Endometriosis

Advanced Women's Health Institute

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What is endometriosis?
The lining of the uterine cavity is called the endometrium. When tissue implants are found outside of the uterus and looks like endometrium under the microscope we call this condition endometriosis. Implants of endometriosis are most commonly found in the pelvic area, on the ovaries, fallopian tubes, the rectum and the bladder dome. There are uncommon reports of endometriosis outside the pelvis such as in the lung, colon, inside the bladder, and even as far away as the brain.
There are four stages of endometriosis. Stage I is referred to as minimal endometriosis because there are not a lot of implants in the pelvis. Stage II is called mild endometriosis and there is more disease. Stage III, or moderate endometriosis, is characterized by even more pain and pelvic organs being affected. Severe endometriosis means stage IV disease and is the most difficult to treat.
The classification is based on whether or not implants are superficial, only on the surface, or deep into the tissue. The location of endometriosis also matters in staging. Points are given for size of implant areas, depth of invasion, ovaries involved and if tissues stuck together because of endometriosis. For more information visit websites such as the American Society of Reproductive Medicine, the Endometriosis Association or the American Association of Gynecologic Laparoscopists.

What causes endometriosis?
The exact cause is unknown. Some feel there is an inherited problem of the immune system.
Endometriosis tends to run in families, which supports a potential genetic link,  
When a woman has a menstrual period she sees the shedding of endometrium and bleeding. What is not visible is the flow of endometrial cells through the fallopian tubes at the time of the period. These cells settle in the pelvic area. Normally the immune system should clean these out. But, because of a possible failure of immune system function the endometrial cells attach to the tissues in the pelvis. Cyclic bleeding in endometriosis then causes worsening cramps due to inflammation of the surrounding tissue.
Endometriosis is stimulated by cyclic ovarian estrogen and progesterone production, so symptoms subside after menopause. HRT(estrogen with progesterone) for menopause may result in pain.

How many women get endometriosis?

The generally quoted occurrence of endometriosis is 10-15% of women. Endometriosis is more common in Caucasian women than other ethnic groups. The majority of women with endometriosis, about 90%, have stage I or II disease. Stage III and IV are less common but usually associated with more pain and faster recurrence.


Is endometriosis cancerous?
Endometriosis itself is not cancer. The incidence of endometrial cancer in women, who have had endometriosis, even if taking estrogen only after a hysterectomy, does not appear very high. There are reports of endometrial cancer arising in endometriosis, so it is possible, but this does not appear to be a contraindication to estrogen for moderate to severe menopausal symptom relief.
 
What are the symptoms of endometriosis?
Common symptoms are:

  • Worsening menstrual cramps
  • Increased days of cramping in the cycle
  • New painful intercourse
  • Cyclic bowel and/or urinary pain
  • Nonspecific bowel and/or urinary pain
  • Lower back pain
  • Pelvic pressure



How is endometriosis diagnosed?
Clinical symptoms, in the absence of other diagnoses such as fibroids, are considered sufficient for discussion and initiation of medical therapy. Endoscopic visual diagnose is still considered standard, however biopsy confirmation is recommended by many, especially in complicated cases of pelvic pain. 

There are two ways to diagnosis of endometriosis. They are transvaginal hydrolaparoscopy and transabdominal Laparoscopy

Transvaginal Hydrolaparoscopy (THL) - This procedure can be performed in the doctor's office with only minimal pain medication and no abdominal incisions. Most patients receive oral sedation 40-50 minutes before and would have the procedure again with the same protocol. The woman rests comfortably on an exam table with legs in holding supports. Local numbing medication is given and the scope inserted just beneath the intersection between the back of the cervix and the vagina. Injection of local is typically worse than introduction of the scope. The patient can see to her anatomy on the monitor and ask questions during the entire procedure which takes about 30 minutes. Saline solution is infused into the pelvis and causes the bowel to float up and out of the waypelvis making it easy to see the ovaries, tubes, and pelvic side walls.








Laparoscopy
- This requires small incisions in the abdomen so a scope can be inserted through the belly button to diagnose or treat endometriosis. A diagnostic laparoscopy can be performed with IV sedation in the office. Operative laparoscopy requires general anesthesia.









What is the best treatment option for endometriosis?
There are 2 choices for managing endometriosis, medical or surgical, and both have their merits.

Medical management – Suppression of cyclic ovarian function will reduce endometriosis pain related symptoms.


Estrogen/progestin contraceptives(EPCs) are generally the first recommendation, especially for younger women. EPCs reduce menstrual cramps, flow, and intercourse related pain in about 50% of cases. Side effects, complications, failure to control or return of symptoms cause the other 50% to seek further consultation.   It is possible to give EPC’s continuously to extend the interval between periods, thus decreasing periods to 6 or less each year. It doesn’t work for every woman but is worth a try.

High dose Progestational agents

GNRHa(gonadotropin releasing hormone agonist) are a class of compounds that selectively stop the pituitary gland from stimulating the ovaries.   

Drugs that suppress the activity of the ovaries can slow the growth of the endometrial tissue implants. There are a variety of medicines, each with their own side effects, so you and your doctor should discuss the options. This can keep the symptoms under control. It should be kept in mind that drug treatment does not cure endometriosis, it will probably return if the treatment is stopped.  There are side effects that can increase the risk of osteoporosis or heart disease. Consultation with your physician is necessary.

Surgical Management

Laparoscopy - This requires small incisions in the abdomen so a scope can be inserted through the belly button to diagnose or treat endometriosis. If endometriosis is identified at the time of diagnostic laparoscopy, an operative laparoscopy can then be performed to remove the endometrial tissue implants. This requires additional small incisions for the placement of graspers, scissors, and other instruments to remove the implants. The procedure is done as an outpatient and return to work is expected in approximately 2 weeks or less.
There are various laparoscopes. Originally, these scopes were 10-mm in size. Advances in fiberoptic technology allow us to now use 3 and 5-mm scopes. It is important to discuss the size of the scope and the accessory ports with the doctor because the size of the incision will contribute to recovery. The Advanced Women's Health Institute uses either a 3 0r 5-mm scope because we feel that 10-mm scopes are no longer necessary.

Open Abdominal Surgery for Endometriosis - This procedure is accomplished using a 4-6 inch open abdominal incision to perform the operation. However, laparoscopy represents a less invasive, less painful approach to endometriosis. 

What about a natural remedy or diet?

It may be possible to manage some symptoms with various alternative methods.Advanced Women's Health Institute is unaware of controlled studies.
If you choose to use some alternative methods, it should be noted that all therapies and diets should be discussed with your physician to make sure that there is no contraindication with any prescriptions or other therapies or treatments being performed or contemplated. Always keep an open communication between all you practitioners.