MEDICAL DICTIONARY
Endometriosis: In endometriosis , cells that normally grow inside the uterus (womb), instead grow outside the uterus.
Summary: Endometriosis is very common; the cause -- and why some women have endometriosis and many others do not -- has not been fully fathomed, although there are several prevalent theories; most women with endometriosis have no symptoms; but pelvic pain during menstruation or ovulation is a frequent symptom of endometriosis; endometriosis may be suspected by during a physical examination; it is confirmed by surgery, usually laparoscopy ; the available treatment includes medication for pain, hormone therapy , and surgery.
Endometrial cells line the uterus and are normally shed each month during menstruation. When endometrial cells grow outside the uterus, the cells implant. These implants occur most commonly within the fallopian tubes and on the outside of the tubes and ovaries, the outer surface of the uterus and intestines and anywhere on the surface of the pelvic cavity. They can also be found, less often, on the surface of the liver, in old surgery scars or, very rarely, in the lung or brain.
Endometrial implants respond to the hormones of the menstrual cycle just as does the normal endometrium. The implants build up during the month and then they break down and during menstruation they bleed internally. Blood from the implants cannot leave the body via the vagina (or by other exit). The internal bleeding, tissue inflammation and, later, scarring cause the symptoms of endometriosis.
Endometriosis occurs in the reproductive years. The average age at diagnosis is 25-30. (It has been reported in girls as young as 11.)
The central theory of the cause of endometriosis is retrograde menstruation. Blood and endometrium tissue from the uterus back up into the fallopian tubes and drip into the pelvic and abdominal cavity. Retrograde menstruation may, it is thought, be due to a defect in the uterus or it may be related to the way the uterus contracts when it is expelling the menstrual tissue. Genetic factors and the immune system probably are also important in determining which women develop endometriosis and where the endometrial cells implant.
The common symptoms and signs are pain (usually pelvic) and infertility. Pelvic pain usually occurs during or just before menstruation and lessens after menstruation. Some women experience pain or cramping with intercourse, bowel movements and/or urination. Even a pelvic examination by a doctor can be painful.
The intensity of pain may change from month to month and vary greatly among women. Some women experience progressive worsening of symptoms while others can have resolution without treatment.
Endometriosis can cause infertility. When laparoscopy is done for infertility studies, endometrial implants can be found in some patients, many of whom may not have painful symptoms of endometriosis. It believed that endometriosis bleeding, inflammation, and scarring can cause distortion of the female reproductive organs (such as obstruction of the fallopian tubes), resulting in infertility. However, the severity of the disease is not necessarily directly related to the degree of infertility.
Other symptoms related to endometriosis include lower abdominal pain , diarrhea or constipation , low back pain , irregular or heavy menstrual bleeding, or even blood in the urine. Rare symptoms of endometriosis include chest pain or coughing blood due to endometriosis in the lungs, headache and/or seizures due to endometriosis in the brain.
Endometriosis can become cancerous in less than 1% of women. Most of the cancers found with the condition, however, appear not to be associated with the implants, but rather occur independently of the disease.
How is endometriosis diagnosed?
Endometriosis can be suspected based on symptoms of pelvic pain and findings during physical examinations in the doctor's office. Occasionally, the doctor can feel nodules (endometrial implants) behind the uterus and along the ligaments that attach to the pelvic wall. At other times, no nodules are felt, but the examination itself causes unusual pain or discomfort. Unfortunately, neither the symptoms nor the physical examinations can be relied upon to establish the diagnosis of endometriosis. Imaging studies, such as ultrasound , can be helpful in studying the pelvis, but still cannot accurately diagnose endometriosis. Direct visual inspection and tissue biopsy of the implants are necessary for accurate diagnosis.
Currently, the only accurate way of diagnosing endometriosis is at the time of surgery (either by open standard laparotomy or laparoscopy). Laparoscopy is the most common surgical procedure for the diagnosis of endometriosis. Laparoscopy is a minor surgical procedure done under general anesthesia or in some cases local anesthesia. It is usually performed as an out-patient procedure (the patient going home the same day). Laparoscopy is performed by first inflating the abdomen with carbon dioxide through a small incision in the navel. A long, thin instrument (laparoscope) is then inserted into the inflated abdominal cavity to inspect the abdomen and pelvis. Endometrial implants can then be directly visualized. During laparoscopy, biopsies (removal of tiny tissue samples for examination under a microscope) can also be performed for a diagnosis. Sometimes biopsies obtained during laparoscopy show endometriosis even though no endometrial implants are visualized during laparoscopy.
Pelvic ultrasound and laparoscopy are also important in excluding malignancies (such as ovarian cancer ) that can mimic endometriosis.
Recently, there has been extensive research into blood testing of endometriosis. Unfortunately, the accuracy of these blood tests has not been firmly established.
How is endometriosis treated?
Endometriosis can be treated with medications and/or surgery. The goals of endometriosis treatments include pain relieve, shrinkage or ablation of the implants, and enhancing fertility.
For pain relief, nonsteroid antiinflammatory drugs or NSAIDs (such as Motrin and Naprosyn) are given to help with menstrual cramping. Narcotic medications are sometimes prescribed when NSAIDs fail to relieve the pain. These analgesic medications have no effect on the endometrial implants.
Endometrial tissue (including implants) is affected by body's estrogen level. Estrogen is a female hormone made by the ovaries. When estrogen levels are low (as in menopause or after surgical removal of ovaries), endometrial tissue shrinks (perhaps even disappears), and symptoms of endometriosis ease.
Recently, a class of medications called GnRH analogs have been developed to treat endometriosis. These medications prevent the natural releasing hormones from being secreted, thereby blocking their stimulating effect on the gonads (ovaries in women). As a result, the normal production of sex hormones (estrogen in women) is reduced. One example of GnRH analog is nafarelin (Synarel). When given by nasal spray for 6 months, Synarel induces a temporary state of menopause , stops menstruation, and lowers estrogen levels. Lowering estrogen levels helps shrink endometrial implants and relieves pain of endometriosis. Low estrogen levels can also cause bone thinning ( osteoporosis ). When use is limited to 6 months, the amount of bone loss is likely to be small. Normal ovarian function resumes once the medication is discontinued. Another GnRH analog is leuprolide (Lupron), which is given by regular injections under the skin. Researchers are trying to find ways of adding other hormones to counter the osteoporosis effect of GnRH analogs, thus allowing them to be used for longer periods of time.
There are other hormones available to treat endometriosis. Some have unpleasant side effects. Danazol (Danocrine) and medroxyprogesterone (Depo-Provera) are examples of medications that provide good control of symptoms but can cause severe side effects such as menstrual changes, breast soreness, rash , and fatigue and, therefore, are often not suitable for long-term use.
Birth control pills are a common hormonal treatment that can alleviate painful menstrual cramps and regulate periods in patients with endometriosis. However, birth control pills treat the symptoms but do not cure the condition. In some patients, the birth control pills can even worsen the condition.
Surgery can be an effective treatment for women with moderate to severe endometriosis. Laparoscopic surgery is rapidly replacing open laparotomy in diagnosing and treating endometriosis in the United States. With laparoscopic surgery , the visible implants can be treated with laser, cautery, or other surgical instruments. Removal or destruction of the endometrial implants can relieve pain symptoms and allow pregnancy to occur in some women. However, in some cases, the condition may be so severe that major open surgery, removing the uterus and the ovaries, is required.
Even though medications and laparoscopic surgery are effective in decreasing implants and relieving pain, endometriosis and symptoms can recur. For example, after completing 6 months of treatment with Synarel, 60% of the patients became symptom free, 32% experienced mild symptoms, and the remaining 8% had moderate to severe symptoms. Of the patients who had complete relief of symptoms, 50% of them remained free of symptoms 6 months after stopping treatment, 33% developed mild symptoms and 17% developed severe symptoms. Even after open radical surgery with removal of the uterus and the ovaries, severe endometriosis can reactivate, especially if hormone replacement is instituted shortly after surgery.
A great deal of effort is currently being focused on diagnosing and treating endometriosis. Newer methods of laparoscopy with smaller incisions and instruments are being developed. Newer drugs and different drug combinations are being explored. A new treatment based on strengthening the immune system (immunotherapy) may be helpful in women in whom there is felt to be an immune system dysfunction. Newer, more sensitive methods of radiological imaging are being examined for diagnostic purposes. Certain proteins in the saliva are being researched as a method of diagnosis. Overall, endometriosis is a condition that can be treated successfully in the majority of women, allowing them to achieve pain relief, pregnancy, or both. A benign condition in which tissue that looks like endometrial tissue grows in abnormal places, most often in the abdomen. Although most women with endometriosis have no symptoms, pelvic pain during menstruation or ovulation can be a symptom of endometriosis. Endometriosis can also be suspected by a doctor during a physical examination and confirmed by surgery, usually laparoscopy. Treatment options include medications for pain, hormone therapy, and surgery. The word "endometriosis" was coined in 1927 by John Sampson who suggested that menstrual blood backed up from the uterus carrying endometrial cells through the fallopian tubes into the abdominal cavity so that these cells could implant, for example, on the ovaries, ureters (the tubes coming from the kidney to the bladder), and the top of the vagina (called the cul-de-sac).
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