Endometriosis is a common gynecological condition that affects 7-10% of women in the general population, and is seen in 38-50% of infertile women, and in 71-87% of women with chronic pelvic pain.
Endometriosis Etiology (Causes)
Endometriosis occurs when the cells that normally line the uterus (endometrium) enter the body and attach to other organs. Endometrial cells have been seen in areas as distant as the lungs and brain, although they most commonly occur in the pelvic area. These endometrial implants can grow and damage the structures they are attached to thus leading to organ dysfunction. Endometriosis is often found on the Fallopian tubes and it can penetrate and obstruct these delicate structures.
Endometrial implants consist of both the following cell types:
- Endometrial gland cells- These cells are normally located in the uterine lining.
- Stromal cells- These are the framework cells that build supportive tissue.
These endometrial cells, which have receptors to both estrogen and progesterone, will become implanted in organs and structures outside of the uterus, where these hormonal activities continue to occur causing bleeding and scarring. These implants can be located in the peritoneum, ovaries, around the fallopian tubes, the gastrointestinal tract (12-37%), around the bladder (20%), and less commonly the vagina.
Endometrial implants vary widely in size, shape, and color. They may be colorless, red or very dark brown. These so called chocolate cysts are called endometriomas filled with thick, old, dark brown blood and are located inside the ovaries.
Monthly hormonal changes cause these implants to grow; when the endometrium sheds and bleeding occurs, so do they, producing inflammation and inviting pain-causing chemicals.
Many theories about the cause of endometriosis, focus on the possibility that endometriosis represents a state of an impaired immune system, which allows the endometrial implants to invade and proliferate. Biopsies of endometriosis will contain large levels of macrophages, which include cytokines and prostaglandins. These factors will produce inflammation and damage the surrounding tissues and cells.
Genetic Link to Endometriosis
There is a 10 fold increase in the incidence of endometriosis in women who have a mother or a sister with this disorder.
Many women may not have any symptoms. When symptoms are present the most common ones include:
- Severe cramps during menstruation, also called dysmenorrhea
- Pelvic pain can occur at any time and may last for 6 months or more and can radiate to the lower back.
- Pain during, or after intercourse, or when inserting and removing tampons
- Pain is associated with urination or bower movements
- Heavy menstruation
- Bleeding or spotting between periods, or for several days prior to the menstrual flow
- Infertility- endometriosis is the third most common cause of infertility, affecting about three to four out of 10 women with endometriosis.
- Associated symptoms include nausea, fatigue, bloating, dizziness, headaches, joint and muscle aches, depression, sleep problems
- Endometriosis and Infertility
- Several theories as to how endometriosis affects fertility include:
- Endometrial implants may affect the fallopian tubes blocking the passage of the egg
- Implants in the ovaries can prevent the release of an egg
- Endometriosis can cause adhesions to form between the uterus and ovaries, and the fallopian tubes, thus preventing ovulation
- Endometriosis can lead to decreased egg quality causing diminished ovarian reserve
- The inflammatory cytokines produced by endometriosis create a hostile environment to sperm, fertilization and implantation
The physician may be able to feel nodules around the ligaments holding the uterus. These may often cause tenderness when palpated.
A pelvic ultrasound is sometimes helpful in the diagnosis of endometriosis if an ovarian endometrioma is detected.
The laparoscopy is the only definitive method used to diagnose endometriosis. This procedure requires general anesthesia. The surgeon makes a small incision in the umbilicus and lower pelvis and carbon dioxide is injected to distend the abdomen. Then a small camera is inserted to view the uterus, tubes and ovaries.
During laparoscopy, the surgeon will determine the stage of endometriosis based upon the size, number, and location of endometriosis.
- Minimal (stage I)
- Mild (stage II)
- Moderate (stage III)
- Severe ( stage IV)
Hormonal therapy- these include oral contraceptives, GnRH agonists, and progestin. They may be given continuously in order to diminish the menstrual cycle.
Danazol- this drug “tells” the brain to stop signaling the ovaries to release an egg, thus shutting down the menstrual cycle and thinning the endometrium and implants. This medication will reduce the menstrual cycle but male hormone like side effects of oily skin, acne, weight gain, and deepening of the voice make this drug a second choice.
GnRH- This medication, given as a nasal spray or an injection, causes a temporary menopause-like state. The uterine lining will thin and menstruation will typically cease. The treatment is used for 3-6 months and when stopped, symptoms may return.
Treating Infertility in Patients with Endometriosis
In women with mild to stage I to II endometriosis, ovulation induction using Clomid, letrozole orgonadotropins in combination with intrauterine insemination (IUI) may be sufficient to induce pregnancy.
Nonsteroidal Anti-inflammatory Drugs- pain killers like ibuprofen, naproxen, or mefenamic acid (Ponstel) could be sufficient for 75% of patients. They are more effective if they are taken 7-10 days prior to the expected menses.
Other Tips for Endometriosis Patients
Women with endometriosis should avoid alcohol caffeine and chocolate. These may contribute to higher levels of estrogen and exacerbate symptoms of endometriosis.
Omega-3 fatty acids, found in fatty fish like sardines and mackerel, can be obtained through purified supplements and are also known as DHA and EPA. These fatty acids have been shown to have anti inflammatory effects and may be helpful in the treatment of endometriosis.
For women with moderate to severe endometriosis conservative surgery (laparoscopy) may be helpful in restoring fertility. The use of GnRH post laparoscopy seems to only delay conception and may not be beneficial in improving pregnancy rates.
Side Effects of Endometriosis Treatment
Hot flashes, vaginal dryness, headaches, sleep problems, and fatigue. Low doses of estrogen or progesterone are given in conjunction with GnRH to prevent those side effects.
Endometriosis and IVF
Several studies have shown that In Vitro Fertilization (IVF) is the superior infertility treatment for women with endometriosis since it bypasses the women’s fallopian tubes and the inflammatory environment induced by endometriosis. IVF success rates are almost equal that of other etiologies like tubal or male factor.