What is Endometriosis and How is it Treated?

March is National Endometriosis Awareness Month.  An estimated 176 million women around the world are affected by endometriosis. Endometriosis is a disorder that affects 1 out of 10 women. It is very important to raise awareness about this disease because many women suffer in silence or suffer from feelings that they are not heard. This disease is misunderstood and is sometimes misdiagnosed or even underdiagnosed. Studies say that endometriosis is the number one cause of chronic pelvic pain and emotional and physical stress. These symptoms can lead to missed work, mood disorders such as anxiety, depression and difficulties with intimacy. Endometriosis can lead to subfertility and infertility which causes further emotional and physical stress.

What is Endometriosis?

Endometriosis is a gynecologic condition and is a disease of menstruation that occurs when the lining of the uterus, or endometrium (made up of endometrial cells) grows outside or migrates outside the womb or uterus, where the tissue does not belong. This leads to a complex process that ultimately leads to inflammation inside the female pelvis.

The Endometrium Lining

It is first important to understand the endometrium to understand endometriosis. The endometrium is the lining that thickens the inner cavity of the uterus for implantation of a new life. Thickening happens when the two major female hormones; estrogen and progesterone are produced. If there is no pregnancy, the lining sheds, which is menstruation. This process takes place every month.  These endometrial cells migrate outside of the uterus they can attach themselves anywhere in the female pelvis; such as the outside of the uterus, fallopian tubes, ovaries, bladder, intestines, bowel, rectum, the lining of the female pelvis called the peritoneum. The rapid increase of these endometrial cells are stimulated by estrogen production.

Who is Affected by Endometriosis and What are the Symptoms?

Most women who suffer from endometriosis are affected in their 20’s and 30’s, during their reproductive years. however it can be found in women as young as 11 and as old as 51. It is not a bias disease meaning it affects women equally, with no regard to race, ethnic or socioeconomic background.

Because of the complex inflammatory process that endometriosis causes, the most common symptom is painful menstruation. Other symptoms of endometriosis include but are not limited to:

• Painful menstrual cramps
• Irregular periods/bleeding
• Heavy menstrual bleeding
• Bowel problems such as chronic constipation, bloating, diarrhea
• Pain with intercourse
• Fatigue and mood disorder
• Nausea and/or vomiting during menstruation
• Chronic Pelvic Pain
• Endometriosis can affect fertility and cause subfertility or infertility

These symptoms affect the overall quality of life and can have a large impact on relationships at home and at work.

What Causes Endometriosis?

The exact causes of endometriosis is unknown because no one theory can fully explain the various ways that endometriosis can present itself, however multiple theories exist. Some of the proposed theories include:

• Retrograde menstruation or backward flow of menstrual blood into the fallopian tube then spillage from the tube into the pelvic cavity. However it is known that the majority of women have retrograde menstruation, yet only about 10% of all women are affected by endometriosis.
• Endometrial cells form outside the uterus before birth and become activated at puberty. There is also a genetic component since females who have a close female relative with endometriosis have a higher likelihood of being affected by endometriosis.
• Other theories involve the immune system and the inability to destroy these abnormal cells. This association is still poorly understood and continues to be researched.

How can Endometriosis be Diagnosed?

Unfortunately, there is no simple method to diagnosing endometriosis at this time. The only way to verify endometriosis is to undergo a surgical procedure called a diagnostic laparoscopy with pathology confirmation of biopsy specimens. There is no lab or saliva test that can diagnose endometriosis, and contrary to popular belief a pelvic ultrasound, CT or MRI also does not diagnose endometriosis. Imaging can be helpful to provide information but does not diagnose endometriosis.

How is Endometriosis Treated?

There are numerous medical treatments for the management of endometriosis symptoms, but the gold standard of treatment is minimally invasive laparoscopic excision surgery. It is a common myth that having a hysterectomy will cure endometriosis. There is no cure for endometriosis and removing the uterus without removing the endometriotic lesions will rarely improve symptoms. Endometriosis is located in areas other than the reproductive organs; as mentioned before, such as the pelvic cavity, bladder, bowel, rectum, etc. However, even after surgical excision of endometriosis, it can still recur. Moreover, the rate of recurrence can depend on multiple factors such as the stage of endometriosis, the expertise of the surgeon with excision of the endometriosis, and if there was continued medical treatment of endometriosis after surgery.

Treating the Symptoms of Endometriosis

The numerous other medical treatments are treating the symptoms but not necessarily the cause. These medical treatments alleviate many of the debilitating symptoms and can greatly improve patients’ quality of life. Endometrial tissue is stimulated by the normal estrogen production during a menstrual cycle, and the goal of many of these medical therapies are to decrease hormonal fluctuations of estrogen production which will decrease the growth of endometriosis. Not all the available therapies work the same for all women. Each woman has to weigh the side effects, risks and benefits of these medical options.

Some of the most common medical treatments include; nonsteroidal anti-inflammatories such as ibuprofen, and hormonal suppressive therapies such as:

• Estrogen/progestin combination
• Progestins
• GnRH agonists and antagonists
• Androgenic steroids
• Antiandrogens
• Other Alternative options include changes in diet, acupuncture, pelvic floor therapy, progesterone therapy, chronic pain management, psychiatric/psychological counseling and therapy.

Endometriosis is an enigma in the medical field that still requires more research to hopefully learn the cause, which in turn could lead to better treatments with less risks and side effects and hopefully a cure. If you have questions or feel you might be suffering from endometriosis, reach out to our CHI Health providers and schedule an appointment.