Endometriosis

The Southeastern Center for Reproductive Surgery specializes in surgical and medical treatments of endometriosis. Our endometriosis specialists have extensive experience and knowledge of this disease as a result of our research, as well as treating thousands of patients with this condition.

Endometriosis is a condition in which tissue similar to the endometrium is present in abnormal locations. "Endometrium" is the tissue that lines the uterine cavity and allows for attachment of the embryo early in pregnancy. The endometrium changes in response to levels of estrogen and progesterone during a woman's cycles, then sheds during menstruation due to abrupt decreases in these hormones. Similar changes occur in endometriotic tissue located outside of the uterus, and accounts for the cyclic pain and inflammation that characterize this disease.

There are many ways in which endometrial tissue may appear in areas outside of the uterus. The most common phenomenon seems to be related to 'retrograde menstruation', in which the menstrual tissue travels back through the tubes into the pelvis, rather than out of the cervix into the vagina. Once in the pelvis, immunologic or other problems present in some women allow this tissue to proliferate and spread. This tissue can also invade adjacent tissues and the cyclic build-up and breakdown causes an inflammatory response, resulting in pain, scar tissue formation, or other problems

Symptoms of Endometriosis

  1. Pelvic Pain - Although there is a general correlation between the amount of pain a woman experiences and the severity of her disease, it is important to note that many women with endometriosis have no pain, and some women with severe pain have only minimal disease. Pain caused by endometriosis is typically located in the pelvis, but may radiate to the hips, thighs, or back. It is often cyclic, being most severe just prior to menses, and resolving during or after menstruation. Pain may also be present throughout the cycle.
  2. Menstrual Cramping - Women with endometriosis experience more severe cramping, which may begin well prior to actual menstruation.
  3. Painful Intercourse - Pain during sexual relations, especially deep penetration, is common in women with endometriosis. This pain may be midline or on the right or left side. It is sometimes worse in midcycle or just before menses.
  4. Infertility - While endometriosis is present in only 5-10 percent of reproductive aged women, it is found in up to 50% of women who undergo diagnostic laparoscopy for infertility. Endometriosis may lead to infertility through a variety of mechanisms. For example, scar tissue from the disease process may cause tubal occlusion or inability of the ovary to release eggs. Endometriomas, or 'chocolate cysts' of the ovaries may also cause significant distortion of pelvic anatomy. Studies of women with endometriosis have often shown other abnormalities that may contribute to infertility. These include alterations in the chemical and cellular composition of the pelvic environment, changes in tubal and ovarian function, and other factors.

Diagnosis of Endometriosis

Endometriosis may be suspected based on a woman's physical exam and history of the above symptoms. In addition, certain laboratory tests (such as serum CA-125 levels and endometrial aromatase activity) may give presumptive evidence of this disease. The 'gold standard' for diagnosing endometriosis, however, remains visual and pathologic confirmation at the time of laparoscopy or laparotomy

Treatment

As with many gynecologic conditions, treatment may be medical or surgical. Either alternative has conservative and aggressive options, and its own unique advantages and disadvantages.

Surgical Therapy

Discussion of treatment should begin with surgical therapy, because a surgeon should always be prepared to treat endometriosis completely at the time of the initial (surgical) diagnosis. In the vast majority of cases, the surgeon should be able to achieve this goal. See Reproductive Surgery for specifics and caveats on surgical management.

Endometriotic lesions may be treated in a variety of ways, including excision, laser vaporization, and electrocautery. However, not all methods are appropriate for all patients. It is crucial for the surgeon to recognize the many different appearances of endometriotic implants, and the fact that the microscopic disease often extends beyond the visible lesions. All disease must be removed or destroyed in order to minimize the risk of recurrence. This is often very time consuming, but can usually be accomplished through the laparoscope.

Scar tissue associated with endometriosis should be removed, not simply cut. Endometriomas, or 'chocolate cysts', which are collections of blood endometriosis within the ovaries, must also be removed by stripping away the cyst wall. Lesser measures, such as simple drainage or cauterization of the cyst wall, will almost always fail to resolve this problem.

Although many general gynecologists will treat this disease, we highly recommend that you seek treatment from a subspecialty board certified reproductive endocrinologist. Membership in the Society of Reproductive Surgeons (an affiliate of the ASRM - see our Links page) shows additional competence and interest in the field. Perhaps most importantly, it is almost never necessary to perform a hysterectomy in managing this disease for an infertile woman.

Medical Therapy

Although we and others are investigating the use of immunomodulators in the treatment of endometriosis, hormonal therapies are still the principal agents used for medical management of this disease.

Oral contraceptives have been used for years to treat the pain associated with endometriosis. Although moderately effective, they do not cause regression of the implants, and are obviously not appropriate for infertile women.

Danazol, which is chemically similar to testosterone, was formerly the 'gold standard' in medical management of endometriosis. Its use is associated with acne, hair growth, and a risk of birth defects if inadvertently given during pregnancy. Therefore, this medication is infrequently used today.

GnRH analogs (Lupron, Synarel, etc.) are the new 'gold standard' for medical treatment of endometriosis. These agents work by lowering estrogen levels, thus causing regression of the endometrial implants. They are very effective in reducing the volume of disease and symptoms of pain. However, recurrences may occur more quickly after medical treatment compared to surgical treatment. In addition, medications are not effective in treating endometriomas (ovarian cysts caused by endometriosis) or scar tissue.

Herbal and 'natural' therapies have not been studied in the treatment of endometriosis and our own experience is that they may cause significant menstrual irregularities. Therefore, they cannot be recommended at present.

Recurrent Disease

Endometriosis may recur, even if properly treated, and even after a successful pregnancy. The recurrence rate approximates 15 percent per year, or 50 percent after 5 years.

Conclusions

Endometriosis is a common yet serious disease that impacts one's health and reproductive potential. Fortunately, excellent therapy is available. It is rarely necessary to perform a hysterectomy in a woman who desires to retain her potential fertility. Advice from a competent subspecialist should always be sought. Additional information may be obtained from our office, or on the web at www.endometriosisassn.org.