Diagnosing and Treating of Endometriosis
Endometriosis is a painful and elusive disease in which endometrial tissue grows and functions outside the uterus. However, there is a similar condition called adenomyosis in which endometrial tissue inside the uterus can also grow abnormally. Adenomyosis usually affects women in their 30s and 40s who have already had several children and it is associated with a greater risk of developing polyps, fibroids and endometrial cancer than endometriosis. And to make matters yet more complicated, there is stromal endometriosis, which does not look like endometriosis, but instead like an abnormal growth in the uterus. This form of endometriosis is often highly malignant and treated as an endometrial cancer. In this post we are going to look at the most common form of endometriosis in which endometrial cells grow outside the uterine cavity.
Risk Factors for Endometriosis
- Obstruction and distortion of reproductive organs due to congenital defects and lifetime developments predisposes affected women to developing endometriosis.
- The risk of developing endometriosis in a woman whose mother or sister have it are up to 10% greater than in other women and so are the chances that the condition will appear earlier in life and be more severe.
- Endometriosis is known to occur twice as often in Japanese women as in Caucasian women.
Causes of Endometriosis
Although a large majority of patients are women in the childbearing years, this disease has been found in girls and women aged 10 to 70. It is estimated that between 10% and 20% of women of childbearing age live with endometriosis. Despite there being several theories as to why and how endometriosis develops, no single cause has yet been established.
Complications of Endometriosis
Many women suffer only from a mild form of endometriosis that passes with minor soreness in the lower abdomen. However, the adhesions and scar tissue that build up in others can eventually lead to freezing the reproductive and other pelvic organs and, along with internal bleeding and other progressive changes, destroy them. As a result, almost half of women with this condition experience infertility problems. Although severe endometriosis can block and bend reproductive organs into abnormality, no direct link has yet been established between infertility and endometriosis. Pregnancy often reduces or even eliminates symptoms, at least temporarily, but it is not a cure. The condition can progress while the baby is developing and symptoms then re-emerge after the child is born. The doctor may encourage women who have a family history of endometriosis to have children early, before the disease brings complications. But this advice does not help women who develop endometriosis as teenagers, especially since women with hereditary predisposition develop serious complications earlier than others.
Documenting a detailed medical history, especially the location of the pain and when it occurs, and performing a thorough pelvic examination are essential first steps to identifying endometriosis. If you believe your symptoms may signal endometriosis, do not leave anything out. For example, spitting up blood during menstruation may seem unrelated to endometriosis, but if it happens regularly, it may suggest endometriosis in the lung. Another example is pain that specifically affects an unusual location in your body and happens only when your period arrives. These observations help to separate the pain caused by endometriosis from the menstrual pain that centers on the reproductive organs.
The aim of the pelvic exam, which involves checking both the vagina and rectum, is to identify abnormalities on the reproductive organs. During this exam the doctor may find nodules formed by endometriosis in the back of the vagina, on the ligaments supporting the uterus and in the rectum or tender and enlarged ovaries, lumps in the abdomen and a uterus that is drawn back and attached to the rectum.
Imaging tests such as ultrasound, magnetic resonance imaging (MRI) or CT scans can be ordered in order to rule out other pelvic disorders and may suggest the presence of endometriosis. However, neither of these techniques is definitive for diagnosis of endometriosis, nor are any reliable laboratory tests.
The only reliable way of diagnosing endometriosis is with surgical techniques, either by opening the abdominal wall with large-incision laparotomy or small-incision laparoscopy. However, laparotomy is now rarely used just to diagnose endometriosis. But, if this operation is required because of some other disease of the pelvis, it provides an opportunity to identify potential endometriosis.
In fact, the only safe and accurate way to distinguish between endometriosis, pelvic inflammatory disease, pelvic growths and other diseases that produce symptoms similar to endometriosis is laparoscopy. With a viewing instrument called laparoscope inserted through a tiny incision near the navel, the doctor is able to see into the abdomen and examine the organs. Implants of endometrial tissue outside the uterus can be seen and distinguished from cysts, fibroids, tumors and adhesions in the pelvic area. So can any fallopian tube obstruction or pelvic inflammatory disease. During laparoscopy, tissue samples can be taken for examination under a microscope to detect the early signs of endometriosis that cannot be yet seen with laparoscope.
Treatment of Endometriosis
Treatment for endometriosis involves medication or surgery or a combination of the two. Treatment with medications focuses on relieving the pain and moderating or suppressing ovulation in order to create a temporary pseudo-menopause. Alternatively, your doctor may prescribe medications to produce a pseudo-pregnancy. The aim of the hormonal therapy is the elimination of the long periods of estrogen production that stimulate the growth of endometrial tissue. Hormonal treatment can reduce both the size and number of endometrial tissues. Potential risks include a temporary failure to menstruate, along with vaginal dryness, a near-menopausal state and problems related to estrogen deficiency.
The aim of surgery is to remove the organic cause of pain and interference with the normal functioning of affected organs. Surgical techniques range from burning up endometrial implants with a laser beam to removing the affected organs altogether. In severe cases of endometriosis, hysterectomy may be considered, in which the uterus and cervix as well as both ovaries are removed. This radical approach suppresses hormonal stimulation of endometrial tissue growth by eliminating the main sources of the hormones.
Unfortunately, no existing treatment can completely prevent endometriosis from reoccurring. Even the most radical surgical removal of endometrial tissue that has established itself outside a woman’s uterus does not guarantee definitive freedom from progression of endometriosis and resulting pain.
Pain medications. In order to ease painful menstrual cramps you may use over-the-counter pain medications containing ibuprofen or naproxen. If the pain is too severe to be handled by OTC drugs, your doctor may prescribe stronger pain relievers such as opioids, e.g. codeine.
Oral contraceptives. When it comes to hormonal medications, any birth control pill can be used to make your period lighter, but those with a high progesterone level are preferred. Potential side effects of birth control pills when treating endometriosis are the same as those experienced when the pills are taken for contraception.
Progesterone and progestin can be taken as a once daily pill, by quarterly injection or they can be administered through an intrauterine device. These medications bring relief by reducing a woman’s period or stopping it completely, which results in shrinking endometrial tissue. Weight gain, water retention, irregular vaginal bleeding and acne are the possible side effects. As with the birth control pills, the treatment with progesterone and progestin usually takes six to nine months until the problem abates. Pregnancy rates after stopping the treatment are highest for these medications.
Gonadotropin-releasing hormone (GnRH) agonists are used to stop the production of ovarian-stimulating hormones in order to put an end to ovulation, menstruation and the growth of endometrial tissue, which results in reducing the pain associated with endometriosis. If you wish to have intercourse while taking these medications, you will need to use barrier contraceptives because GnRH agonists are not reliable contraceptives. Gonadotropin-releasing hormone agonists come in the form of a nasal spray taken daily, monthly or quarterly injection or as an implant beneath the skin. The treatment typically lasts six months. Among their side effects are problems sleeping, tiredness, hot flashes, depression, headache, vaginal dryness, joint and muscle stiffness and bone loss. Taking a low dose of estrogen or progestin along with gonadotropin-releasing hormone agonists may help reduce some of these unwanted effects.
Danazol is yet another medication that used to be prescribed for the treatment of endometriosis but it has been largely replaced by GnRH agonists due to the risk of harming a developing fetus and severe masculinizing side effects. In general, side effects of danazol are more severe than those of other hormonal medications used to treat endometriosis.
Laparoscopy makes it possible to diagnose and surgically treat endometriosis during the same visit. A surgeon using a laparoscope, inserted through a tiny cut near the navel to look all around the organs and diagnose endometriosis, can also use it to aim an obliterating laser beam at problematic tissue growths, adhesions and other obstructions to normal functions. The laser cuts, coagulates and vaporizes tissue cells with microscopic precision, using the heat produced by its concentrated light. Besides the laser, other cutting and tissue burning instruments such as heated electrodes can also be used with the scope.
The advantages of laparoscopy include rapid diagnosis and treatment, reduced tissue injury, bleeding and scarring, fewer post-op complications, shorter hospital stay and a faster, less painful recovery. Although laparoscopy is a minimally invasive surgery, you should expect to have tenderness around the incision for about a week. Trauma from manipulation of the organs and left-over gas in abdominal cavity may cause discomfort in the abdomen, neck and shoulder. Some patients may also feel nausea for a few days. Those, who were under general anesthesia during the operation, may briefly experience a sore throat and difficulty concentrating.
Laparotomy is a major surgery that involves opening up the abdominal cavity. This procedure is used when endometriosis is so widespread that it cannot be removed through the tiny cut used in laparoscopic surgery. In contrast to laparoscopy, recovery is slower and more painful, hospital stay is longer and there is a greater risk of post-operation infection.
Hysterectomy is either partial or complete removal of the uterus plus removal of both ovaries. It is a method of the last resort for treating recurrent endometriosis, especially for women in their reproductive years. The patient needs to weigh the long-term consequences of the premature menopause that results from the operation.
Where to Find More Information: Endometriosis.org