Endometriosis Ectopic Endometrium

What is Endometriosis?

Endometriosis is the presence of the tissue that normally lines the uterus (endometrium) outside of the uterus. Common sites for endometriosis include the ovaries, fallopian tubes, the ligaments that support the uterus, intestine, bladder, cervix, vagina, and external genitalia (vulva).

Endometriosis has also been uncommonly found outside the pelvis and abdomen, including the lung.

Endometriosis responds to hormones of the menstrual cycle. Each month endometrial implants grow and thicken, just like the lining of the uterus. If there is no pregnancy, the implants will break down and bleed. But unlike the tissue in the uterus, endometriosis has no way of leaving the body when it breaks down. Pain can result, as can inflammation and formation of scar tissue. The cause of endometriosis is unclear, but the most common theory is "retrograde menstruation" in which some menstrual blood flows backward out the fallopian tubes rather than exiting through the vagina. Endometrial cells in the menstrual flow may then attach themselves to various locations. Another theory suggests that endometrial cells may spread through the lymph or blood circulations.

The exact incidence of endometriosis is unknown, because surgery is required for a positive diagnosis. But it is estimated that about ten percent of all women develop some degree of endometriosis before reaching menopause. Endometriosis most commonly occurs in childless women between the ages of 25 and 40, but can affect any woman (including those with children) at any time during her childbearing years. A woman whose mother, sister, or daughter has endometriosis is up to seven times more likely to have it than a woman with no affected relatives. When a woman becomes pregnant, or menopausal, the endometriosis shrinks and much of the pain may go away. However, any scar tissue that has developed will remain, and may continue to cause pain even though the menstrual cycle has ceased.

How is it diagnosed?

History: The symptoms of endometriosis vary widely. Pelvic pain and abnormal or heavy menstrual bleeding are most commonly reported. There may be severe abdominal and/or lower back pain that begins prior to a menstrual period, becoming more severe towards the end of a period.

Other possible symptoms are fatigue, pain with intercourse, diarrhea, constipation, or painful bowel movements during the menstrual period, rectal bleeding or blood in the urine only during the menstrual period, and irregular bleeding or spotting between periods.

Cramping lower abdominal pain may occur any time during the cycle. A large endometrial growth can cause the sensation of pelvic pressure. Infertility is commonly reported, affecting about 30% to 40% of women with endometriosis.

The amount of pain is not related to the extent of endometriosis; some women with large or numerous growths have no pain, while other women with only minimal growths may experience severe pain.

Many women with endometriosis have no symptoms.

Physical exam: Pelvic examination might detect the endometrial growths or tender areas when the uterus is moved. Growths may also be seen if located in the upper vagina or on the cervix. However, many women have no abnormal findings on physical examination.

Tests: Laparoscopy, a surgical procedure, is currently the most common and accurate method to identify endometriosis. A small lighted telescope is inserted into the abdomen, and the pelvis and abdomen are inspected visually. Laparoscopy can reveal the location and size of endometrial growths, and can help in making treatment decisions. Laparoscopic diagnosis should be confirmed by biopsy.

In women with infertility and pain, Ca125 levels may be used. Ca125 levels are higher in moderate to severe endometriosis and can be used for both diagnosis and to follow the effects of therapy.

Additional tests may be necessary to explore other diagnoses with similar symptoms, such as a pregnancy test for ectopic pregnancy, urinalysis for urinary infection, colonoscopy or barium enema to rule out bowel disease (such as diverticulitis), or ultrasound to rule out ovarian cancer.

How is Endometriosis treated?

The approach to treatment is influenced by severity of symptoms, the extent of the disease, the age of the woman, and her desire for future childbearing. Treatment can include careful observation, medical therapy, surgery, or a combination of these.In women with no symptoms or only mild discomfort, careful observation may be all that is needed (there is no evidence that early treatment will prevent or lessen later symptoms). Pain relievers may be useful.

Hormone treatment for endometriosis includes birth control pills, high doses of another female hormone (progestins), or a male hormone derivative. Hormone therapy may help halt the spread and reduce the pain of endometriosis by interrupting the menstrual cycle.

Another treatment option is a synthetic hormone-like substance (GnRH analog), which temporarily interrupts the production of estrogen and produces a medical menopause. With this treatment the endometrial growths often shrink, providing significant relief from the symptoms.

Conservative surgical treatment is to relieve painful symptoms of endometriosis while attempting to preserve the woman's ability to become pregnant in the future. Endometrial implants and scar tissue can be cut or destroyed by an electrical current or laser, done through a laparoscope; the ovaries and fallopian tubes are left alone if normal. Painful symptoms can be relieved through this treatment, but may return.

More extensive surgery is undertaken only when all other options have failed. This may involve removal of the uterus (hysterectomy) and both ovaries (oophorectomy), perhaps including the fallopian tubes (bilateral salpingo-oophorectomy). Although these methods may help prevent the recurrence of endometriosis, they also leave the woman unable to bear children and in a permanent state of menopause. Even after menopause (natural or surgically produced), endometriosis can be reactivated if the woman takes estrogen replacement, but it does not recur in the majority of women.

Medications

• You may use non-prescription drugs, such as nonsteroidal anti-inflammatory drugs (NSAIDs), to relieve minor pain.
• Stronger pain relievers may be prescribed.
• Oral contraceptives, progestrogens, danazol and gonadotropin-releasing hormones (Gn-RH) are commonly used drugs for treating endometriosis by suppressing ovarian function.

Motrin (Ibuprofen), Soma (Carisoprodol), Danazol tablets, Femara (Letrozole), Apri (Desogestrel), Alesse (Levonorgestrel), Arimidex (Anastrozole), Aygestin (Norethindrone), Ovral (Norgestrel)

Activity

• Exercise, such as walking, helps in relieving pain and reduces estrogen levels that may slow the growth of endometriosis.
• Some activity restrictions may apply following surgical therapies.

Diet

Avoid caffeine because it seems to aggravate pain in some women.

What might complicate it?

Scar tissue (adhesions) can form, causing intestinal obstruction. Growths on or near the bladder can interfere with urinary function. Blood trapped inside the ovary can build up, causing a non-cancerous tumor (endometrioma). The disease can result in infertility. Recurring chronic pain or infertility may lead to depression and emotional issues. Side effects are frequent with hormonal treatment.

Predicted outcome

Most women are able to obtain significant relief from pain and remain able to bear children. Current treatment offers relief from symptoms but not a cure. Endometriosis may even recur following surgery. The course of endometriosis in any individual cannot be predicted.

Alternatives

Other possibilities include pelvic inflammatory disease, ovarian cysts or cancer, dysmenorrhea, a pelvic tumor, urinary tract infection, ectopic pregnancy, functional bowel disease, diverticulitis, and chronic appendicitis.

Appropriate specialists

Gynecologist and general surgeon.

Last updated 15 November 2011