Endometriosis

Endometriosis is a progressive and often debilitating condition affecting approximately 10 percent of women of reproductive age. It is also present in 40 percent of women with infertility, making it one of the most common causes of infertility.

This often painful condition occurs when endometrial cells develop outside of their normal location inside the uterus. These misplaced cells still respond to hormonal changes in the same way as those lining the uterus so the tissue grows and sheds blood at the same time as the woman's menstrual period. But instead of flowing out of the body through the vagina, the blood shed by the misplaced cells has no way of leaving the body and the resulting internal bleeding can lead to chronic inflammation and the formation of adhesions and scar tissue. Areas commonly affected by these endometrial lesions include the ovaries, fallopian tubes, the ligaments that support the uterus, the area between the vagina and rectum, near c-section scars, on the outer surface of the uterus, and on the lining of the pelvic cavity. In rare cases, endometrial growths may even be found in the lung, arm, thigh, and other locations.

Endometriosis most often affects women between the ages of 25 and 44, but can also strike teenagers. Women who have given birth after the age of 30 may be at greater risk to develop it, as are Caucasian women, although it can affect women of any race; and it is more common in first-degree relatives (mothers, sisters, daughters), suggesting a possible genetic link.

Some women with endometriosis are symptom-free, while others have the condition for many years before experiencing any painful symptoms. But for many others, it can cause severe pain that interferes with daily life and, because it is a progressive disease, lesions and symptoms tend to worsen over time. Symptoms may include:

• Pelvic tenderness
• Pain during sexual intercourse
• Fatigue
• Abdominal bloating
• Premenstrual spotting
• Heavy periods
• Pain during ovulation as well as during menstrual periods
• Painful urination and bowel movements during periods
• Diarrhea
• Constipation
• Nausea and vomiting
• Endometriosis can also affect women emotionally, causing them to feel depressed, frustrated, confused, and develop a poor self-image.

Diagnosis is often made by taking a history of symptoms and using transvaginal ultrasound to locate lesions. However, a definite diagnosis is usually made using laparoscopy that shows the precise location, size, and extent of the growths. A woman is usually diagnosed as having mild, moderate, or severe endometriosis, based on the amount of scarring and diseased tissue found.

The exact cause of endometriosis is still unknown, and most experts believe it is a combination of several factors. Probable theories include:

Retrograde menstruation - Some endometrial cells back up from the uterus through the fallopian tubes, implant in the abdomen and grow. Although many experts believe this migration occurs in all women, an immune or hormonal problem may allow the tissue to grow in women who develop endometriosis. However, this theory alone does not explain why women who undergo tubal ligation or hysterectomy can still experience symptoms of endometriosis.

Immune system dysfunction - Immunological changes have been observed in women with endometriosis and it is believed that an abnormality in the immune system allows the endometrial cells that are shed normally to attach elsewhere and grow. However, scientists are not sure whether the changes are responsible for the endometriosis, or vice versa.

Lymph or blood system transfer - Some scientists believe that endometrial tissue is distributed to other parts of the body through the lymph system or bloodstream.

Embryonic tissue - Some tissues present in the abdomen retain the ability they had in the embryo stage to transform into endometrial cells.

Genetic cause - Endometriosis tends to run in families, although the mode of inheritance is not understood. Women with an affected mother or sister are more likely to develop endometriosis.

Environmental causes - A link between exposure to dioxin and endometriosis has been demonstrated in research. Dioxin is a byproduct of pesticide and bleached pulp and paper products manufacturing.

Treatment

Doctors often treat endometriosis using a combination of drug therapy and surgery, and personalize treatment for each woman depending on the severity of the disease and its location, the woman's age, if she hopes to get pregnant, and the extent of pain or other symptoms. If you have mild endometriosis, you may need only over-the-counter pain medication or stronger, prescription pain medications. Many drug treatments also focus on decreasing estrogen production to relieve symptoms (endometriosis relies on estrogen for growth), so doctors may prescribe birth control pills or other hormones to halt menstruation for patients not trying to get pregnant.

Endometrial lesions can often be removed surgically by laparoscopy or traditional abdominal surgery, depending on the number of lesions. In cases of severe pain the nerves around the uterus or pelvis may be severed surgically or a hysterectomy may be necessary; however, the lesions may not be confined to the reproductive organs so the endometriosis may return in the case of a hysterectomy.

There is no clinical evidence to support the use of alternative therapies in the treatment of endometriosis; however, many women have found relief from symptoms using homeopathy, osteopathy, and Traditional Chinese Medicine.

Infertility

It may take longer to become pregnant if you have endometriosis; and for many women, the condition renders them completely infertile. Doctors often recommend their patients not delay having children because endometriosis is a progressive disease, so the longer you have it, the greater your chance of becoming infertile. Endometriosis can cause infertility for the following reasons:

• Scar tissue from endometriosis can form adhesions on the ovary and limit the release of eggs.
• New research has shown that women with endometriosis-related infertility lack a certain enzyme in their uterus that allows an embryo to attach to the uterine wall, thereby preventing pregnancy.
• Adhesions affecting the fallopian tubes may interfere with their ability to pick up an egg released by an ovary and transport it to the uterus.
• Lesions may form inside a fallopian tube, blocking it and making fertilization impossible.
• Endometriosis can disrupt the ovaries' normal cycle of egg development and release.
• The peritoneal fluid in women with endometriosis contains an increased number of scavenger cells, which have the ability to destroy sperm cells, making fertilization unlikely.
• In advanced stages of endometriosis, internal organs may fuse together causing a condition known as a "frozen pelvis.

Pregnancy rates following treatment for endometriosis range from approximately 35 to 65 percent; however, the more endometriosis a patient has, the less likely she is to become pregnant following treatment. Medical or surgical treatment of mild endometriosis will not dramatically increase a woman's chance of becoming pregnant; however, women with severe endometriosis may improve their chance by undergoing surgical treatment. Infertility treatment for women with endometriosis usually involves ovarian stimulation and intrauterine insemination, followed by IVF and GIFT if necessary. Unfortunately, ovarian stimulation and intrauterine insemination are often unsuccessful in women with severe endometriosis, especially if the pelvic anatomy is very distorted. However, pregnancy rates using IVF and GIFT are usually good if the woman is relatively young (under 40) and if she produces enough eggs during the ovarian stimulation.

Support

Women who suffer from endometriosis may find advice, information, and help from support groups who specialize in endometriosis. The Endometriosis Association is a self-help organization of women with endometriosis and others interested in exchanging information about endometriosis, offering mutual support and help, educating the public about the disease, and promoting research. Another support group, Endometriosis.org, facilitates collaboration and information sharing between women with endometriosis, clinicians, and scientists.