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What is Endometriosis?

Endometriosis is the presence of endometrial tissue (the lining of the inside of the uterus), in a location outside of the uterus.

How does Endometriosis cause problems?

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{link to the “endometriosis” section under Infertiity Overview}. 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.

How common is endometriosis?

Endometriosis is relatively common, affecting women of child-bearing age. More than 5 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.[3]

What causes endometriosis?

It is not known what causes endometriosis. There are several theories:

  1. Retrograde menstruation: Endometrial cells shed into the uterus during a period are carried backwards through the tubes and into the pelvis where they can implant.
  2. Transport by Circulation: Endometrial cells are carried from the uterus to other areas of the body via lymphatics and blood vessels.
  3. Embryonic cell growth: Cells within the abdomen and pelvis turn into endometrial cells
  4. Faulty immune system: The immune system is unable to detect and destroy endometrial tissue outside of the uterus.

 

endometriosis overview

What are the symptoms?

Symptoms can vary greatly depending on the location and severity of the endometriosis.[1]

These include:

  1. Painful menses
  2. Pain with bowel movements
  3. Pain with sexual intercourse
  4. Low back pain
  5. Bowel or bladder symptoms, especially near the time of a period (for example, blood in urine or stool that only occurs during menses)
  6. Infertility

It is thought that endometriosis causes pain due to active bleeding, release of biochemicals that cause that cause inflammation and pain, and even increased nerve sensitivity related to the implants.[2] 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.

 

endometriosis symptoms

How do I know if I have endometriosis?

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.

Endometriosis

Endometriosis2

Endometriotic implant

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.

Stage - chart

 

Severe Endometriosis
Normal - Endometriosis
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 towards 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.

How is endometriosis treated?

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

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.

1. Pain Medication

Pain from endometriosis is most commonly treated with nonsteroidal anti-inflammatory drugs (NSAIDS) such as Ibuprofen, Motrin, and Advil. They are readily available, of low cost, have low side effects, and are not addictive. Narcotic medications (such as Vicodin, Percocet, Tylenol #3) can be used for more severe pain butare associated with much greater side effects, and have the potential to create dependence or even addiction.

2. Hormonal Medication

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

             1. Combined estrogen and progestin oral contraceptives

  • Birth control pills
  • Patch
  • NuvaRing

Advantages of these is that they are generally well tolerated and can be taken indefinitely.

2. Progesterone only

  • Depo Provera: Progesterone given as an injection in the muscle every 3 months. Most women will have either very light periods or no period at all with prolonged use. Possible size effects include weight gain, irregular bleeding, fluid retention and depression. Prolonged use may result in loss of bone mineral density but usually return to normal levels once the medication is discontinued and menstrual cycles resume.
  • Oral Progesterone: High dose progesterone taken daily will usually cause menstrual cycles to cease. This is a much cheaper option but can have unpleasant side effects such as weight gain, irregular bleeding, and mood changes.
  • Mirena Intrauterine Device (IUD): This type of IUD is implanted with levonorgestrel, a progesterone that is slowly released into the uterus. Unlike the other progesterone-only methods, systemic side effects such as weight gain and mood swings are uncommon. There is no loss in bone-mineral density. Irregular bleeding may occur for some women. Over 20% will not have a period at all after 1 year of use. Once inserted, the Mirena IUD is effective for 5 years but can be removed if the patient wishes to get pregnant. One study showed that the Mirena IUD was as effective as Depo-Lupron in managing pain due to endometriosis.
  • Implanon: A matchstick-size rod embedded with progesterone that is inserted just under the skin of the upper arm. Once implanted it is effective for 3 years and slowly releases the hormone into the body. The most frequent side effect is irregular bleeding. Less common side effects are weight gain, acne, and mood changes.

3. Depot-Lupron

This medication is given as an injection either once per month or every 3 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 flushes, mood swings, depression, vaginal dryness and weight gain. Treatment is generally limited to 6 months due to risk of severe osteoporosis.

4. Danazol

An oral anti-progesterone medication generally given for up to 6 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 flushes, mood swings, andmuscle cramps. It can also have a negative effect on cholesterol.

3. Acupuncture

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.

4. Diet

At this time there are no dietary guidelines for the treatment of endometriosis.

Surgical Management

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

Definitive Surgery:

Hysterectomy with or without removal of the ovaries is for women who do not desire fertility, for women for whom conservative surgery has failed. Of all 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 6 times higher than if they are removed.

Conservative Surgery:

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 milder disease. Conservative surgery improves pain (80% of women reported improvement in their symptoms 6 months after surgery) but it does not cure endometriosis. 40-80% of women will have a recurrence of pain within 2 years of surgery.Following conservative surgery with medical management can help to extend the length of pain control.

1. Fulguration of endometriosis

Burning the endometriotic implants to destroy the abnormal endometriotic implants.

2. Resection of endometriosis

Removing the endometriotic implants. Resection is more effective than fulguration for deep infiltrating endometriosis.

3. Resection of ovarian endometriomas

Endometriomas should be completely removed and not just drained, otherwise there is a 88% chance it will return. Medical management of endometriomas larger than 1cm has not shown to be effective.
Ovary with EndometriomaEndometrioma being Resected from Ovary

4. PresacralNeurectomy
For women with extreme pain that is concentrated in the middle of the pelvis, cutting the nerves that sense pain in the middle of the pelvis can improve symptoms.For women with generalized pain or pain in areas other than the middle of the pelvis, this procedure has not been shown to be more effective than resection or fulguration of endometriosis. Risks of this procedure include postoperative chronic constipation and urinary dysfunction.
endometriosis treatment

Why CIGS for Endometriosis Treatment?

Although endometriosis is a relatively common condition, it’s 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 Hysterectomy. However, there are also procedures that can preserve the uterus, tubes, and ovaries as much as possible, and at CIGS, we’re 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 doesn’t 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’s easy to see why you should see a CIGS surgeon for your endometriosis surgery.

At CIGS, 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’re undergoing a definitive surgery or a conservative surgery for your endometriosis, when you have it done at CIGS, you know you’re working with a professional who concentrates only on this type of procedure.

Have the least invasive endometriosis surgery possible. Did you know that 60% 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’re more expensive. At CIGS, we have the advanced training to perform the surgery laparoscopically, which is far superior to open and robotic surgeries. It’s less painful, leaves minimal scarring, and allows you to recover quickly.

As a patient and consumer, you should be discriminating and analytical when choosing a surgeon. Know that CIGS surgeons are true surgical specialists: they’re board certified, fellowship trained, and concentrate completely on GYN surgery. We have offices in Bethesda, MD; Annapolis, MD; and Reston, VA for your convenience. Give us a call at 1-888-787-4379.