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Endometriosis
Endometriosis, a cause of female infertility, is a benign (non-cancerous)
condition in which the lining of the uterus (called the endometrium)
migrates / grows outside the uterine cavity and is present in places
where it is not normally found. In these sites, the misplaced tissue
may grow as small patches called implants, in thicker penetrating
nodules or may form cysts within the ovary called endometriomas.
Endometriosis is usually confined to the pelvis. Common sites of involvement
are the ovaries, the space behind the uterus (cul-de-sac, rectum,
uterosacral ligaments) and urinary bladder. Although most common in
the pelvis, endometriosis has been documented in nearly every location
of the body, including such remote and unusual sites as the brain,
sciatic nerve, lungs and even skin.
Endometrial tissue whether it is inside or outside the uterus, responds
similarly to the cyclic ovarian hormones estrogen and progesterone.
Estrogen causes growth of the endometrium in the first half of the
cycle. Progesterone which is produced by the ovaries in the second
half of the menstrual cycle complements the work begun by estrogen
and stimulates the endometrial cells to mature and prepare for possible
implantation and pregnancy. When no pregnancy occurs, the endometrium
is shed out of the uterine cavity as menstrual flow. The menstrual
discharge contains chemical products called prostaglandins which stimulate
the uterine muscles to contract and causes cramping. The endometriotic
implants outside the uterus also continue to break down and bleed
periodically; the result is internal bleeding, degeneration of blood
and tissue shed from the growths, irritation and inflammation of the
surrounding areas, and formation of painful web like scar tissue called
adhesions. This scar tissue can bind the pelvic organs to each other,
block the fallopian tubes or impair ovulatory function.
According to the American College of Obstetricians and Gynecologists
(ACOG), endometriosis is a common condition affecting 10 to 15 percent
of reproductive-age women. Endometriosis occurs in about 30 percent
of all infertility cases.
CAUSES OF ENDOMETRIOSIS
In spite of a lot of research on the subject, it is still not completely
understood why some women develop endometriosis while others do not.
There are several theories as to how endometriosis begins, none of
which have been proven.
- The immunologic theory: Research
has shown that many women with endometriosis appear to have subtle
defects in their immune system. The Retrograde theory: Retrograde
menstruation is the backward flow or the spillage of menstrual
blood into the pelvis through open fallopian tubes.
- The Retrograde theory: Retrograde
menstruation is the backward flow or the spillage of menstrual
blood into the pelvis through open fallopian tubes.
- Transplantation theory: refers
to the movement of endometrial cells throughout the pelvis (and
even outside of the pelvis) through blood and lymphatic systems.
- Metaplastic theory: refers to
coelomic metaplasia or the ability of certain cells to change
into endometrial cells.
- Genetic theory: Heredity is
also said to be a factor in endometriosis. Women who have sisters
or a mother with endometriosis have a greater incidence of the
disease.
Some believe that endometriosis may actually be caused by "a combination
of several factors."
SYMPTOMS OF ENDOMETRIOSIS
The symptoms of endometriosis vary from one patient to another. The
clinical presentation and symptoms of the disease are frequently related
to the anatomical site of the disease. The most common symptom is
pelvic pain, which can be spontaneous non-cyclic pain, painful menstrual
periods, pain with intercourse or chronic pelvic pain. Other symptoms
include abnormal uterine bleeding, spotting prior to periods, severe
cramping, infertility, diarrhea and painful bowel movements especially
during menstruation, abdominal tenderness, painful or burning urination,
urinary frequency, retention, or urgency.
Menstrual cramps are caused by contractions of uterine muscle initiated
by prostaglandins released from the endometrial tissue.
Pain during intercourse or dyspareunia occurs because of pressure
on tender endometriotic nodules present in the uterosacral ligaments
behind the lower portion of the uterus, near the top of the vagina
or due to scar tissue binding the ovary to the vagina.
The magnitude of the symptoms may not correlate with the extent of
the disease. Symptoms may be completely disabling or mild. Sometimes
the condition is present and causes few to no symptoms or a patient
with severe disease may have very little pain. However, the likelihood
of infertility does increase as the severity of the disease increases.
Endometriosis rarely causes symptoms following natural or surgical
menopause.
WHAT DOES ENDOMETRIOSIS LOOK LIKE
Early implants look like small, flat patches or flecks of dark paint
sprinkled on the pelvic surface.
"Chocolate cyst": Ovarian endometriosis
probably starts as a surface lesion. The process becomes invasive
and the endometriotic lesion internalizes into the ovarian tissue.
Once the menstrual flow and debris collect at the site of endometriosis
in the ovaries, endometrial cysts form that are filled with chocolate-colored
liquid. These are commonly called chocolate cysts, or endometrioma.
These are nothing more than cysts which represent debris from prolonged
cyclic menstruation in an enclosed area. These cysts may sometimes
attain impressive size, with some documented as large as a baseball
or grapefruit that completely obliterate the normal ovary. However,
usually there is a well-demarcated separation between the cyst wall
and the normal adjacent ovarian tissue.
ENDOMETRIOSIS AND INFERTILITY
Endometriosis has been identified as a major cause of infertility.
Endometriosis with scarring that distorts the anatomy of the pelvic
organs may impair fertility. Adhesions may interfere with relese of
eggs from the ovary or pick-up of the egg by the fallopian tubes.
It appears that implants located far from the tubes and ovaries may
also impair fertility. This may be because prostaglandins or other
chemicals released from the implants may interfere with ovulation,
entry of the egg into the tube, and fertilization. Endometriosis is
the cause of infertility in approximately 35% of women with the disease.
When there is no distortion of the pelvic organs or blockage of the
fallopian tubes, endometriosis is less likely to impair fertility.
Some women with endometriosis conceive without trouble.
The risk of miscarriage is higher for women with untreated endometriosis.
This could be because of chemicals that can be toxic to the embryo
or possibly due to changes in the immune system.
With appropriate treatment pregnancy can certainly be achieved by
a woman with endometriosis. Sometimes, surgery may improve the chance
of pregnancy in women with endometriosis.
DIAGNOSIS OF ENDOMETRIOSIS
The diagnosis of endometriosis cannot be made from symptoms alone,
since some patients may be asymptomatic. A pelvic exam may show visible
implants occasionally in the cervix or vagina. Tender, enlarged or
fixed ovaries may cause clinical suspicion of endometriosis.
The gold standard to diagnose endometriosis is by laparoscopy, a surgical
procedure in which a thin scope is placed through the belly button
into the abdomen to view the uterus, ovaries, and fallopian tubes
directly. This procedure helps to visually confirm the presence of
endometriosis as well as to gauge its extent. The amount of endometriosis
is assigned a numerical score based on the amount of superficial and
deep disease detected and the amount of adhesive disease. The disease
will be classified as stage 1 (minimal), stage 2 (mild), stage 3 (moderate)
or stage 4 (extensive) based on the amount of scarring and diseased
tissue found.
While a biopsy of the lesion does document the presence of endometrial
tissue, the gross appearance of endometriosis and visual inspection
of the pelvis is also considered adequate and accurate for diagnosis
of endometriosis. Surgeons can videotape the laparoscopy for documentation
and this can be reviewed at a later date if there are any questions.
Ultrasounds, MRIs, CT Scans and other diagnostic tests are not conclusive
for the diagnosis of endometriosis. Measurement of CA 125 levels in
the blood is not specific to endometriosis and is generally not used
to detect endometriosis.
TREATMENT OF ENDOMETRIOSIS
Endometriosis is a progressive disease. While there is no known cure
for endometriosis, medications and surgery can help delay the progression
of the disease. In general, endometriosis is managed most effectively
with a combination of properly performed surgery and the use of appropriate
medical therapies. A combination of symptoms, physical findings, test
results and patient goals are taken into consideration to plan treatment
options.
Medications that are helpful in alleviating symptoms and controlling
pain include gonadotropin-releasing hormone (GnRH) agonists including
Lupron, Aromatase inhibitors such as Letrozole and birth control pills.
The goal of hormonal medication is to simulate pregnancy or menopause,
both of which are known to inhibit the progression of endometriosis.
These treatments suppress the growth of normal and misplaced endometrial
tissue.
Surgical Management includes laparoscopic surgery to remove the lesions--laser
laparoscopy can drain endometriotic cysts, remove endometrial tissue
and blockages from the body by excision, fulguration, cauterization,
and ablation. Hysterectomy is also an option but will not eradicate
the disease.
Patients with infertility may benefit from in vitro fertilization.
After surgery, approximately 50% of patients experience major pain
relief, a further 30% have adequate improvement and the final 20%
are not improved. In 50% of patients, symptoms can recur with 6 months
to a year.
Alternative medicine, acupuncture, herbal therapy, massage techniques,
good nutrition, and adopting a generally healthy lifestyle may also
contribute towards improving symptoms.
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