Diagnosing and Treating Endometriosis

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If you've been having painful periods, possibly with pelvic pain that continues even after your period ends, you should talk to your health care provider about evaluating you for endometriosis.

Endometriosis is a chronic, gynecological condition in which the uterine lining, called the endometrium, grows outside the uterus. This uterine tissue typically remains within the pelvic cavity but has been known to appear in the abdomen, such as in the ovaries, bowels or fallopian tubes, or, more rarely, in the lungs, skin and other regions of the body.

The problem with this "traveling" tissue is that it still responds to monthly hormonal signals to grow and shed. Unlike tissue lining the uterus, however, endometrial tissue elsewhere in your body can't leave your body, so it bleeds wherever it is. Your body interprets this bleeding as an attack. White blood cells swoop in to protect you and repair the damage, causing inflammation. This inflammation is not only painful but can lead to painful scar tissue called adhesions. Some studies suggest this misplaced endometrial tissue may develop its own nerve supply to communicate with the brain, another reason behind the severe pain of endometriosis.

About 40 percent to 60 percent of all women with pain during their periods have endometriosis, as do about 20 percent to 30 percent of women who have problems getting pregnant. The condition is more common in middle-aged women, and the symptoms become more severe with age. The diagnosis is often made around age 40.

We don't know what causes endometriosis, although there are several possibilities. One is that menstrual blood doesn't flow completely out of the cervix (the opening of the uterus to the vagina), but is pushed backward out of the uterus through the fallopian tubes into the pelvic cavity.

In addition to pelvic pain and abnormal bleeding, other symptoms of endometriosis include:

• Diarrhea and painful bowel movements, especially during menstruation
• Painful intercourse
• Abdominal tenderness
• Severe cramping
• Backache
• Severe menstrual cramps

To diagnose endometriosis, your doctor first conducts a thorough medical history and physical examination, including a pelvic exam. You will likely undergo a transvaginal ultrasound, in which a wand is inserted into your vagina. The wand emits sound waves, which transmit an image of your pelvic region so it can be evaluated by your doctor. This test doesn't always pick up signs of endometriosis.

The only test that can definitely diagnose or rule out the condition is laparoscopy. This is a surgical procedure performed under general anesthesia in which the doctor inserts a miniature telescope called a laparoscope through your naval to view the pelvic region. The doctor should not rely on what he or she sees during the exam but should remove a tiny piece of the outer layer of the lining of the uterus to confirm the presence of endometrium elsewhere in your body.

If you are diagnosed with endometriosis, there are several treatment options:

• Medication. Medications to treat endometriosis are designed to suppress ovulation, which prevents hormones from signaling endometrial tissue to grow and shed. All are equally effective, and all relieve pain from endometriosis. Specific medications include:
  • Oral contraceptives. Side effects may include nausea and headaches.
  • GnRH analogues are hormonal treatments that block estrogen production, which stimulates the growth of the endometrial tissue. However, GnRH drugs are typically only used for six months. They cause menopausal symptoms like hot flashes, and by blocking estrogen can weaken bones or increase your risk of heart disease.
  • Medroxyprogesterone or other progestins. These synthetic versions of progesterone can be given via injection or orally. Side effects include weight gain, depressed mood and abnormal uterine bleeding.
  • Danazol (Danocrine), a male hormone that suppresses ovulation. Side effects may include weight gain, hair growth and acne. This drug is rarely prescribed these days.

Once medical treatment stops, more than 50 percent of women find their symptoms return within a year.

• IUD. An IUD that emits a progestin called levonorgestrel can help with symptoms of endometriosis. In some women it suppresses ovulation, and in most women it reduces painful bleeding episodes. Side effects may include irregular bleeding. The IUD needs to be replaced every five years in women under 40.
• Surgery. Surgery to remove endometrial tissue can be performed laparoscopically, avoiding an abdominal incision. In this surgery, the tissue is removed either by laser, heat or both. Some doctors also destroy uterine nerve tissue, preventing the transmission of pain signals to the brain. Excisional surgery is effective in about 80 percent of women. However, other studies find symptoms recur in between 20 percent and 30 percent of women, despite optimal treatment.

As you can see, endometriosis is a complex condition that can significantly affect the quality of a woman's life. If you're diagnosed with this condition, don't despair; together, you and your doctor should be able to find a treatment, or combination of treatments, to relieve your pain and bleeding.