What is endometriosis?

Endometriosis is a painful, chronic condition that affects 5% to 10% of women of childbearing age.

In endometriosis, the type of cells that normally grow only on the inside of the uterus are found in other locations, most commonly on the ovaries, the fallopian tubes, the outside of the uterus, the lining of the pelvis, the ligaments that support the uterus, the bladder, and the bowel. Occasionally, these cells are even found as far away as the lungs.

The problem is that these cells go through the same changes that intrauterine cells go through during a menstrual cycle; that is, the cells build up during the month and bleed with menstruation.

Unlike the blood produced from the inside of the uterus, however, the sticky fluid released from endometrial growths has no escape route, and leads to inflammation and scarring, producing the symptoms and problems linked to endometriosis, such as chronic pain, bowel complaints, and infertility.

Endometriosis runs in families. In fact, a study from Iceland found that a woman was not only 5 times as likely to have endometriosis if her sister had it as well, she was also more likely to end up with endometriosis if a cousin was affected.

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What causes endometriosis?

The oldest theory is that during menstruation, some menstrual blood flows backwards through the fallopian tubes and results in intrauterine cells "implanting" in other areas.

Many women, however, experience retrograde flow without developing endometriosis, so if retrograde flow does play a role, it probably exerts its effect only in a woman who has an immune or hormonal problem that allows these cells to implant elsewhere.

Some people feel that endometriosis is actually an autoimmune disease like type 1 diabetes, multiple sclerosis, and some thyroid disorders; that is, a disease in which the body's immune system turns against its own cells. In fact, women with endometriosis suffer disproportionately from autoimmune diseases.

Another popular theory holds that endometrial growths are produced while a woman is still a fetus, and become active when estrogen is released during puberty.

Yet another theory proposes that environmental toxins play a large role in this disease.

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What are the symptoms of endometriosis?

The most common symptom of endometriosis is pain in the pelvis and low abdomen before and during menstruation.

Other common symptoms are pain with intercourse, heavy menstrual bleeding, bowel problems such as painful bowel movements during periods, diarrhea, or constipation, and painful urination during periods.

Infertility is also a very common feature of endometriosis.

It's important to know that the amount of pain a woman experiences does not correlate well with the number of endometrial growths she has, so that some women with only a few endometriomal growths can have lots of pain, while others with many growths will have only minimal pain.

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How is endometriosis diagnosed?

Endometriosis is often suspected from a typical history of pain in a woman in her reproductive years.

Sometimes, endometriosis is picked up when the doctor feels a "mass" on the ovaries produced by an endometriosis cyst, but the diagnosis can only be confirmed with a laparoscopy, a "keyhole" look into the pelvis. This also allows the doctor to gauge the extent of the disease.

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How is endometriosis treated?

A healthy lifestyle - diet, exercise, weight control, stress reduction - can help with the symptoms of endometriosis.

The pain of endometriosis is most often treated with analgesics, usually nonsteroidal anti-inflammatory medications such as ibuprofen, although many women occasionally require more potent medications, and some require them regularly.

Endometriosis can also be treated with medications that stop ovulation such as oral contraceptives (which can be taken continuously to avoid periods altogether), progesterone (such as Depo-provera), and with other medications such as the GnRH agonists and danazol (a synthetic testosterone that is also sometimes used for severe cases of endometriosis). Danazol, however, produces many side effects (hot flashes, acne, weight gain, masculinization effects such as voice deepening and growth of the clitoris, mood swings, and others), and it has also been linked to an increased risk of ovarian cancer, so its use should be very limited.

Surgery has an important role to play in endometriosis. First, laparoscopy confirms the diagnosis and extent of the disease. Second, many women are helped immensely when endometrial tissue is excised, that is, when the surgeon finds the growths and destroys them. Equally important, appropriate surgery can improve the chances of pregnancy.

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Art Hister, MD 
in association with the MediResource Clinical Team