Endometriosis is an illness that affects women of childbearing age with debilitating pain and infertility. Endometriosis causes multiple symptoms that can be difficult to manage, diagnose, and treat. It is thought to affect 5-10% of pre-menopausal women in the United States.
Alternative Names for Endometriosis
The name endometriosis comes from the Latin form of the words “endo,” meaning “inner;” the portion of the word “metri” refers to the uterus or womb; and “-osis” means “condition.” Although the name describes the adverse condition of the uterus, endometriosis can also affect surrounding structures within the pelvis and abdominal cavity.
Endometriosis has also been called by other names that refer to the unusual results of the disease itself. It has been named adenomyosis, which is a type of endometriosis in which uterine lining implants and grows within the muscular walls of the uterus itself. Endometriosis may also be referred to as chocolate cysts or endometriomas, both of which are by-products of the disease.
Chocolate cysts are pockets of blood that are found growing outside the uterus within the pelvic cavity. Because the blood inside the cyst is old, it has a dark appearance, similar to that of chocolate. Endometriomas are another name for growth of endometrial tissue found in various locations throughout the abdominal and pelvic cavity.
Symptoms of the Disease
Symptoms of endometriosis are similar but may vary in severity. Some women may suffer from extreme pain and heavy bleeding with their menstrual periods. Other women may be unaware that they are affected by endometriosis until they receive a diagnosis of infertility. The following symptoms are indications of endometriosis:
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- Pelvic pain
- Heavy bleeding with menstrual periods
- Spotting or bleeding between periods
- Pain with urination
- Pain with bowel movements
- Gastrointestinal symptoms, such as diarrhea or constipation
- Pain with intercourse
Pelvic pain is the most common sign for women experiencing endometriosis. Pain may be located within the pelvic area, near the uterus, or it may radiate to the back. Some women feel pain near the location of their ovaries; it may radiate into the abdomen, down the legs, or up into the shoulder. The pain can be a constant dull ache, sharp and intermittent, or a combination of both. The severity of pain varies with each woman, some experiencing acute pain that is debilitating. Others suffer from a constant, dull ache. A percentage of women experience no pain with endometriosis.
Endometriosis can cause excessive bleeding during a woman’s menstrual period, resulting in heavy flow. The period may last significantly longer than average, continuing many days or even weeks at a time. Menstrual flow may have large clots and be associated with severe uterine cramping. A heavy menstrual flow is difficult for many women to manage and can be extremely uncomfortable.
Timetable & Menstrual Cycle
The end of a menstrual period typically indicates that approximately a month will pass before starting another. For the patient with endometriosis, there may be spotting of blood or recurring bleeding similar to menstrual flow but lasting for a shorter duration. This occurs mid-cycle and may be associated with menstrual symptoms, such as cramps. This can be challenging to manage for many women, as they may be unprepared for breakthrough bleeding mid-cycle.
Some women with endometriosis experience pain with urination. Endometrial tissue may migrate from the inside of the uterus to the bladder or ureters and implant itself. The action of emptying the bladder can then cause pain during urination or during the sensation of having to void. There may be small amounts of blood that is seen in the urine.
Bowel Movement Issues
Pain during a bowel movement is an associated symptom of endometriosis, as the bowel and rectum become locations for the implantation of endometrial tissue. The pain and bleeding at these sites results in pain during movement of the bowels. A woman may also experience small amounts of blood in the stool.
Infertility & Female Issues
Infertility is closely associated with endometriosis. For women that do not experience pain or bleeding symptoms that are typical of the disease, infertility is often the source of diagnosis. There can be multiple sources of infertility for the woman suffering from endometriosis. The implantation of endometrial lining in various parts of the pelvic cavity leads to bleeding and scar tissue formation that can block the process of fertilization. For example, scar tissue build-up within the fallopian tubes can prevent a released egg from finding its way to the uterus for fertilization.
A hormonal imbalance is often associated with endometriosis, and in order to achieve pregnancy and successfully grow a baby to term, a delicate balance of hormones must remain in the body. Endometriosis involves an imbalance that may prevent implantation of a fertilized egg into the uterus, or the growth of the egg into a fetus, resulting in miscarriage.
Some women experience gastrointestinal symptoms such as diarrhea or constipation. Lesions of endometrial lining may localize on the bowel or intestine, causing a change in bowel habits and producing loose stools or reducing the frequency of bowel movements.
Endometrial lesions may occasionally appear in or near the vagina or cervix of a woman, or they may deposit in the peritoneal cul-de-sac. The cul-de-sac is the area located between the back wall of the uterus and the rectum. Endometrial lesions found in these locations can cause pain during sexual intercourse.
Fatigue is the result of several symptoms of endometriosis, including management of chronic pain and blood loss. Any chronic disease that leaves a patient handling negative symptoms such as pain can become exhausting. The body utilizes some of its own resources to respond to pain, but after an extended period of time, the body’s energy may become depleted, resulting in fatigue.
Large amounts of blood loss through menstruation or internal bleeding from lesions can also result in fatigue. For women with exceptionally heavy amounts of bleeding, laboratory tests such as an iron panel should be checked for possible anemia.
The management of chronic disease also leads to the possibility of depression for women with endometriosis. Living with constant pain, as well as experiencing discomfort during typically normal activities can be exhausting. Infertility for a couple with a desire to have a child can be a heartbreaking event, leaving them hoping for a baby but feeling depressed because of the illness. Women diagnosed with endometriosis should consider the possibility of depression as a potential long term effect of the disease and seek treatment if necessary.
Causes of Endometriosis
There is not one exact cause of endometriosis, but several theories have developed, all of which have research to back up some of their ideas. The process of menstruation typically develops as a monthly episode where the body releases an egg from one of two ovaries located near the uterus. The ovaries are connected to the uterus with the fallopian tubes, each a passageway for the egg to travel as it moves toward fertilization.
During the time preceding ovulation, the uterus has built up a healthy amount of interior lining made of blood and tissue that will provide a place for a fertilized egg to implant and then grow into a fetus. Without fertilization, the egg is shed along with this endometrial lining approximately once a month during menstruation.
The entire process of ovulation through menstruation is managed by specific hormones within the body. Two common hormones, called estrogen and progesterone are responsible for many of these factors, such as the maturation of an egg before ovulation and the development of endometrial lining in the uterus.
Endometriosis occurs when some of the endometrial lining that is normally found in the uterus migrates to other parts of the pelvic cavity and implants itself on other structures. These endometrial lesions can be found on many parts of the body, including the ovaries, the fallopian tubes, the bowel, the bladder, the ureters, or the wall of the peritoneum.
In rare cases, lesions have been found on the diaphragm and even the lungs of some women. Although the lesions implant on areas outside the uterus, during the process of menstruation, the lesions bleed just as if they were still inside the uterus. It is this internal bleeding that causes pain and the multiple symptoms associated with endometriosis.
The reasons for the wandering endometrial tissue are unclear, but are thought to be related to one of the hormones affecting menstruation: estrogen. Increased amounts of estrogen have impacted the quantity of endometrial tissue found in other parts of the body, and is responsible for the monthly bleeding associated with the lesions.
Another theory that may be a source of endometriosis is the concept of retrograde menstruation. In this situation, the body proceeds through the menstrual cycle as usual, but when it is time for the interior lining of the uterus to be shed, some of the blood and tissue travels up into the fallopian tubes and toward the ovaries where it exits into the pelvic cavity. This then allows some particles of the endometrial lining to attach to various internal organs and continue the process of endometriosis.
A genetic factor has also been attributed to the development of endometriosis. The risk of a woman developing the disease is ten times greater if she has close family member, such as a mother or sister, with endometriosis. The role of hormones in the process of heredity contributes to some of the changes that occur during the menstrual cycle, giving women that are direct relatives related menstrual symptoms, and therefore a genetic probability of disease development.
Risk factors for developing endometriosis are related to some of the causes of the disease. Endometriosis is primarily a disease that affects women during their childbearing years, although it can also be found in post-menopausal women. Because of this, a woman of childbearing age (between menarche and menopause) is at a greater risk of developing endometriosis. Women that have a close female relative with the disease are also at greater risk. In addition, those women that take estrogen supplements are at risk due to the presence of the hormone related to the disease.
There is little that can be done to prevent endometriosis, especially for women that are unaware that they have the illness. Endometriosis is a disease that is treated after symptoms appear. Awareness seems to be the highest form of prevention, as well as taking care of the body. Women should be aware of the risk factors associated with endometriosis and monitor their own body system for signs of the disease.
For women that suffer from heavy periods, vitamin supplements that contain iron may be effective in handling fatigue. The use of hormone supplements should be well monitored by a physician to determine if the body may be developing a hormone imbalance.
Diagnosis of endometriosis is definitively made only by surgery. A physician can recommend surgery if a patient presents with the symptoms of endometriosis that is not managed by pain control or if she desires a pregnancy. A doctor should take a complete history of the woman, including menstruation, number of pregnancies, sexually transmitted diseases, and sexual history. The physician may ask about family members with endometriosis to find a possible genetic link. Lab work may be ordered to check for estrogen and progesterone levels.
If a woman is seeking treatment for infertility, a physician may attempt to treat the condition before performing surgery to rule out endometriosis. This typically occurs if infertility is one of the only symptoms. Infertility procedures, such as the administration of medications to induce ovulation, as well as intrauterine insemination may be performed in an attempt to achieve pregnancy first.
A physician may perform a procedure called a hysterosalpingogram (HSG), which is a test to determine if the fallopian tubes are clear. If a woman is presenting with infertility and may have endometriosis, lesions may have appeared within the fallopian tubes, causing blockage or scar tissue that can prevent an egg from reaching the uterus for fertilization. During an HSG, a doctor administers a solution into the cervix of the patient where it travels up into the uterus, through the fallopian tubes, and into the ovaries.
The solution can be seen on x-ray and the physician is able to take radiographic images of the process to see the flow of fluid and determine if the fallopian tubes may be blocked. A blockage does not indicate definitively that endometriosis is present, but it can explain a reason for infertility, giving the doctor a reason to look for other possible signs of endometriosis.
Surgical procedures to diagnose endometriosis include a laparoscopy to look for lesions in the pelvis. The doctor makes several small incisions in the abdomen and inserts a tube with a lighted camera on the end into the pelvic cavity. This enables the physician to look for lesions on organs and throughout the pelvis. If lesions are found, they can then be removed. The use of laparoscopy gives a physician a definite diagnosis of endometriosis and can help control some pain of the disease following the procedure.
Endometriosis is diagnosed according to stages, which depends on the severity of lesions, not the associated symptoms. Stage one is considered minimal, and there are very few lesions found outside the uterus. Stage two is referred to as mild endometriosis. There are more lesions and they are found deeper within the tissue.
Scar Tissue & Painful Side Effects
There is also the presence of scar tissue. Stage three is moderate endometriosis, which includes everything found in stages one and two, as well as implantations found on the ovaries. Stage four is inclusive of all stages, with large lesions and significant amounts of scar tissue. Stage four is considered severe endometriosis.
Pain and symptoms are not part of the diagnosis of which stage the disease is in. A woman may have severe pain, but with minimal lesions. Alternatively, a woman may present with only a diagnosis of infertility and no other symptoms yet have a diagnosis of stage four endometriosis with extensive scar tissue.
Treatment of endometriosis is based on the stage of life of the woman and the severity of symptoms. For the childbearing woman who wishes for a future pregnancy, symptoms are treated through pain medication and other comfort measures. For example, pelvic pain can be helped with the use of anti-inflammatory medications and a heating pad to reduce discomfort. Surgery to remove lesions and scar tissue is also an option for the woman suffering severe symptoms but who still plans to have children. Surgery can reduce pain and bleeding associated with the disease and retains the internal structures needed for pregnancy.
Women that do not wish for a pregnancy have other options for treatment beyond comfort measures. The use of hormone therapy, particularly that found in oral contraceptives can reduce symptoms of pain and regulate menstrual bleeding. Progesterone is a hormone that can counterbalance excessive estrogen, the cause of many endometriosis symptoms.
Surgery can also be an option for painful symptoms. Beyond laparoscopy to remove lesions and scar tissue, there is an option of removal of the uterus, fallopian tubes, and ovaries. This provides relief from excessive menstrual bleeding and can help with chronic pain, but is an invasive option that is reserved for the woman with particularly difficult symptoms.
Endometriosis can be a difficult disease to detect and to treat. Millions of women suffer from this disease throughout their childbearing years, making conception difficult and monthly periods unmanageable. Through the help of a physician, women suffering from endometriosis can be accurately diagnosed, and depending on their stage of life and desires, can be treated and find relief from these difficult symptoms.