Endometriosis
Description and Symptoms
Endometriosis is one of the most difficult conditions in gynecology to manage for patients and physicians.This disease affects many women of reproductive age, and causes significant pain, bleeding, scar tissue formation, and infertility. The growth and spread of endometriosis is through estrogen production from the ovaries. The origin of endometriosis is from the endometrial lining within the cavity of the uterus. There are several theories regarding the cause of endometriosis, the most accepted being the mechanism of “retrograde menstruation.” In patients without endometriosis, the endometrial lining “sloughs” when pregnancy is not achieved.This results is flow of blood and fragments of the lining from the uterine cavity through the vagina, and is termed menstrual flow. In patients with endometriosis, it is thought that the menstrual flow is also “retrograde” through the fallopian tubes and into the pelvic cavity. In other words some of the flow is backwards into the pelvis. The fragments of the endometrial lining in some patients will adhere to the lining of pelvic structures including the ovaries, uterus, fallopian tubes, bladder, rectum, ureters, and intestines.
With each subsequent menstrual cycle, estrogen production from the ovaries stimulates growth of the endometrial lining in the uterus AND also stimulates growth of the endometrial tissue implants in the pelvis.These implants, called endometriotic implants, grow and slough into the pelvic lining each menstrual cycle. Pain, inflammation and scarring, and the formation of collections of endometriosis to the ovaries, called endometriomas, results.Pain with endometriosis is the most severe symptom, and can be quite severe during the menstrual cycle. Extreme scar tissue can occur with extensive endometriosis, also adding to the pain both during the menstrual cycle and between menstrual periods. The level pain is not dependent upon the amount of endometriosis present. Some patients with a single small implant of endometriosis will have significant, incapacitating pain. Other patients with extensive endometriosis and formation of large endometriomas will have minimal symptoms.In most patients, pain is dependent on the amount of endometriosis present.
Endometriosis is a leading cause of infertility as well. It is thought that endometriosis is an inflammatory process that inhibits normal ovarian function and fertility. The scar tissue from endometriosis can affect the fallopian tubes, and prevent normal tubal function also causing infertility. Although some patients do become pregnant on their own with endometriosis, the majority of patients do not. In many cases of infertility due to endometriosis, assisted reproductive technology, or IVF (invitro fertilization) is necessary to help patients with endometriosis become pregnant.
Diagnosis
As with pelvic masses, ultrasound is used to diagnosis collections of endometriosis in the ovaries, called endometriomas. They appear as complex pelvic masses by ultrasound. MRI can also be used, but is much more expensive. Imaging studies cannot determine what a mass is, but can characterize a mass as simple or complex, and can determine the size of a mass. Ultrasound for example can identify a 4 cm fluid collection as a possible “endometrioma” in the ovary based on the characteristics seen. It is not possible for ultrasound, MRI, or CT scan to confirm that endometriosis is present. This can only be determined by removing the endometriotic cyst and confirming by pathology.
Many patients who have endometriosis have a normal ultrasound or MRI. This is because endometriotic implants that are small cannot be detected by any imaging study. For these patients, a diagnostic laparoscopy is needed to confirm and treat endometriosis. A diagnosis of endometriosis should never be made on clinical symptoms alone. When diagnostic laparoscopy is performed, biopsies must be taken to confirm endometriosis is present before treatment can begin.
Treatment
The doctors at CGS believe that endometriosis should be diagnosed first before treatment can begin. Although some gynecologists believe that the diagnosis can be made clinically, at CGS we believe that surgical management is a very important part of the diagnosis and treatment. There are many conditions that can cause pelvic pain that can mimick endometriosis. These include adenomyosis, interstitial cystitis - a chronic inflammatory condition of the bladder that is a significant cause of pelvic pain, dysfunctional uterine bleeding and dysmenorrhea (pain with menstrual cycles) of unknown cause, and other GYN pathology such as scar tissue from infection and prior surgery. The following steps are used by CGS to diagnose and treat patients with endometriosis.
- A complete history is obtained to determine if there has been prior surgical therapy or medical therapy for endometriosis, assessment of symptoms, and fertility status.
- Diagnostic laparoscopy is scheduled to assess the extent of endometriosis.
- At the time of laparoscopy, resection (removal) of all endometriotic disease is completed using retroperitoneal and extended procedures as needed. All specimens are sent for pathological analysis to confirm the presence of endometriosis.
- Those patients desiring fertility will have conservative surgery only, meaning that the uterus, tubes, and ovaries will not be removed if possible. Those patients not desiring fertility may undergo removal of the uterus and one or both ovaries depending on the need to preserve ovarian production of estrogen. Patients with extensive disease not interested in fertility may benefit from surgery to remove the uterus, tubes, and ovaries to eliminate pain and progression of endometriosis. For these patients, hormone supplementation using estrogen can be given to control symptoms of menopause.
- Medical therapy is given for those patients in which surgical therapy has been completed. Medical therapy can be given to suppress further growth of endometriosis. It can also be used for those patients in which all the disease could not be resected. Birth control pills are used for suppression in mild cases, while Lupron, a medication which stops all estrogen production, is given for more extensive cases.
- Patients desiring fertility are scheduled to see a Reproductive Endocrinologist for consultation regarding treatments such as IVF to achieve pregnancy.