Endometriosis is the presence of endometrial tissue (the lining of the inside of the uterus) in a location outside of the uterus.
Because the displaced endometrial tissue continues to function as it normally would, it grows and thickens with each menstrual cycle. It also breaks down and bleeds every month. Normal endometrial tissue exits the body through the vagina during a period, but endometriotic tissue is trapped. This can cause pain and irritation to the surrounding tissue, sometimes causing scar tissue, adhesions (organs sticking together), and infertility. Some women may have severe debilitating pain, while others have no symptoms at all. Endometriosis occurs most commonly within the pelvis but has been reported in nearly every other location of the body. Endometriosis on the ovary can cause cysts called endometriomas, which are filled with menstrual debris.
Endometriosis is relatively common, affecting women of child-bearing age. More than five million women in the US have endometriosis. Endometriosis affects women of all ethnicities but may be more common among Caucasian women. Rates are higher among women with very painful periods or chronic pelvic pain. Women with infertility are more likely to have endometriosis.[1-2]. Having a first-degree relative with endometriosis increases the risk of having endometriosis.
It is not known what causes endometriosis. There are several theories:
Symptoms can vary greatly depending on the location and severity of the endometriosis.
It is thought that endometriosis causes pain due to active bleeding, release of biochemicals that cause inflammation and pain, and even increased nerve sensitivity related to the implants. Adhesions and cysts created by endometriosis can cause significant pain as well. The extent of endometriotic implants is not correlated with the amount of pain a patient reports. It is possible for a patient to have severe debilitating pain yet only very small implants.
A definitive diagnosis can only be made by direct visualization of the endometriotic lesions. The best way to do this is by a diagnostic laparoscopy where a small thin camera is inserted into the abdomen and the entire pelvis can be inspected. Suspicious lesions can be resected for a diagnosis. Classically, endometriosis looks like dark brown “powder burn” spots within the pelvis, but it can also appear as raised reddish patches, whitish lesions, clear blebs, or yellowish-brown lesions.
Adhesions can also be present and can vary widely in severity. Endometriosis is classified by the American Society of Reproductive Medicine according to the location, depth, and spread of the disease.
There are several advantages to proceeding with a diagnostic laparoscopy. Once the endometriosis is identified, it can also be treated by resection or ablation. For patients who are found NOT to have endometriosis, this may help to avoid a long course of medical therapy directed toward the wrong diagnosis.
Since endometriotic lesions are very small, they are unable to be seen by imaging studies, such as ultrasound or CT scan. Exceptions to this are if endometriotic cysts are present in the ovaries.
Endometriosis is treated either medically, surgically, or a combination of both. Treatment is directed at pain control, halting the progression of disease, and infertility treatment. Since endometriosis can vary widely from patient to patient, treatment must be tailored to each individual, depending on her specific conditions and goals.
Medical management includes management of pain with analgesics, as well as hormonal suppression. Bear in mind that medical management is used to treat symptoms, but does nothing to improve fertility, treat adhesions, or resolve endometriomas.
Pain from endometriosis is most commonly treated with nonsteroidal anti-inflammatory drugs (NSAIDS) such as Ibuprofen, Motrin, and Advil. They are readily available, inexpensive, have low side effects, and are not addictive. Narcotic medications (such as Vicodin, Percocet, Tylenol #3) can be used for more severe pain but are associated with much greater side effects, and have the potential to create dependence or even addiction.
Hormonal medication is used to inhibit the growth of the endometriotic cells. Since the endometriotic implants grow in response to the rise and fall of hormones during a menstrual cycle, hormonal medication may help slow the growth by suppressing the cycle. Since many women experience their worst symptoms during their periods, hormonal management that stops periods from occurring can be helpful. Unfortunately, the effects of hormonal medication are temporary. Symptoms of endometriosis usually return once the medication is stopped
Advantages of these are that they are generally well-tolerated and can be taken indefinitely.
This medication is given as an injection either once per month or once every three months. It greatly reduces the amount of estrogen in the body and produces a temporary menopause-like state.Some studies have shown it to be more effective than birth control pills in treating endometriosis-related pain. It is not usually used as a first-line medication because it is very expensive and has significant potential side effects, such as loss of bone density, hot flashes, mood swings, depression, vaginal dryness and weight gain. Treatment is generally limited to six months due to risk of severe osteoporosis.
This oral anti-progesterone medication is generally given for up to six months.Because it acts like a weak male hormone, it can cause unacceptable side effects such as weight gain, acne, oily skin, increased facial hair, and smaller breasts, in addition to hot flashes, mood swings, and muscle cramps. It can also have a negative effect on cholesterol levels.
There are very few studies regarding use of acupuncture for the treatment of pain due to endometriosis. One study showed that it was more effective than traditional Chinese herbal medication.
At this time, there are no dietary guidelines for the treatment of endometriosis.
Surgical management is often performed for acute pain, symptoms that have failed medical management, presence of infertility, or presence of a pelvic mass. Surgical management is divided into two categories: definitive management and surgical management.
Hysterectomy with or without removal of the ovaries is for women who do not desire fertility or for women for whom conservative surgery has failed. Of all of the methods to treat endometriosis, a hysterectomy with removal of both ovaries results in the best long-term pain control. If the ovaries are preserved, the chance that symptoms will return is six times higher than if they are removed.
Conservative surgery preserves the uterus, tubes and ovaries as much as possible. Surgery is focused on removing endometriosis and improving symptoms. This is usually done for women who are not yet finished with childbearing or who have a milder form of the disease. Conservative surgery improves pain (80 percent of women reported improvement in their symptoms six months after surgery), but it does not cure endometriosis. Forty to 80 percent of women will have a recurrence of pain within two years of surgery. Following conservative surgery with medical management can help extend the length of pain control.
Burning the endometriotic implants to destroy the abnormal endometriotic implants.
Removing the endometriotic implants. Resection is more effective than fulguration for deep-infiltrating endometriosis.
Endometriomas should be completely removed and not just drained, otherwise there is an 88 percent chance it will return. Medical management of endometriomas larger than one cm has not shown to be effective.
Although endometriosis is a relatively common condition, it is never easy to be diagnosed. You need to find medical experts who will be by your side throughout the entire process: from your diagnosis, to exploring your options, to your endometriosis management or surgery.
If your case of endometriosis requires surgical management, you may require a Hysterectomy. However, there are also procedures that can preserve the uterus, tubes, and ovaries as much as possible, and at CIGC, we are all about performing the most minimally invasive procedures to treat your condition.
Why shouldn’t my OB/GYN perform my endometriosis surgery? Your OB/GYN may be a good doctor, but they are a generalist, not a surgical specialist. The majority of the practice of an OB/GYN is dedicated to Obstetrics care, so your doctor does not get nearly enough patient volume or practice to learn the best surgical techniques. The average OB/GYN performs 27 hysterectomies per year, while the average GYN surgeon performs 400. Since a heavy surgical volume is necessary to develop and maintain surgical expertise, it is easy to see why you should see a CIGC surgeon for your endometriosis surgery.
At CIGC, our specialists have made a commitment to surgery. We perform a higher volume of cases, see a wider range of case types, and undergo comprehensive training sessions. Our surgeons have learned advanced techniques and procedures, and have learned to perform even the most complex surgeries with the lowest complication rates. Whether you are undergoing a definitive surgery or a conservative surgery for your endometriosis, when you have it done at CIGC, you know you are working with a professional who concentrates only on this type of procedure.
Have the least invasive endometriosis surgery possible. Did you know that 60 percent of hysterectomies in this country are still performed open, which results in severe pain, higher complication rates, and a longer recovery period? Many clinics are also employing robotics, which require more incisions and leave more scars – not to mention they are more expensive. At CIGC, we have the advanced training to perform the surgery laparoscopically, which is far superior to open and robotic surgeries. It is less painful, leaves minimal scarring, and allows you to recover more quickly.
As a patient and consumer, you should be discriminating and analytical when choosing a surgeon. Know that CIGC surgeons are true surgical specialists: they are board-certified, fellowship-trained, and concentrate completely on GYN surgery. We have offices in Bethesda and Annapolis, Maryland, as well as in Reston, Virginia for your convenience. Give us a call at (888) 787-4379.