Frequently Asked Questions - Gynecology

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Endometrios is is a common cause of pelvic pain that strikes 10-20% of American women. Normally, during the menstrual cycle tissue builds up and breaks down within the uterus. In endometriosis, endometrial tissue (tissue from the lining of the uterus) is found outside the uterus. During the menstrual cycle this tissue builds up and breaks down in the same way but there is no way for it to leave the body. The implants bleed internally, causing irritation, inflammation, and scarring.

Women with endometriosis have symptoms ranging from mild to severe, although some women have no symptoms at all. Symptoms can include menstrual cramps, pain during sex, low back pain, constipation, pain with bowel movements, and infertility. Some women have chronic pelvic pain.

Symptoms are usually at their peak just prior to and with the menstrual period. Symptoms are not indicative of the severity of the endometriosis. A woman with severe pain may have minimal disease, while a woman with severe disease may have no symptoms.

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What Causes Endometriosis? There is no simple explanation for endometriosis. One school of thought is that it is caused by "retrograde menstruation", meaning the flow during the menstrual period backs up into the fallopian tubes. This flow carries endometrial tissue that attaches to the ovaries, uterus, and other organs. This theory though, does not explain why women who have had a tubal ligation continue to develop endometriosis. Only one in ten women with known retrograde menstruation develops endometriosis.

Another idea is that all the tissues where endometriosis is found develop from the same part of the embryo. It is thought that the irritation of wandering menstrual blood causes these tissues to change into functioning endometrial tissue. There is no conclusive evidence, though, that tissues from a common embryonic source can change this way.

Another suggestion is the "immune defect" theory. This theory is based on the high levels of certain antibodies in the blood of endometriosis patients and the fact that women with close relatives with the disease are at greater risk. These women may have an immune reaction against their own tissues. Research into this theory is ongoing.

How is it diagnosed? A pelvic exam is the first step. The doctor will examine your cervix and vagina, along with feeling for any lumps or tender points on the uterus, fallopian tubes, and ovaries. Sometimes the endometrial implants can be felt upon examination (but not always).

When your medical history and exam suggest endometriosis as a possibility, a laparoscopy may be offered to diagnose endometriosis. This surgical procedure allows the doctor to see the internal pelvic structures directly.

Laparoscopy is a simple, outpatient procedure. A thin, lighted tube is inserted into a small incision in the navel, allowing the physician to view the organs on a television screen. The physician can note the location, size, and extent of any endometrial implant.

What treatment is available? Endometriosis is a chronic condition with no real cure. There are many factors to consider when you and the doctor choose a treatment method. One factor is whether to preserve fertility – do you want to become pregnant, either now or in the future? Another factor is the severity of your symptoms. Endometriosis can be treated with medication, surgery, or a combination of both.

What drugs are available? Hormones may help slow the growth of the endometrial implants. They do not, though, reduce adhesions (scar tissue) that cause pain. The most commonly used hormones are birth control pills, progestins, gonadotropin-releasing hormone (GnRH) agonists and Danazol.

Birth Control Pills - the hormones in birth control pills keep the menstrual flow lighter and shorter, which can help relieve pain.
Progestin - Progestin is used to shrink endometrial implants. It works against the effects of estrogen on the endometriosis. You probably won't have a period while on the medication.
Gonadotropin-releasing hormone (GnRH) agonists - This medication causes a pseudo-menopausal state. It shuts down the ovaries, without surgically removing them. It does this by overloading the pituitary so FSH and LH are not produced. This pseudo-menopausal state stops the growth of endometrial tissue (inside and outside the uterus) and reduces the pain of endometriosis. The side effects, though, are the symptoms of menopause - hot flashes, headaches, and vaginal dryness. There is also an increased risk of osteoporosis. Treatment usually does not last for more than six months without the addition of estrogen or bone density monitoring. The side effects abate when treatment is discontinued.
Danazol - Danazol is a synthetic hormone that also reduces the pituitary's production of the hormones FSH (follicle stimulating hormone) and LH (lutenizing hormone). Like the GnRH agonists, Danazol causes a pseudo menopausal state. The endometrial implants shrink and pain is reduced. Treatment can last from 3 to 9 months. Side effects include hair, skin, mood, voice, and sex drive change. Some women complain of weight gain, bloating, and vaginal dryness.

What about surgery? Excision is now the recommended method to remove endometriosis implants and the scar tissue associated with it. In most cases this procedure can be successfully completed with a laparoscope.

A laparotomy, which involves opening up the abdominal cavity, is sometimes required for more widespread disease that can't be reached through the tiny incision used in the laparoscopy.

If you plan to have no more children, complete hysterectomy may be the final surgical approach. If the disease is seriously affecting your health and lifestyle, you may wish for a definitive treatment.