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Women’s Reproductive Health: Endometriosis

Ann Witt, M.D., and Natalie Staats Reiss, Ph.D., edited by Benjamin McDonald, MD

Endometriosis occurs when the endometrium, or the uterine lining, grows outside of the uterus. Most commonly this growth occurs in the abdominal cavity. Endometriosis occurs in approximately 5% of women.

Symptoms/Risks:

woman in painThe symptoms noticed most frequently by women who have endometriosis are pain in the pelvic area or difficulty getting pregnant. Pelvic pain, which sometimes increases during the period of time right before a woman's period, occurs in the majority of women with endometriosis.

A woman has an increased risk of developing endometriosis if she has a history of a shorter menstrual cycle (occurring closer to every 21 days rather than the average of every 28 days), prolonged menstrual bleeding (longer than 1 to 4 days), or an early onset of her first menstrual period (before age 12). Interestingly, there is a lower risk of endometriosis for women who smoke or who are overweight. This is striking, given that in most other situations obesity and smoking increase the risk of diseases. Obviously, however, women should not attempt to gain weight or start smoking to decrease their risk of endometriosis!

Diagnosis:

Initially, the diagnosis of endometriosis is based on symptoms such as abdominal pain along with long menstrual cycles. When there has been no improvement in symptoms despite treatment, or when a woman is trying to get pregnant, she may undergo laparoscopic surgery. Laparoscopy rules out other causes of abdominal pain, confirms the diagnosis of endometriosis, and can include a procedure to destroy extra tissue.

During laparoscopy, a woman will be put to sleep with anesthesia. Then, very small cuts are made on the woman's abdomen. These cuts allow the insertion of small tubes attached to a camera, which are used to see internal organs. After the cuts are made, a harmless gas is placed into the abdomen to allow better visualization of the organs. Using the camera, the surgeon determines which organs (e.g., ovaries, uterus, intestines) are affected by the endometrial tissue. Following the laparoscopy, the gas is removed from the abdomen. Sometimes, women experience stomach pain or cramping for a short period of time after the procedure. Typically, a woman recovers very quickly, often going home the same day.

Treatment:

The medical treatment of endometriosis focuses on stopping ovulation (the time in the menstrual cycle when an egg is released for fertilization by sperm) to minimize the growth of the endometrium. A woman can take "birth control pills", either combination estrogen and progesterone oral contraceptive pills (OCPs), or progesterone-only pills such as Medroxyprogesterone and Provera to block endometrial growth. The most common side effects of progesterone medications are breast tenderness, uterine spotting and depression.

If a woman does not respond positively to OCPs or progesterone pills, then laparoscopic surgery to destroy the extra endometrial tissue is often performed. Destroying or removing the extra tissue helps to decrease pain and increases the possibility of becoming pregnant. Less commonly, the medications Danazol and Gestrinone are used to treat endometriosis. These drugs lower estrogen levels and increase androgen levels to stop ovulation. Negative side effects include increased cholesterol levels, weight gain, and some male physical traits such as deepening of the voice and excessive hair growth.

When a woman's main symptom is pelvic pain, non-steroidal anti-inflammatory medications, like ibuprofen, are used along with OCPs. If a woman's main concern is fertility, laparoscopic tissue destruction is usually used earlier in the course of treatment. Women who are interested in reading more information about infertility can visit that topic center.

Prognosis:

Endometriosis can worsen, improve or remain unchanged over the years. If a woman requires treatment, surgery may have lower rates of recurrence (developing endometriosis again) than other forms of medical treatment. Studies on the frequency of recurrence are limited. The available information suggests that the rate of recurrence five years after laparoscopic treatment is lower compared to other medical treatments such as OCP's. While the choice of treatment may affect recurrence, the severity of a woman's endometriosis is also a factor (more severe cases have a higher risk of recurrence).