycle and stops the growth of the endometrial tissue. This method is useful in relieving the symptoms of endometriosis such as painful menstruations, pelvic pain and difficult or painful sexual intercourse.

There are several possible side effects to treatment with male hormones. These include hot flashes/sweating, vaginal dryness, weight gain, decreased breast size, acne/oily skin, a slight increase of body or facial hair, deepening of the voice and decreased libido. Some of the masculinizing side effects may not be reversible once treatment is stopped.

GnRH (Gonadotropin-Releasing Hormone) Analogs

A new treatment option for women with endometriosis involves the use of GnRH analogs. When taken over a period of six months, GnRH analogs interrupt the production of estrogen, producing a medically-induced menopause. As a result, the endometrial tissues often shrink, providing significant relief from the pain associated with the disease.

There are currently two GnRH analogs on the market to treat endometriosis. The major difference between the two is the dosage form. One is administered by a physician through a monthly injection. This method relieves the patient from the burden of remembering to take daily medication. The monthly office visits also allow the patient to ask questions about her condition and enables the physician to monitor her progress. The other GnRH analog is administered through a nasal spray that must be taken twice a day.

Treatment with GnRH analogs offer a success rate similar to that of the male hormone derivative, but masculinizing side effects are seen much less frequently. Side effects of treatment with GnRH analogs can include: hot flashes, decreased libido and vaginal dryness. A small amount of bone loss may also occur during therapy, but this is partially or completely recovered once treatment has stopped. A woman is capable of becoming pregnant while being treated with a GnRH analog. It is therefore important that a woman use a non-hormonal barrier contraceptive, specifically a condom or diaphragm, as a precautionary measure.

The best decision is an informed decision

Endometriosis affects each woman differently. Ultimately, the choice of treatment for endometriosis is up to each individual woman. This brochure provides you with general information about the disease. Women should review all of their options fully with their physician and with those closest to them. Whatever treatment a woman chooses, she should pursue it with confidence.



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