What is Endometriosis?

The lining of the uterus is known as the endometrium. Endometriosis is a gynecologic condition in which bits of tissue similar to endometrium are found in areas of the body outside the uterus. Endometriosis lesions can appear anywhere in the pelvic cavity: on the ovaries, the fallopian tubes, the pelvic sidewall and the uterosacral ligaments. They can also appear outside the pelvic cavity - in the intestines, appendix, rectum, and even such far-flung places as the nose, although this is not common.

These lesions, termed "endometriosis implants," respond to female hormones like estrogen and progesterone, just like the endometrial lining does.  They can even bleed in microscopic amounts just like a menstrual period.  This bleeding leads to local irritation and inflammation in the sites of implantation.  The inflammation causes scar tissue to form, causing pelvic pain and impeding normal functioning of pelvic organs.

What is the Cause of Endometriosis?

The cause of endometriosis remains unknown, although a cornucopia of theories, ranging from bacterial infection to genetic abnormalities, has been proposed to explain this baffling disease. One theory suggests that endometrial cells, which are present in the menstrual flow, can back up into the fallopian tubes, implanting there and in the ovaries, then spreading through various routes, such as the lymphatic system, to implant in other parts of the body.

Endometriosis Symptoms

The most common symptom of endometriosis is pelvic pain, often coinciding with the normal bleeding that occurs during the menstrual cycle - although pain may occur at any time.  Pelvic pain results from the accumulation of scar tissue in the most common site, the fallopian tubes, although the ovaries or any organ affected by endometriosis and the resultant scarring can experience pain from inflammation and adhesions to other organs. Other common endometriosis symptoms include pelvic masses that result from endometriosis cysts, called endometriomas, growing in the ovaries.  Endometriomas are also known as "chocolate cysts." The endometriotic tissue in them undergoes its own "menstrual bleeding" during the menstrual cycle; the congealed blood trapped within the cyst resembles chocolate syrup. Pain that occurs during intercourse, known as dyspareunia, can also be a symptom of endometriosis. Finally, infertility is one of the major symptoms that results in patients seeking endometriosis treatment.

Endometriosis and Pregnancy: Does Endometriosis Cause Infertility?

There is a strong association between endometriosis and infertility, but a true cause-and-effect relationship has not been firmly established. In the following examples, infertility can result if:

• Endometriosis lesions in the fallopian tubes cause scarring to the point of blockage, preventing sperm and egg interaction. In extreme cases, reproductive organs are fused together and do not function properly.
• Ovarian cysts composed of endometriosis lesions (endometriomas, or “chocolate cysts”) impair egg production and ovulation.

In women with untreated endometriosis who are trying to conceive, the monthly fecundity (chance of pregnancy each month) is 2-10%, compared to 15-20% in the general population.  Some studies have suggested that 30%-50% of women with endometriosis experience infertility.

Endometriosis Diagnosis

All of the symptoms described above may point towards an endometriosis diagnosis, but are not sufficient to establish a diagnosis.  A pelvic exam can sometimes allow your gynecologist to identify endometriosis lesions by palpation (feel), but again, this is not reliable enough for a conclusive diagnosis of endometriosis.  The only true way to diagnose the condition is through a minimally invasive exploratory surgery of the abdominal cavity called laparoscopic surgery. Laparoscopic surgery employs a minimal incision in the abdomen, through which a lighted, fiber-optic tube containing a camera and surgical instruments is introduced, affording the surgeon an excellent view of the pelvic and abdominal region. In this way, any endometriosis lesions can be easily identified and the endometriosis diagnosis can be confirmed.

Endometriosis Treatment Objectives and Approaches

In terms of treatment, it is important to clarify your goals.  Some patients do not wish to conceive and just want relief from their pain.

For pain relief only (not infertility treatment):

A) Endometriosis Drug Treatment

• NSAID Pain Relievers - Non-steroidal anti-inflammatory drugs like naproxen (Aleve) can often help in management endometriosis pain. If necessary, opiates such as codeine can be used.
• Hormones - Stopping menstruation and simulating conditions that exist during pregnancy using hormones results in a lack of stimulation of endometriosis lesions. Without stimulation, the lesions atrophy instead of growing, leading to decreased inflammation and therefore pain relief.  The following are effective hormone treatments for relieving endometriosis pain; however, they are not meant to be used in addressing infertility, as they either actually prevent pregnancy or do not help in conception:
  • Danazol - Danazol is a synthetic androgen, or male hormone, that stops women from menstruating and causes endometriotic tissue to atrophy.
  • Progesterone - Progesterone or a derivative such as medroxyprogesterone acetate (Provera or Depo-Provera) is a contraceptive. It works as an endometriosis treatment by creating a pseudo-pregnancy state.
  • GnRH Agonists - GnRH (gonadotropin-releasing hormone) agonists, such as Lupron (leuprolide acetate), work by suppressing estrogen production. When the endometriosis lesions are starved of estrogen, they cannot grow or undergo menstrual bleeding, and they atrophy over time. Lupron is administered by injection, and is given daily, and patients inject the medication themselves. A much more convenient formulation, called Lupron Depot, is therefore preferred by most patients and doctors. Lupron Depot is a pellet that is implanted under the skin that delivers a measured dose of Lupron for three months. The convenience of this dosage form makes it an appealing option for endometriosis pain treatment.
  • Aromatase Inhibitors - A fairly new drug treatment proposed for endometriosis is a class of medicines called aromatase inhibitors. The two aromatase inhibitors on the market are letrozole (Femara) and anastrozole (Arimidex). They work by suppressing aromatase, an enzyme responsible for estrogen production. Aromatase inhibitors are more often used to treat gynecologic cancers, and are not currently FDA-approved as an endometriosis treatment.

You may have seen "natural" or "alternative" endometriosis treatments being promoted on the web or in other media.  One such natural treatment for endometriosis is called Endovan; it purports to be an effective endometriosis treatment and is offered as an alternative to surgery and hormones. There’s even an endometriosis diet being touted as a cure for the disease.  There is no clinical evidence whatsoever that any of these types of natural or alternative treatments can relieve endometriosis symptoms.

B) Endometriosis Surgery

The most popular type of endometriosis surgery today involves using laparoscopy to remove endometriosis lesions from the pelvic region. The lesions are often "burned off" by a procedure called laser ablation. The laser apparatus is just one of the instruments passed through the laparoscope. (Note: This should not be confused with the term "endometrial ablation," which refers not to ablation of endometriosis lesions, but rather to ablation of the endometrium (in the uterus) - two very different things!) In addition to the destruction of pelvic endometriosis lesions, surgery to remove ovarian cysts and adhesions is also accomplished using laparoscopy. Surgical destruction and removal of endometriosis has also been shown to decrease pain for longer periods of time than drug treatment, but repeat surgery may be required in the future.

The endometriosis treatment that offers the best hope for a cure is a total hysterectomy - this is the removal of the uterus, both ovaries, and the fallopian tubes. This is a drastic treatment option, and should not be undertaken lightly, as pregnancy is no longer possible.  Also, a cure cannot be completely guaranteed; rarely, endometriosis may return after hysterectomy.

Endometriosis Treatment to Address Infertility

For patients wishing to conceive, the best scientific evidence points to the need for an aggressive treatment plan.  Often patients with endometriosis need advanced treatments such as GnRH agonists (Lupron/Lupron Depot), and frequently, IVF.  In our experience as fertility specialists, we find that endometriosis results in a much greater infertility problem than the severity of the symptoms might suggest.  Our patients with endometriosis who want to conceive tend to perform very well during the process of IVF; in fact, they do as well as patients that do not have endometriosis when undergoing IVF.

SCRC: Specialists in Endometriosis Treatment

If you have been previously diagnosed with endometriosis, or suspect that you have it (based on painful periods, pelvic pain or pain with sexual intercourse), you should see a specialist in a timely fashion.  At SCRC, during your initial consultation, we will review endometriosis in depth with you, as well as look for clinical clues as to your diagnosis.  After a complete evaluation, our physicians will individualize a treatment plan for you.  It may include laparoscopic surgical evaluation of your reproductive organs, or proceeding directly with fertility treatments.  We prefer to reserve surgical management for our younger patient population. We find that older patients may do much better by proceeding directly to IVF.

We are keenly aware that diagnosis and treatment of endometriosis is often a complex situation that requires specialized training, patience, and skill. Improving your quality of life, while helping you conceive and build your family, is our primary concern.