Endometriosis

Some women with endometriosis have few or no symptoms while others have pain or difficulty becoming pregnant.
There is no cure for endometriosis, but there are several treatment options. The best treatment depends on your individual situation.

How common is endometriosis ?

Overall, the prevalence of endometriosis is not known because it requires an operation to diagnose it. Many women have either no symptoms or very mild symptoms which do not warrant an operation.
Endometriosis has been found to be present in the following groups of women

• 1 percent of women undergoing major surgery for any gynecologic indication
• 1 to 7 percent of women undergoing tubal sterilization
• 12 to 32 percent of women of reproductive age undergoing laparoscopy to determine the cause of pelvic pain
• 9 to 50 percent of women undergoing laparoscopy for infertility versus 6.7 percent of women undergoing laparoscopy with no past infertility.
• 50 percent of teenagers undergoing laparoscopy for evaluation of chronic pelvic pain or dysmenorrhea

What Causes Endometriosis?

The cause of endometriosis is not known. A common theory is that some menstrual blood and endometrium flows backwards through the fallopian tubes and into the pelvis during a period. This tissue then grows where it lands in the pelvis. This is called the retrograde (backwards) menstruation theory. There are also several other theories.

How does Endometriosis cause problems?

Endometriosis implants respond to changes in estrogen. The implants may grow and bleed like the uterine lining does during the menstrual cycle. Surrounding tissue can become irritated, inflamed, and swollen. The breakdown and bleeding of this tissue each month also can cause scar tissue, called adhesions, to form. Sometimes adhesions can cause organs to stick together. The bleeding, inflammation, and scarring can cause pain, especially before and during menstruation.

What are the symptoms of Endometriosis?

Some women with endometriosis have no symptoms. The most common symptom is pelvic pain, especially with periods.

Pain may occur
Just before or during your period
Between periods, with worsened pain during the period
During or after sex
With bowel movements or while urinating, especially during your period
Pelvic pain can also be caused by many other conditions, such as pelvic infections, bladder conditions and irritable bowel syndrome. Often women with endometriosis have more than one condition contributing to their pain.

Some women with endometriosis have no symptoms. The most common symptom is pelvic pain, especially with periods.

How is Endometriosis diagnosed?

Your doctor might suspect that you have endometriosis based on your symptoms of pelvic pain or painful periods. However, the only way to know for sure if you have endometriosis is to have surgery.

This is usually a laparoscopy or ‘keyhole’ surgery. Sometimes a small amount of tissue is removed during the procedure to confirm the diagnosis. This is called a biopsy.
Endometriosis is considered mild, moderate, or severe depending on what is found during surgery. The severity of endometriosis is difficult to predict based on symptoms alone. Women with mild disease can have severe symptoms, and women with severe disease can have mild symptoms.

What Problems can I expect from Endometriosis?

Apart from pain endometriosis can cause:

Difficulty falling pregnant

Endometriosis can make it more difficult to become pregnant. This might occur because endometriosis causes scar tissue to develop, which can damage the ovaries or fallopian tubes. However, even women with endometriosis who do not have scar tissue can have difficulty becoming pregnant.

In women who become pregnant, endometriosis does not harm the pregnancy. Symptoms of endometriosis may improve after pregnancy. However pregnancy has not been shown to prevent the progression of endometriosis disease in the pelvis.

Ovarian cysts (Endometriomas)

Women with endometriosis can develop ovarian cysts containing endometriosis; these are called endometriomas. Endometriomas are usually filled with old blood that resembles chocolate syrup; thus, they are sometimes called chocolate cysts. Endometriomas are sometimes seen during a pelvic ultrasound or felt during a pelvic exam.

Most women with endometriomas will also have endometriosis elsewhere in their pelvis.

How is endometriosis treated?

Treatment for endometriosis depends on the extent of the disease, your symptoms, and whether you want to have children.

Endometriosis may be treated with medication, surgery, or both. Treatments include

• Nonsteroidal antiinflammatory drugs
• Hormonal birth control and progestogens such as Visanne.
• Other forms of hormone treatment (gonadotropin releasing hormone agonists)
  Surgery

When pain is the primary problem, medication is often tried first.
If treatment does not improve your pain within three to six months, surgery is a reasonable next step.

In other cases, surgery is performed to diagnose endometriosis and remove it before you take any medicine.

The best treatment depends on your symptoms, age, future plans to become pregnant.
Medical treatment

Nonsteroidal antiinflammatory drugs (NSAIDs)

NSAIDs are a type of pain medicine that can help to relieve the pain caused by endometriosis. The medicine works by stopping the release of prostaglandins, one of the main chemicals responsible for painful menstrual periods. NSAIDs do not shrink or prevent the growth of endometriosis.

Most NSAIDs are available over the counter including:

• Ibuprofen
• Naproxen sodium sold as Naprosyn, and store brands

NSAIDs do not always relieve endometriosis related pain. Serious side effects from NSAIDs, although uncommon, include stomach upset, kidney problems, and worsened high blood pressure. So be sure to follow the instructions closely.

Hormonal birth control treatments
Hormonal birth control, including the combined pill, injectable, implantable and intra-uterine progestins (IUD) are often helpful in treating pain because they reduce heavy bleeding. Hormonal birth control works best in women who do not have severe pain.

Combined oral contraceptive pill (containing both oestrogen and progestins)
Women with endometriosis taking the pill are often advised to skip their periods and take hormone containing pills continuously for 3 or more months. This allows you to have fewer periods and have less pain and bleeding during each period. Because the combined oral contraceptive pill contains oestrogen it probably does not prevent the progression of endometriosis, but it does improve painful periods. On stopping the pill the endometriosis pain is often worse than before.

The most common side effects of hormonal birth control are:

• Nausea
• Breast tenderness
• Irregular vaginal bleeding or spotting

These side effects usually improve after using the treatment for several months.

Progestins

Progestins are a synthetic form of a natural hormone called progesterone. This treatment might be recommended for women who do not get pain relief from or who cannot take hormonal birth control that contains estrogen (such as smokers). Progestins are available by prescription and usually given as a pill, implant, IUD or injection.

Side effects of progestins can be bothersome for some women. The most common side effects include: bloating, weight gain, irregular vaginal bleeding, and significantly worsened anxiety and depression.

Gonadotropin releasing hormone agonists

Gonadotropin releasing hormone (GnRH) agonists are medicines that work by causing a temporary menopause. They are not commonly used in endometriosis treatment because they can only be taken for a short period of time, they cause menopausal side-effects and they are expensive. Most endometriosis requires longer term treatment. The treatment causes the ovaries to stop producing estrogen, which causes the endometriosis implants to shrink.
No hormonal treatment can be used if you are trying to fall pregnant.

Surgical treatments
Surgery may be performed if you:
Have severe pain
Have tried medicines but still have bothersome pain
Have a cyst or mass in the pelvic area.
Are having trouble getting pregnant and endometriosis might be the cause.

Laparoscopy is most commonly used to diagnose and treat endometriosis. The goal of surgery is to remove endometriosis implants and scar tissue. More than 80 percent of women who have surgery have less pain for several months after surgery. There is a chance that the pain will come back.

What if I still have severe pain that does not go away even after I have had treatment ?

If pain is severe and does not go away after treatment and you do not want to become pregnant in the future, your doctor may discuss a hysterectomy and removal of your ovaries with you. It is uncommon to require this treatment.