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Endometriosis
 The
Southeastern Center for Reproductive Surgery specializes in surgical and
medical treatments of endometriosis. Our endometriosis specialists have
extensive experience and knowledge of this disease as a result of our
research, as well as treating thousands of patients with this condition.
Endometriosis is a condition in which tissue similar
to the endometrium is present in abnormal locations. "Endometrium"
is the tissue that lines the uterine cavity and allows for attachment
of the embryo early in pregnancy. The endometrium changes in response
to levels of estrogen and progesterone during a woman's cycles, then sheds
during menstruation due to abrupt decreases in these hormones. Similar
changes occur in endometriotic tissue located outside of the uterus, and
accounts for the cyclic pain and inflammation that characterize this disease.
There are many ways in which endometrial tissue may
appear in areas outside of the uterus. The most common phenomenon seems
to be related to 'retrograde menstruation', in which the menstrual tissue
travels back through the tubes into the pelvis, rather than out of the
cervix into the vagina. Once in the pelvis, immunologic or other problems
present in some women allow this tissue to proliferate and spread. This
tissue can also invade adjacent tissues and the cyclic build-up and breakdown
causes an inflammatory response, resulting in pain, scar tissue formation,
or other problems
Symptoms of Endometriosis
- Pelvic Pain - Although there is a general correlation
between the amount of pain a woman experiences and the severity of her
disease, it is important to note that many women with endometriosis
have no pain, and some women with severe pain have only minimal disease.
Pain caused by endometriosis is typically located in the pelvis, but
may radiate to the hips, thighs, or back. It is often cyclic, being
most severe just prior to menses, and resolving during or after menstruation.
Pain may also be present throughout the cycle.
- Menstrual Cramping - Women with endometriosis experience
more severe cramping, which may begin well prior to actual menstruation.
- Painful Intercourse - Pain during sexual relations,
especially deep penetration, is common in women with endometriosis.
This pain may be midline or on the right or left side. It is sometimes
worse in midcycle or just before menses.
- Infertility - While endometriosis is present in
only 5-10 percent of reproductive aged women, it is found in up to 50%
of women who undergo diagnostic laparoscopy for infertility. Endometriosis
may lead to infertility through a variety of mechanisms. For example,
scar tissue from the disease process may cause tubal occlusion or inability
of the ovary to release eggs. Endometriomas, or 'chocolate cysts' of
the ovaries may also cause significant distortion of pelvic anatomy.
Studies of women with endometriosis have often shown other abnormalities
that may contribute to infertility. These include alterations in the
chemical and cellular composition of the pelvic environment, changes
in tubal and ovarian function, and other factors.
Diagnosis of Endometriosis
 Endometriosis
may be suspected based on a woman's physical exam and history of the above
symptoms. In addition, certain laboratory tests (such as serum CA-125
levels and endometrial aromatase activity) may give presumptive evidence
of this disease. The 'gold standard' for diagnosing endometriosis, however,
remains visual and pathologic confirmation at the time of laparoscopy
or laparotomy
Treatment
As with many gynecologic conditions, treatment may be
medical or surgical. Either alternative has conservative and aggressive
options, and its own unique advantages and disadvantages.
- Surgical Therapy: Discussion of treatment
should begin with surgical therapy, because a surgeon should always
be prepared to treat endometriosis completely at the time of the initial
(surgical) diagnosis. In the vast majority of cases, the surgeon should
be able to achieve this goal. See Reproductive
Surgery for specifics and caveats on surgical management.
Endometriotic lesions may be treated in a variety of ways, including
excision, laser vaporization, and electrocautery. However, not all methods
are appropriate for all patients. It is crucial for the surgeon to recognize
the many different appearances of endometriotic implants, and the fact
that the microscopic disease often extends beyond the visible lesions.
All disease must be removed or destroyed in order to minimize the risk
of recurrence. This is often very time consuming, but can usually be
accomplished through the laparoscope.
Scar tissue associated with endometriosis should be removed, not simply
cut. Endometriomas, or 'chocolate cysts', which are collections of blood
endometriosis within the ovaries, must also be removed by stripping
away the cyst wall. Lesser measures, such as simple drainage or cauterization
of the cyst wall, will almost always fail to resolve this problem.
Although many general gynecologists will treat this disease, we highly
recommend that you seek treatment from a subspecialty board certified
reproductive endocrinologist. Membership in the Society of Reproductive
Surgeons (an affiliate of the ASRM - see our Links
page) shows additional competence and interest in the field.
Perhaps most importantly, it is almost never necessary to perform a
hysterectomy in managing this disease for an infertile woman.
- Medical Therapy: Although we and others are
investigating the use of immunomodulators in the treatment of endometriosis,
hormonal therapies are still the principal agents used for medical management
of this disease.
Oral contraceptives have been used for years to treat the pain
associated with endometriosis. Although moderately effective, they do
not cause regression of the implants, and are obviously not appropriate
for infertile women.
Damazol, which is chemically similar to testosterone, was formerly
the 'gold standard' in medical management of endometriosis. Its use
is associated with acne, hair growth, and a risk of birth defects if
inadvertently given during pregnancy. Therefore, this medication is
infrequently used today.
GnRH analogs (Lupron, Synarel, etc.) are the new 'gold standard'
for medical treatment of endometriosis. These agents work by lowering
estrogen levels, thus causing regression of the endometrial implants.
They are very effective in reducing the volume of disease and symptoms
of pain. However, recurrences may occur more quickly after medical treatment
compared to surgical treatment. In addition, medications are not effective
in treating endometriomas (ovarian cysts caused by endometriosis) or
scar tissue.
Herbal and 'natural' therapies have not been studied in the treatment
of endometriosis and our own experience is that they may cause significant
menstrual irregularities. Therefore, they cannot be recommended at present.
Recurrent Disease
Endometriosis may recur, even if properly treated, and
even after a successful pregnancy. The recurrence rate approximates 15
percent per year, or 50 percent after 5 years.
Conclusions
Endometriosis is a common yet serious disease that impacts one's health and reproductive potential. Fortunately,
excellent therapy is available. It is rarely necessary to perform a hysterectomy in a woman who desires to retain her potential
fertility. Advice from a competent subspecialist should always be sought. Additional information may be obtained from our
office, or on the web at www.endmetriosisassn.org.
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