Managing endometriosis

Pain and symptoms can be managed with therapy

By: Dr. Susan McCoy
   When tissue which normally lines the uterus, also known as the endometrium, is found outside the uterus, the resulting condition is called endometriosis.
   This stray tissue is usually found in the pelvic portion of the abdomen, on the ovaries, the fallopian tubes, the uterus and its supporting ligaments, and on and below the tissue that lines the pelvic cavity.
   Endometriosis implants also occur frequently on the surface of the bladder and lower bowel which are both in close proximity to the uterus. Less frequently, endometriosis is found in the cervix or vulva, in abdominal scars and as far away as the lung.
   This painful condition affects an estimated 7-10 percent of women in the general population and up to 50 percent of pre-menopausal women.

   The most common symptoms of endometriosis are: pain that occurs before and during the menstrual period; pain that occurs during sexual intercourse; chronic pelvic pain; infertility.
   In addition, endometriosis that involves the other organs in the pelvis may result in dysfunction of these organs such as painful defecation or diarrhea, or bloody urine with bladder involvement.
   Complicating matters further are the many asymptomatic women with endometriosis (found incidentally during other surgical procedures), the vast number of women who have painful periods with no identifiable pathology and the common conditions that mimic symptoms of endometriosis, such as irritable bowel syndrome and pelvic inflammatory disease (the result of infection).
   How does this disease develop?
   When the endometrial tissue is displaced, and there are many theories as to why this happens, it develops into growths or lesions which respond to the menstrual cycle in the same way that the tissue of the uterine lining does: each month the tissue builds up, breaks down and sheds.
   Menstrual blood flows from the uterus and out of the body through the vagina, but the blood and tissue shed from endometrial growths has no way of leaving the body. The results are internal bleeding caused by the breakdown of the blood and tissue from the lesions, and inflammation. When endometriosis occurs, it can cause pain, infertility and the formation of scar tissue.
   One way to diagnose endometriosis is with a minor surgical procedure known as laparoscopy. This outpatient procedure, done under anesthesia, enables direct visualization inside the abdomen and pelvis through a tiny lighted tube that is inserted through one or more small abdominal incisions. This procedure can confirm the diagnosis and help to determine the extent of the disease.
   Destruction of endometrial lesions can be performed during laparoscopy using lasers or electrocautery, or the lesions can be surgically removed. However, it is not always necessary to diagnose or treat endometriosis surgically and in many instances a trial of hormonal suppression can be undertaken in patients with suspected endometriosis after carefully ruling out other causes of pelvic pain. At the present time, there is much controversy concerning the role of the surgery versus medical therapy in the treatment of this condition.
   While there is no cure for endometriosis, there are a variety of treatment options, including pain management, hormone therapy, surgery or a combination of these.
   To determine the best course of treatment, it is essential that physicians consider each woman’s case individually and discuss with that woman what each option can achieve. Treatment goals may include relief of pain, shrinking or slowing endometrial growths, preserving or restoring fertility, and preventing or delaying a recurrence of the symptoms.
   To offer patients pain relief, doctors often recommend over-the-counter pain relievers such as aspirin and Tylenol, as well as prostaglandin inhibitors such as ibuprofen and naproxen sodium. In some cases, prescription drugs may be required.
   Hormone-based treatments such as oral contraceptives, progesterone drugs, danazol and gonadotropin-releasing hormone drugs aim to stop ovulation for as long as possible. This is often a good choice for women who are not concerned with fertility. While some women may experience side effects depending on the type of therapy, these side effects can be managed by altering the dosage and type of therapy offered.
   When medical therapy has failed, when endometriosis forms large cystic lesions in the ovaries, when the diagnosis of pelvic pain is uncertain, or when scar tissue prevents egg pick-up by the fallopian tube, surgery may be necessary.
   As previously mentioned, many surgical treatments can be performed through the laparoscope, although extensive dissection of deep penetrating endometrial lesions should be done by experienced pelvic laparoscopists.
   It is not uncommon to follow conservative surgery with a course of hormonal suppression. In severe cases, hysterectomy, removal of endometrial growths and removal of the ovaries is necessary. Unfortunately, even post hysterectomy, these women have about a 15 percent chance of recurrence.
   The good news is that for most women, symptoms can be controlled with the therapies discussed. In addition, many patients with chronic pain conditions may benefit from complementary interventions such as exercise, healthy diet and relaxation techniques.
   Although the cause of endometriosis is unknown, there are many interesting theories concerning the disease. There is one theory that holds that during menstruation, some of the menstrual tissue may back up through the fallopian tubes, where it can take root and grow in the abdomen. This theory is known as the retrograde menstruation theory or transtubal migration theory.
   There are some experts who believe that experiencing some menstrual tissue backup is normal for all menstruating women and that an immune system problem or a hormonal problem allows this tissue to grow in the women who develop endometriosis.
   Yet another theory suggests that the lymphatic system or the blood system can distribute endometrial tissue from the uterus to other parts of the body.
   Some experts look to the genetic makeup of a family for an explanation, suggesting that some families may have factors that predispose them to endometriosis. In cases where endometriosis is found in abdominal scars, surgical transplantation falls under suspicion.
   There are those experts who suggest that some adult tissues lining the pelvic and abdominal cavity retain the ability to transform into endometrial tissue under certain circumstances. In addition, there are those who hold environmental theories. Although there are many theories that attempt to explain the cause or causes of endometriosis, for those afflicted with the condition, the cause is not as important as the treatment.
   Fortunately, women of today have many more choices of treatment. There is no need for any woman to suffer in silence. Working with your physician, you can get control of endometriosis.
   Dr. Susan McCoy is a gynecologist on staff at The Medical Center at Princeton. Health Matters appears Fridays in the Lifestyle section of The Princeton Packet and is contributed by The Medical Center at Princeton.