Endometriosis is a gynecological condition in which cells from the lining of the uterus (endometrium) appear and flourish outside the uterine cavity, most commonly on the membrane which lines the abdominal cavity, the peritoneum. The uterine cavity is lined with endometrial cells, which are under the influence of female hormones. Endometrial cells in areas outside the uterus are also influenced by hormonal changes and respond in a way that is similar to the cells found inside the uterus. Symptoms of endometriosis are pain and infertility. The pain often is worse with the menstrual cycle and is the most common cause of secondary dysmenorrhea. Endometriosis was first identified by Baron Carl von Rokitansky in 1860. In simple terms, Endometriosis is a condition in which the tissue that lines the uterus is also found outside the uterine cavity, which can cause pelvic pain and infertility.
Epidemiology:
Endometriosis is typically seen during the reproductive years; it has been estimated that endometriosis occurs in roughly 6–10% of women. Symptoms may depend on the site of active endometriosis. Its main but not universal symptom is pelvic pain in various manifestations. Endometriosis is a common finding in women with infertility.Endometriosis has a significant social and psychological impact.
Causes
Every month, a woman's ovaries produce hormones that tell the cells lining the uterus to swell and get thicker. Your uterus sheds these cells along with blood and tissue through your vagina when you have your period.
Endometriosis occurs when these cells grow outside the uterus in other parts of your body. This tissue may attach on your:
-Ovaries
-Bowel
-Rectum
-Bladder
-Lining of your pelvic area.
It can grow in other areas of the body, too.
These growths stay in your body--they do not shed when you have your period. But, like the cells in your uterus, these growths react to the hormones from your ovaries. They grow and bleed when you get your period. Over time, the growths may add more tissue and blood. The buildup of blood and tissue in your body leads to pain and other symptoms.
No one knows what causes endometriosis. One idea is that when you get your period, the cells may travel backwards through the fallopian tubes into the pelvis. Once there, the cells attach and grow. However, this backward period flow occurs in many women. Researchers think that the immune system in women with endometriosis may cause the condition.
Endometriosis is common. Sometimes, it may run in families. Endometriosis probably starts when a woman begins having periods. However, it usually isn't diagnosed until ages 25 - 35.
You are more likely to develop endometriosis if you:
-Have a mother or sister with endometriosis
-Started your period at a young age
-Never had children
-Have frequent periods or they last 7 or more days
-Have a closed hymen, which blocks the flow of menstrual blood during the period
symptoms
-Pain is the main symptom of endometriosis. You may have:
-Painful periods
-Pain in your lower belly before and during your period
-Cramps for a week or two before and during your period. Cramps may be steady and range from dull to severe.
-Pain during or following sexual intercourse
-Pain with bowel movements
-Pelvic or low back pain that may occur at any time.
You may not have any symptoms. Some women with a lot of tissue in their pelvis have no pain at all, while some women with milder disease have severe pain.
How Endometriosis is diagnosed.
Endometriosis can be suspected based on symptoms of pelvic pain and findings during physical examinations in the doctor's office. Occasionally, during a rectovaginal exam (one finger in the vagina and one finger in the rectum), the doctor can feel nodules (endometrial implants) behind the uterus and along the ligaments that attach to the pelvic wall. At other times, no nodules are felt, but the examination itself causes unusual pain or discomfort.
Unfortunately, neither the symptoms nor the physical examinations can be relied upon to conclusively establish the diagnosis of endometriosis. Imaging studies, such as ultrasound, can be helpful in ruling out other pelvic diseases and may suggest the presence of endometriosis in the vaginal and bladder areas, but still cannot definitively diagnose endometriosis. For an accurate diagnosis, a direct visual inspection inside of the pelvis and abdomen, as well as tissue biopsy of the implants are necessary.
As a result, the only accurate way of diagnosing endometriosis is at the time of surgery, either by opening the belly with large-incision laparotomy or small-incision laparoscopy.
Laparoscopy is the most common surgical procedure for the diagnosis of endometriosis. Laparoscopy is a minor surgical procedure done under general anesthesia, or in some cases under local anesthesia. It is usually performed as an out-patient procedure (the patient going home the same day). Laparoscopy is performed by first inflating the abdomen with carbon dioxide through a small incision in the navel. A long, thin viewing instrument (laparoscope) is then inserted into the inflated abdominal cavity to inspect the abdomen and pelvis. Endometrial implants can then be directly seen.
During laparoscopy, biopsies (removal of tiny tissue samples for examination under a microscope) can also be performed for a diagnosis. Sometimes biopsies obtained during laparoscopy show endometriosis even though no endometrial implants are seen during laparoscopy.
Pelvic ultrasound and laparoscopy are also important in excluding malignancies (such as ovarian cancer) that can cause symptoms that mimic endometriosis symptoms.
Treatment
What type of treatment you have depends on:
;Your age
;Severity of your symptoms
;Severity of the disease
;Whether you want children in the future
There are different treatment options.
PAIN RELIEVERS
1. If you have mild symptoms, you may be able to manage cramping and pain with:
2. Exercise and relaxation techniques
3. Over-the-counter pain relievers. These include ibuprofen (Advil), naproxen (Aleve), and acetaminophen (Tylenol).
4. Prescription painkillers, if needed, for more severe pain
5. Regular exams every 6 - 12 months so your doctor can make sure the disease is not getting worse
HORMONE THERAPY
These medicines can stop endometriosis from getting worse. They may be given as pills, nasal spray, or shots. Only women who are not trying get pregnant should have this therapy. Hormone therapy will prevent you from getting pregnant. Once you stop therapy, you can get pregnant again.
Birth control pills. With this therapy, you take pills for 6 - 9 months without stopping. Taking these pills relieves most symptoms. However, it does not prevent scarring or treat any damage that has already occurred.
Progesterone pills or injections. This treatment helps shrink growths. However, side effects can include weight gain and depression.
Gonadotropin-agonist medications. These medicines stop your ovaries from producing the hormone estrogen. This causes a menopause-like state. Side effects include hot flashes, vaginal dryness, and mood changes. Treatment is usually limited to 6 months because it can weaken your bones.
SURGERY
Your doctor may recommend surgery if you have severe pain that does not get better with other treatments.
1. Laparoscopy helps diagnose the disease and can also remove growths and scar tissue. Because only a small cut is made in your belly, you will heal faster than other types of surgery.
2. Laparotomy involves making a large incision (cut) in your belly to remove growths and scar tissue. This is major surgery, so healing takes longer.
3. Laparoscopy or laparotomy may be a good option if you want to become pregnant, because they treat the disease and leave your organs in place.
4. Hysterectomy is surgery to remove your uterus, fallopian tubes, and ovaries. If your ovaries are not removed, symptoms may return. You would only have this surgery if you have severe symptoms and do not want to have children in the future.
Prognosis
Proper counseling of patients with endometriosis requires attention to several aspects of the disorder. Of primary importance is the initial operative staging of the disease to obtain adequate information on which to base future decisions about therapy. The patient's symptoms and desire for childbearing dictate appropriate therapy. Not all therapy works for all patients. Some patients have recurrences after surgery or pseudo-menopause. In most cases, treatment will give patients significant relief from pelvic pain and assist them in achieving pregnancy.
The underlying process that causes endometriosis may not cease after surgical or medical intervention. Studies have shown that endometriosis recurs at a rate of 20 to 40 percent within five years following conservative surgery,unless hysterectomy is performed or menopause reached. Monitoring of patients consists of periodic clinical examinations and sonography.
Vaginal childbirth decreases recurrence of endometriosis. In contrast, endometriosis recurrence rates have been shown to be higher in women who have not given birth vaginally, such as in Cesarean section.
Hormone therapy and laparoscopy cannot cure endometriosis. However, in some women, these treatments may help relieve symptoms for years.
Removal of the uterus, fallopian tubes, and both ovaries (a hysterectomy) gives you the best chance for a cure.
Possible Complications
Endometriosis can lead to problems getting pregnant. However, most women with mild symptoms can still get pregnant. Laparoscopy to remove growths and scar tissue may help improve your chances of becoming pregnant. If it does not, you may want to consider fertility treatments.
Other complications of endometriosis include:
•
Long-term pelvic pain that interferes with social and work activities
•
Large cysts in the pelvis that may break open (rupture)
In rare cases, endometriosis tissue may block the intestines or urinary tract.
Very rarely, cancer may develop in the areas of tissue growth after menopause.
Endometriosis and cancer risk
Women with endometriosis have an increased risk for development of certain types of cancer of the ovary, known as epithelial ovarian cancer (EOC), according to some research studies. This risk is highest in women with endometriosis and primary infertility (those who have never borne a child), but the use of oral contraceptive pills (OCPs), which are sometimes used in the treatment of endometriosis, appears to significantly reduce this risk.
The reasons for the association between endometriosis and ovarian epithelial cancer are not clearly understood. One theory is that the endometriosis implants themselves undergo transformation to cancer. Another possibility is that the presence of endometriosis may be related to other genetic or environmental factors that also increase a women's risk of developing ovarian cancer.
Prevention
Birth control pills may help to prevent or slow down the development of the endometriosis.
Epidemiology:
Endometriosis is typically seen during the reproductive years; it has been estimated that endometriosis occurs in roughly 6–10% of women. Symptoms may depend on the site of active endometriosis. Its main but not universal symptom is pelvic pain in various manifestations. Endometriosis is a common finding in women with infertility.Endometriosis has a significant social and psychological impact.
Causes
Every month, a woman's ovaries produce hormones that tell the cells lining the uterus to swell and get thicker. Your uterus sheds these cells along with blood and tissue through your vagina when you have your period.
Endometriosis occurs when these cells grow outside the uterus in other parts of your body. This tissue may attach on your:
-Ovaries
-Bowel
-Rectum
-Bladder
-Lining of your pelvic area.
It can grow in other areas of the body, too.
These growths stay in your body--they do not shed when you have your period. But, like the cells in your uterus, these growths react to the hormones from your ovaries. They grow and bleed when you get your period. Over time, the growths may add more tissue and blood. The buildup of blood and tissue in your body leads to pain and other symptoms.
No one knows what causes endometriosis. One idea is that when you get your period, the cells may travel backwards through the fallopian tubes into the pelvis. Once there, the cells attach and grow. However, this backward period flow occurs in many women. Researchers think that the immune system in women with endometriosis may cause the condition.
Endometriosis is common. Sometimes, it may run in families. Endometriosis probably starts when a woman begins having periods. However, it usually isn't diagnosed until ages 25 - 35.
You are more likely to develop endometriosis if you:
-Have a mother or sister with endometriosis
-Started your period at a young age
-Never had children
-Have frequent periods or they last 7 or more days
-Have a closed hymen, which blocks the flow of menstrual blood during the period
symptoms
-Pain is the main symptom of endometriosis. You may have:
-Painful periods
-Pain in your lower belly before and during your period
-Cramps for a week or two before and during your period. Cramps may be steady and range from dull to severe.
-Pain during or following sexual intercourse
-Pain with bowel movements
-Pelvic or low back pain that may occur at any time.
You may not have any symptoms. Some women with a lot of tissue in their pelvis have no pain at all, while some women with milder disease have severe pain.
How Endometriosis is diagnosed.
Endometriosis can be suspected based on symptoms of pelvic pain and findings during physical examinations in the doctor's office. Occasionally, during a rectovaginal exam (one finger in the vagina and one finger in the rectum), the doctor can feel nodules (endometrial implants) behind the uterus and along the ligaments that attach to the pelvic wall. At other times, no nodules are felt, but the examination itself causes unusual pain or discomfort.
Unfortunately, neither the symptoms nor the physical examinations can be relied upon to conclusively establish the diagnosis of endometriosis. Imaging studies, such as ultrasound, can be helpful in ruling out other pelvic diseases and may suggest the presence of endometriosis in the vaginal and bladder areas, but still cannot definitively diagnose endometriosis. For an accurate diagnosis, a direct visual inspection inside of the pelvis and abdomen, as well as tissue biopsy of the implants are necessary.
As a result, the only accurate way of diagnosing endometriosis is at the time of surgery, either by opening the belly with large-incision laparotomy or small-incision laparoscopy.
Laparoscopy is the most common surgical procedure for the diagnosis of endometriosis. Laparoscopy is a minor surgical procedure done under general anesthesia, or in some cases under local anesthesia. It is usually performed as an out-patient procedure (the patient going home the same day). Laparoscopy is performed by first inflating the abdomen with carbon dioxide through a small incision in the navel. A long, thin viewing instrument (laparoscope) is then inserted into the inflated abdominal cavity to inspect the abdomen and pelvis. Endometrial implants can then be directly seen.
During laparoscopy, biopsies (removal of tiny tissue samples for examination under a microscope) can also be performed for a diagnosis. Sometimes biopsies obtained during laparoscopy show endometriosis even though no endometrial implants are seen during laparoscopy.
Pelvic ultrasound and laparoscopy are also important in excluding malignancies (such as ovarian cancer) that can cause symptoms that mimic endometriosis symptoms.
Treatment
What type of treatment you have depends on:
;Your age
;Severity of your symptoms
;Severity of the disease
;Whether you want children in the future
There are different treatment options.
PAIN RELIEVERS
1. If you have mild symptoms, you may be able to manage cramping and pain with:
2. Exercise and relaxation techniques
3. Over-the-counter pain relievers. These include ibuprofen (Advil), naproxen (Aleve), and acetaminophen (Tylenol).
4. Prescription painkillers, if needed, for more severe pain
5. Regular exams every 6 - 12 months so your doctor can make sure the disease is not getting worse
HORMONE THERAPY
These medicines can stop endometriosis from getting worse. They may be given as pills, nasal spray, or shots. Only women who are not trying get pregnant should have this therapy. Hormone therapy will prevent you from getting pregnant. Once you stop therapy, you can get pregnant again.
Birth control pills. With this therapy, you take pills for 6 - 9 months without stopping. Taking these pills relieves most symptoms. However, it does not prevent scarring or treat any damage that has already occurred.
Progesterone pills or injections. This treatment helps shrink growths. However, side effects can include weight gain and depression.
Gonadotropin-agonist medications. These medicines stop your ovaries from producing the hormone estrogen. This causes a menopause-like state. Side effects include hot flashes, vaginal dryness, and mood changes. Treatment is usually limited to 6 months because it can weaken your bones.
SURGERY
Your doctor may recommend surgery if you have severe pain that does not get better with other treatments.
1. Laparoscopy helps diagnose the disease and can also remove growths and scar tissue. Because only a small cut is made in your belly, you will heal faster than other types of surgery.
2. Laparotomy involves making a large incision (cut) in your belly to remove growths and scar tissue. This is major surgery, so healing takes longer.
3. Laparoscopy or laparotomy may be a good option if you want to become pregnant, because they treat the disease and leave your organs in place.
4. Hysterectomy is surgery to remove your uterus, fallopian tubes, and ovaries. If your ovaries are not removed, symptoms may return. You would only have this surgery if you have severe symptoms and do not want to have children in the future.
Prognosis
Proper counseling of patients with endometriosis requires attention to several aspects of the disorder. Of primary importance is the initial operative staging of the disease to obtain adequate information on which to base future decisions about therapy. The patient's symptoms and desire for childbearing dictate appropriate therapy. Not all therapy works for all patients. Some patients have recurrences after surgery or pseudo-menopause. In most cases, treatment will give patients significant relief from pelvic pain and assist them in achieving pregnancy.
The underlying process that causes endometriosis may not cease after surgical or medical intervention. Studies have shown that endometriosis recurs at a rate of 20 to 40 percent within five years following conservative surgery,unless hysterectomy is performed or menopause reached. Monitoring of patients consists of periodic clinical examinations and sonography.
Vaginal childbirth decreases recurrence of endometriosis. In contrast, endometriosis recurrence rates have been shown to be higher in women who have not given birth vaginally, such as in Cesarean section.
Hormone therapy and laparoscopy cannot cure endometriosis. However, in some women, these treatments may help relieve symptoms for years.
Removal of the uterus, fallopian tubes, and both ovaries (a hysterectomy) gives you the best chance for a cure.
Possible Complications
Endometriosis can lead to problems getting pregnant. However, most women with mild symptoms can still get pregnant. Laparoscopy to remove growths and scar tissue may help improve your chances of becoming pregnant. If it does not, you may want to consider fertility treatments.
Other complications of endometriosis include:
•
Long-term pelvic pain that interferes with social and work activities
•
Large cysts in the pelvis that may break open (rupture)
In rare cases, endometriosis tissue may block the intestines or urinary tract.
Very rarely, cancer may develop in the areas of tissue growth after menopause.
Endometriosis and cancer risk
Women with endometriosis have an increased risk for development of certain types of cancer of the ovary, known as epithelial ovarian cancer (EOC), according to some research studies. This risk is highest in women with endometriosis and primary infertility (those who have never borne a child), but the use of oral contraceptive pills (OCPs), which are sometimes used in the treatment of endometriosis, appears to significantly reduce this risk.
The reasons for the association between endometriosis and ovarian epithelial cancer are not clearly understood. One theory is that the endometriosis implants themselves undergo transformation to cancer. Another possibility is that the presence of endometriosis may be related to other genetic or environmental factors that also increase a women's risk of developing ovarian cancer.
Prevention
Birth control pills may help to prevent or slow down the development of the endometriosis.
