Endometriosis
Endometriosis
Endometriosis is a noncancerous condition in which tissue similar to the endometrium (uterine lining) grows outside your uterus and adheres to other structures, most commonly in the pelvis, such as on the ovaries, bowel, fallopian tubes or bladder. Rarely it implants in other places, such as the liver, lungs, diaphragm and surgical sites. It is a common cause of pelvic pain and infertility.
Endometriosis Symptoms
Historically thought of as a disease that affects adult women, endometriosis is increasingly being diagnosed in adolescents, as well.
The most common symptoms are painful menstrual periods and/or chronic pelvic pain.
Others include:
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Diarrhea and painful bowel movements, especially during menstruation
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Intestinal pain
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Painful intercourse
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Abdominal tenderness
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Backache
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Severe menstrual cramps
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Excessive menstrual bleeding
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Painful urination
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Pain in the pelvic region with exercise
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Painful pelvic examinations
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Infertility
It is important to understand that other conditions aside from endometriosis can cause any or all of these symptoms and other causes may need to be ruled out. These include, but are not limited to, interstitial cystitis, irritable bowel syndrome, inflammatory bowel disease, pelvic adhesions (scar tissue), ovarian masses, uterine abnormalities, fibromyalgia, malabsorption syndromes and, very rarely, malignancies.
When endometriosis tissue grows outside of the uterus, it continues to respond to hormonal signals—specifically estrogen—from the ovaries telling it to grow. Estrogen is the hormone that causes your uterine lining to thicken each month. When estrogen levels drop, the lining is expelled from the uterus, resulting in menstrual flow (you get your period). But unlike the tissue lining the uterus, which leaves your body during menstruation, endometriosis tissue is essentially trapped.
With no place to go, the tissue bleeds internally. Your body reacts to the internal bleeding with inflammation, a process that can lead to the formation of scar tissue, also called adhesions. This inflammation and the resulting scar tissue may cause pain and other symptoms.
Recent research also finds that this misplaced endometrial tissue may develop its own blood supply to help it proliferate and nerve supply to communicate with the brain, one reason for the condition's severe pain and the other chronic pain conditions so many women with endometriosis suffer from.
The type and intensity of symptoms range from completely disabling to mild. Sometimes, there aren't any symptoms at all, particularly in women with so-called "unexplained infertility."
If your endometriosis results in scarring of the reproductive organs, it may affect your ability to get pregnant. In fact, 30 to 40 percent of women with endometriosis are infertile. Even mild endometriosis can result in infertility.
Researchers don't know what causes endometriosis, but many theories exist. One suggests that retrograde menstruation—or "reverse menstruation"—may be the main cause. In this condition, menstrual blood doesn't flow out of the cervix (the opening of the uterus to the vagina), but, instead, is pushed backward out of the uterus through the fallopian tubes into the pelvic cavity.
But because most women experience some amount of retrograde menstruation without developing endometriosis, researchers believe something else may contribute to its development.
For example, endometriosis could be an immune system problem or local hormonal imbalance that enables the endometrial tissue to take root and grow after it is pushed out of the uterus.
Other researchers believe that in some women, certain abdominal cells mistakenly turn into endometrial cells. These same cells are the ones responsible for the growth of a woman's reproductive organs in the embryonic stage. It's believed that something in the woman's genetic makeup or something she's exposed to in the environment in later life changes those cells so they turn into endometrial tissue outside the uterus. There's also some thinking that damage to cells that line the pelvis from a previous infection can lead to endometriosis.
Some studies show that environmental factors may play a role in the development of endometriosis. Toxins in the environment such as dioxin seem to affect reproductive hormones and immune system responses, but this theory has not been proven and is controversial in the medical community.
Other researchers believe the endometrium itself is abnormal, which allows the tissue to break away and attach elsewhere in the body.
Endometriosis may have a genetic link, with studies finding an increase in risk if your mother or sister had the disorder. No specific genetic mutation has been clearly linked with the disease.
Diagnosis - Endometriosis
Gynecologists and reproductive endocrinologists, gynecologists who specialize in infertility and hormonal conditions, have the most experience in evaluating and treating endometriosis.
The condition can be very difficult to diagnose, however, because symptoms vary so widely and may be caused by other conditions.
Among the ways doctors diagnose the disease are:
Laparoscopy. Currently, laparoscopy is the gold standard for the diagnosis of endometriosis and is commonly used for both diagnosis and treatment. Performed under general anesthesia, the surgeon inserts a miniature telescope called a laparoscope through a small incision in the navel to view the location, size and extent of abnormalities (such as adhesions) in the pelvic region.
However, merely looking through the laparoscope can't diagnose deep endometriosis disease, in which the endometrial tissue is hidden inside adhesions or underneath the lining of the abdominal cavity. More extensive dissection is needed to diagnose and treat this type of disease.
Many women have a combination of both deep and superficial (in which the endometrial tissue can be easily seen) endometrial disease.
Peritoneal tissue biopsy. During the laparoscopy, the doctor may remove a tiny piece of peritoneal tissue (the inner layer of the lining of the abdominal cavity) or other suspicious areas to help establish the diagnosis of endometriosis. This is recommended by the American College of Obstetricians and Gynecologists (ACOG), which notes that only an experienced surgeon familiar with the appearance of endometriosis should rely on visual inspection alone to make the diagnosis. A biopsy, however, is not mandatory to diagnose endometriosis, and a negative biopsy does not rule out the presence of this disease in other areas within the abdomen.
Ultrasonography, MRI and CT scan. An ultrasound uses sound waves to visualize the inside of your pelvic region, while an MRI uses magnets and a CT scan uses radiation. While these tests can occasionally suggest endometriosis, particularly ovarian endometriotic cysts called "endometrioma," or rule out other conditions, none can definitively confirm the condition.
At this point, there is no established noninvasive method to diagnosis endometriosis, which is frustrating for both women and their health care providers.
Pelvic exam. Your doctor will perform a physical examination, including a pelvic exam, to aid in the evaluation. The examination will not diagnose endometriosis but may allow your doctor to feel nodules, areas of tenderness or masses on the ovaries that may suggest endometriosis.
Medical history. A detailed medical history may offer your health care professional the earliest clues in making the correct diagnosis.