Endometriosis
The Southeastern Center for Reproductive Surgery specializes in surgical and
medical treatments of endometriosis. Our endometriosis specialists have
extensive experience and knowledge of this disease as a result of our
research, as well as treating thousands of patients with this condition.
Endometriosis is a condition in which tissue similar
to the endometrium is present in abnormal locations. "Endometrium"
is the tissue that lines the uterine cavity and allows for attachment
of the embryo early in pregnancy. The endometrium changes in response
to levels of estrogen and progesterone during a woman's cycles, then sheds
during menstruation due to abrupt decreases in these hormones. Similar
changes occur in endometriotic tissue located outside of the uterus, and
accounts for the cyclic pain and inflammation that characterize this disease.
There are many ways in which endometrial tissue may
appear in areas outside of the uterus. The most common phenomenon seems
to be related to 'retrograde menstruation', in which the menstrual tissue
travels back through the tubes into the pelvis, rather than out of the
cervix into the vagina. Once in the pelvis, immunologic or other problems
present in some women allow this tissue to proliferate and spread. This
tissue can also invade adjacent tissues and the cyclic build-up and breakdown
causes an inflammatory response, resulting in pain, scar tissue formation,
or other problems
Symptoms of Endometriosis
- Pelvic Pain - Although there is a general
correlation between the amount of pain a woman experiences
and the severity of her disease, it is important to note that
many women with endometriosis have no pain, and some women
with severe pain have only minimal disease.
Pain caused by endometriosis is typically located in the
pelvis, but may radiate to the hips, thighs, or back. It is
often cyclic, being most severe just prior to menses, and
resolving during or after menstruation. Pain may also be
present throughout the cycle.
- Menstrual Cramping - Women with endometriosis
experience more severe cramping, which may begin well prior
to actual menstruation.
- Painful Intercourse - Pain during sexual
relations, especially deep penetration, is common in women
with endometriosis. This pain may be midline or on the
right or left side. It is sometimes worse in midcycle or
just before menses.
- Infertility - While endometriosis is
present in only 5-10 percent of reproductive aged women,
it is found in up to 50% of women who undergo diagnostic
laparoscopy for infertility. Endometriosis may lead to
infertility through a variety of mechanisms. For example,
scar tissue from the disease process may cause tubal
occlusion or inability of the ovary to release eggs.
Endometriomas, or 'chocolate cysts' of the ovaries may also
cause significant distortion of pelvic anatomy.
Studies of women with endometriosis have often shown
other abnormalities that may contribute to infertility.
These include alterations in the chemical and cellular
composition of the pelvic environment, changes in tubal
and ovarian function, and other factors.
Diagnosis of Endometriosis
Endometriosis may be suspected based on a
woman's physical exam and history of the above symptoms. In
addition, certain laboratory tests (such as serum CA-125
levels and endometrial aromatase activity) may give presumptive
evidence of this disease. The 'gold standard' for diagnosing
endometriosis, however, remains visual and pathologic confirmation
at the time of laparoscopy or laparotomy
Treatment
As with many gynecologic conditions, treatment may be
medical or surgical. Either alternative has conservative and aggressive
options, and its own unique advantages and disadvantages.
- Surgical Therapy: Discussion of
treatment should begin with surgical therapy, because a
surgeon should always be prepared to treat endometriosis completely
at the time of the initial (surgical) diagnosis. In the vast
majority of cases, the surgeon should be able to achieve this
goal. See Reproductive Surgery
for specifics and caveats on surgical management.
Endometriotic lesions may be treated in a variety of ways,
including excision, laser vaporization, and electrocautery.
However, not all methods are appropriate for all patients. It
is crucial for the surgeon to recognize the many different
appearances of endometriotic implants, and the fact that the
microscopic disease often extends beyond the visible lesions.
All disease must be removed or destroyed in order to minimize
the risk of recurrence. This is often very time consuming, but
can usually be accomplished through the laparoscope.
Scar tissue associated with endometriosis should be removed,
not simply cut. Endometriomas, or 'chocolate cysts', which are
collections of blood endometriosis within the ovaries, must
also be removed by stripping away the cyst wall. Lesser
measures, such as simple drainage or cauterization of the
cyst wall, will almost always fail to resolve this problem.
Although many general gynecologists will treat this disease,
we highly recommend that you seek treatment from a subspecialty
board certified reproductive endocrinologist. Membership in
the Society of Reproductive Surgeons (an affiliate of the
ASRM - see our Links page)
shows additional competence and interest in the field.
Perhaps most importantly, it is almost never necessary to
perform a hysterectomy in managing this disease for an
infertile woman.
- Medical Therapy: Although we and others are
investigating the use of immunomodulators in the treatment of endometriosis,
hormonal therapies are still the principal agents used for medical management
of this disease.
Oral contraceptives have been used for years to treat the pain
associated with endometriosis. Although moderately effective, they do
not cause regression of the implants, and are obviously not appropriate
for infertile women.
Damazol, which is chemically similar to testosterone, was formerly
the 'gold standard' in medical management of endometriosis. Its use
is associated with acne, hair growth, and a risk of birth defects if
inadvertently given during pregnancy. Therefore, this medication is
infrequently used today.
GnRH analogs (Lupron, Synarel, etc.) are the new 'gold standard'
for medical treatment of endometriosis. These agents work by lowering
estrogen levels, thus causing regression of the endometrial implants.
They are very effective in reducing the volume of disease and symptoms
of pain. However, recurrences may occur more quickly after medical treatment
compared to surgical treatment. In addition, medications are not effective
in treating endometriomas (ovarian cysts caused by endometriosis) or
scar tissue.
Herbal and 'natural' therapies have not been studied in the treatment
of endometriosis and our own experience is that they may cause significant
menstrual irregularities. Therefore, they cannot be recommended at present.
Recurrent Disease
Endometriosis may recur, even if properly treated, and
even after a successful pregnancy. The recurrence rate approximates 15
percent per year, or 50 percent after 5 years.
Conclusions
Endometriosis is a common yet serious disease that impacts one's health and reproductive potential. Fortunately,
excellent therapy is available. It is rarely necessary to perform a hysterectomy in a woman who desires to retain her potential
fertility. Advice from a competent subspecialist should always be sought. Additional information may be obtained from our
office, or on the web at www.endmetriosisassn.org.
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