Pathophysiology: Endometriosis (en-doe-me-tree-O-sis) is an often painful disorder in which tissue that normally lines the inside of your uterus — the endometrium — grows outside your uterus (endometrial implant). Endometriosis most commonly involves your ovaries, bowel or the tissue lining your pelvis. Rarely, endometrial tissue may spread beyond your pelvic region. Common signs and symptoms of endometriosis may include: • Painful periods (dysmenorrhea). Pelvic pain and cramping may begin before and extend several days into your period and may include lower back and abdominal pain. • Pain with intercourse. Pain during or after sex is common with endometriosis. • Pain with bowel movements or urination. You're most likely to experience these symptoms during your period. • Excessive bleeding. You may experience occasional heavy periods (menorrhagia) or bleeding between periods (menometrorrhagia). • Infertility. Endometriosis is first diagnosed in some women who are seeking treatment for infertility. • Other symptoms. You may also experience fatigue, diarrhea, constipation, bloating or nausea, especially during menstrual periods. Statistics: Endometriosis is an estrogen-dependent disease and, thus, usually affects reproductive-aged women. This condition has a prevalence rate of 20-50% in infertile women, but it can be as high as 80% in women with chronic pelvic pain. In a large series involving adolescent females with chronic pelvic pain, 45% were found to have endometriosis at laparoscopy. Of note, only 25% had a normal pelvis. In that series, the rate of endometriosis was found to increase with age from 12% in females aged 11-13 years to 45% in females aged 20-21 years. In an earlier study, evidence of endometriosis was found during laparoscopy in 20-50% of asymptomatic women. A familial association exists, with a 10-fold increased incidence in women with an affected first-degree relative. Monozygotic twins are markedly concordant for endometriosis.
Treatment: An over-the-counter pain reliever, such as the nonsteroidal anti-inflammatory drugs (NSAIDs) ibuprofen (Advil, Motrin IB, others) or naproxen (Aleve, others), to help ease painful menstrual cramps. However, if you find that taking the maximum dose doesn't provide full relief, you may need to try another approach to manage your signs and symptoms. Hormone therapy Supplemental hormones are sometimes effective in reducing or eliminating the pain of endometriosis. That's because the rise and fall of hormones during the menstrual cycle causes endometrial implants to thicken, break down and bleed. Hormone medication may slow the growth and prevent new implants of endometrial tissue. However, hormonal therapy isn't a permanent fix for endometriosis. It's possible that you could experience a recurrence of your symptoms after stopping treatment. Hormonal therapies used to treat endometriosis include: • Hormonal contraceptives. Birth control pills, patches and vaginal rings help control the hormones responsible for the buildup of endometrial tissue each month. Most women have lighter and shorter menstrual flow when they're using a hormonal contraceptive. Using hormonal contraceptives — especially continuous cycle regimens — may reduce or eliminate the pain of mild to moderate endometriosis. • Gonadotropin-releasing hormone (Gn-RH) agonists and antagonists. These drugs block the production of ovarian-stimulating hormones, lowering estrogen levels and preventing menstruation. This causes endometrial tissue to shrink. Gn-RH agonists and antagonists can force endometriosis into remission during the time of treatment and sometimes for months or years afterward. Because these drugs create an artificial menopause, taking a low dose of estrogen or progestin along with Gn-RH agonists and antagonists may decrease menopausal side effects, such as hot flashes, vaginal dryness and bone loss. Your periods and the ability to get pregnant return when the medication is stopped. • Medroxyprogesterone (Depo-Provera). This injectable drug is effective in halting menstruation and the growth of endometrial implants, thereby relieving the signs and symptoms of endometriosis. Its side effects can include weight gain, decreased bone production and depressed mood, among others. • Danazol. This drug suppresses the growth of the endometrium by blocking the production of ovarian-stimulating hormones, preventing menstruation and the symptoms of endometriosis. However, danazol may not be the first choice because it can cause serious side effects and can be harmful to the baby if you become pregnant while taking this medication. Conservative surgery If you have endometriosis and are trying to become pregnant, surgery to remove as much endometriosis as possible while preserving your uterus and ovaries (conservative surgery) may increase your chances of success. If you have severe pain from endometriosis, you may also benefit from surgery — however, endometriosis and pain may return
Your doctor may do this procedure laparoscopically or through traditional abdominal surgery in more extensive cases. In laparoscopic surgery, your surgeon inserts a slender viewing instrument (laparoscope) through a small incision near your navel and inserts instruments to remove endometrial tissue through another small incision. Assisted reproductive technologies Assisted reproductive technologies, such as in vitro fertilization, to help you become pregnant are sometimes preferable to conservative surgery. Doctors often suggest one of these approaches if conservative surgery is ineffective. In severe cases of endometriosis, surgery to remove the uterus and cervix (total hysterectomy) as well as both ovaries may be the best treatment. Hysterectomy alone is not effective — the estrogen your ovaries produce can stimulate any remaining endometriosis and cause pain to persist. Hysterectomy is typically considered a last resort, especially for women still in their reproductive years. You can't get pregnant after a hysterectomy. Finding a doctor with whom you feel comfortable is crucial in managing and treating endometriosis