What Is Endometriosis? Symptoms, Causes, Treatment

Endometriosis is the growth of tissue that is normally found in the lining of the uterus (endometrium) in a location outside of the uterine cavity. It can occur on the ovaries, surface of the uterus, on the intestine, or in other organs. With the changing hormone levels during the menstrual cycle, the tissue may grow and break down, leading to pain and eventual scar formation. This condition is estimated to impact more than 10% of US women ages 15-44.

The most common symptom of endometriosis is pain that occurs prior to, during, or after menstruation. The pain can occur during sexual intercourse, during urination, or during bowel movements. Some women have severe, disabling pain. It can also cause chronic pain in the low back or pelvis. Other women have mild symptoms or no symptoms.

Most women report having mild pain with menstruation, and over-the-counter medications may provide relief. If your menstrual pain is persistent, severe enough to interfere with normal activity, or lasts longer than two days, consult your doctor.

Endometriosis can begin in teens as early as the first menstrual period. It’s important to consult a physician if a teenager has menstrual pain that is severe enough to interfere with normal activity. Over-the-counter pain medications and careful recording of the symptoms may be the first step in management. Treatment options for teens and adults are the same.

Infertility can be the first sign of endometriosis in many women. An estimated 30% to 50% of women with endometriosis are infertile. The reason for this is not well understood, and scarring of the reproductive tract may play a role. Hormonal factors also may be involved. Fortunately, treatments to overcome infertility are effective for many women.

Severe menstrual pain can be caused by other conditions, including fibroid tumors. Fibroid tumors are noncancerous growths of the muscle tissue of the uterus. They can cause heavier than normal menstrual bleeding and cramping. Both endometriosis and fibroids can cause pain at other times of the month as well.

Why endometriosis develops is poorly understood. Hereditary factors seem to play a role, and some areas of endometrial cells outside of the uterus may be present at birth. It is also possible that endometrial cells may travel to abnormal areas during menstrual bleeding, during surgeries, or through the bloodstream. Immunological factors may be involved, as a defect in the immune system could cause failure to eliminate the misplaced endometrial cells.

The brown cells seen here are endometrial cells removed from an abnormal growth on an ovary.

Risk factors for endometriosis are varied. It is most common in women:

• who are in their 30s and 40s.
• who have not given birth.
• who have periods that last longer than 7 days.
• who started menstruating before age 12.
• who have short menstrual cycles (shorter than 28 days).
• who have a family history (mother or sister) of the condition.

Taking notes about your pattern of symptoms can help your doctor determine if you have endometriosis.

When tracking endometriosis symptoms, note the following:

• The severity of the pain
• When the pain occurs
• The duration of the pain
• Any changes such as worsening of the pain
• Pain during sex, urination, or bowel movements
• Pain that restricts normal activities

A pelvic examination will help your doctor identify anything abnormal in the ovaries, cervix, or uterus. This exam can sometime reveal masses, scars, or cysts that are due to endometriosis. The pelvic exam can sometimes identify other conditions that can cause similar symptoms.

Even though imaging studies cannot confirm the diagnosis of endometriosis, ultrasound, CT, or MRI scans are sometimes used to help in diagnosis as these scans can detect larger areas of endometriosis or cysts related to endometriosis.

Laparoscopy, a surgical procedure, is the only way to definitively diagnose endometriosis. In this procedure, the surgeon examines the inside of the abdomen and pelvis with a viewing instrument inserted through a small incision. Small tissues samples (biopsies) can be taken for examination by a pathologist to confirm the diagnosis.

Medications like acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen can help relieve the pain, but these do not affect the endometriosis itself.

Taking oral contraceptives to reduce the amount of menstrual flow can often reduce the pain associated with endometriosis symptoms while producing shorter and lighter menstrual cycles. Sometimes the pills are taken continuously, without breaks for a menstrual period. Progesterone-only therapy (as opposed to combined estrogen and progesterone therapy) can be given by injection or pill form. The endometriosis symptoms may return after the therapy is discontinued.

Other hormonal therapies mimic the hormonal state of menopause, eliminating menstrual periods and reducing the pain of endometriosis. GnRH agonists interrupt the production of female hormones.

List of GnRH Agonists

• leuprolide (Lupron)
• nafarelin (Synarel)
• goserelin (Zoladex)

These agonists can have unpleasant side effects such as hot flashes, vaginal dryness, bone loss, and changes in mood. Danazol (Danocrine) is another medication that lowers estrogen levels and has some weak male hormone activity. Its side effects can include acne, facial hair development, weight gain, reduction in breast size, and voice and mood changes.

At the time of laparoscopy, the surgeon can remove endometriosis growths or scars. Most women will have pain relief after this is done, but recurrence of endometriosis symptoms occurs in about 45% of women a year later. Recurrence is more likely with time. Hormone treatments after surgery may reduce the chance that endometriosis symptoms will return.

Very severe cases of endometriosis may require open abdominal surgery to remove endometrial growths, or even a hysterectomy (removal of the uterus). Part or all of the ovaries may also be removed in these cases. Even with removal of the uterus and ovaries, endometriosis returns in about 15% of women.

Laparoscopic surgery to remove growths can help affected women get pregnant. Treatments like in vitro fertilization can also help overcome infertility associated with endometriosis.

While endometriosis can’t be prevented, some lifestyle measures can help manage the condition and improve endometriosis symptoms. Exercise may help relieve pain through the production of endorphins. Some women find that techniques like yoga, massage, acupuncture, and meditation are helpful in managing symptoms.

There is no medical cure for endometriosis, although treatments can help manage symptoms. However, endometriosis symptoms go away with menopause for most women. Many women find that endometriosis symptoms are relieved during pregnancy. And in about one-third of cases, the symptoms disappear on their own.