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The pain...it’s the pain that is making my life miserable!” Jan sat dejectedly across from me in the exam room and lamented about the tract her life had taken over the past few months.
“It hurts during my cycle, and now it’s gotten where it hurts most all the month. It’s a dull pain, sort of like a bad tooth ache in my pelvic area, and sometimes it’s better and sometimes it’s worse, but it’s always there. And sex is totally out of the question. The pain with that has become intolerable. I can’t even look at my husband that way anymore, and I don’t have to tell you that’s not good.”
Jan has endometriosis and her life had become dominated by this disease that affects almost 3 to 10 percent of reproductive-age women. Some estimate that 25 to 40 percent of all women with an infertility problem have some degree of endometriosis.
What Is Endometriosis?
Endometriosis is a condition where the cells that normally line the inside of the uterine cavity (known as endometrial cells) escape or implant outside the uterus in other areas of the pelvis. These implants can be as small as a pinhead or as large as a basketball and can exist close to the uterus, like on the ovaries, or even as far away as the bowel or even the lungs. Because of this diversity of location and appearance the symptoms of endometriosis can be multiple and divergent. Some common symptoms may include:
• Painful periods. Pelvic pain and cramping may begin before and extend several days into your period and may include lower back and abdominal pain.
• Pain with intercourse. Pain during or after sex is common with endometriosis.
• Pain with bowel movements or urination. You’re most likely to experience these symptoms during your period.
• Excessive bleeding. You may experience occasional heavy periods or bleeding between periods.
• Infertility. Endometriosis is first diagnosed in some women who are seeking treatment for infertility.
• Other symptoms. You may also experience fatigue, diarrhea, constipation, bloating or nausea, especially during menstrual periods.
The amount of endometriosis doesn’t necessarily correlate with the degree of symptoms. In other words, you can have a small amount and have major symptoms, or a large mass and few symptoms.
Understanding the Cause and Diagnosing the Condition
There is still some confusion as to the cause of endometriosis. Most agree that it is multifactorial, meaning that there are several potential sources and often times many conditions in the same patient that give rise to the endometriosis.
One major theory is called retrograde menstruation. This is where some of the shedding endometrial cells during a period escape back through the tubes and deposit inside the pelvic cavity. There, they continue to respond to the hormonal cycle and grow and proliferate.
The diagnosis of endometriosis can be a tricky task. Because of the diverse nature of its size, location and symptoms, endometriosis can masquerade as a number of other conditions. There is no conclusive simple tests to diagnose endometriosis. In other words, you can’t have blood drawn or an X-ray done to tell you if you have it. The diagnosis is based on what you describe, a few tests such as an ultrasound (mainly to rule out other conditions) and a good physical exam.
Often a surgical procedure called a laparoscopy is necessary to actually see and biopsy the lesions to complete the diagnosis. In many cases there can be a high index of suspicion that endometriosis exists based on your symptoms, but until you see it the final conclusion is up in the air.
Once the diagnosis is correctly made, treatment can ensue. The treatment of endometriosis can be divided into two broad categories, medical and surgical and often, successful treatment involves both.
• Hormonal contraceptives. Birth control pills, patches and vaginal rings help control the hormones responsible for the buildup of endometrial tissue each month. Using hormonal contraceptives—especially continuous cycle regimens—can reduce or eliminate the pain of mild to moderate endometriosis.
• Gonadotropin-releasing hormone (Gn-RH) agonists and antagonists. These drugs block the production of ovarian-stimulating hormones. This action prevents menstruation and dramatically lowers estrogen levels, causing endometrial implants to shrink. These drugs create an artificial menopause that can sometimes lead to troublesome side effects, such as hot flashes and vaginal dryness.
• Danazol. Another drug that blocks the production of ovarian-stimulating hormones, preventing menstruation and the symptoms of endometriosis. In addition, it suppresses the growth of the endometrium.
• Depo-Provera. This injectable drug is effective in halting menstruation and the growth of endometrial implants, thereby relieving the signs and symptoms of endometriosis. Its side effects can include weight gain, decreased bone production and depressed mood.
• Conservative surgery. This option removes endometrial growths, scar tissue and adhesions without removing your reproductive organs. Your doctor may do this procedure laparoscopically or through traditional abdominal surgery in more extensive cases.
• Hysterectomy. In severe cases of endometriosis, surgery to remove the uterus and cervix (total hysterectomy) as well as both ovaries may be the best treatment. Surgery is typically considered a last resort, especially for women still in their reproductive years.
Dr. Eaker is an Augusta Ob/GYN and author. He and his wife, Susan, have two teenage daughters.