Endometriosis is a gynecologic condition in which tissues similar to the lining of the uterus (called “endometrial stroma and glands”– normally located only inside the uterus) are found elsewhere in the body. Endometriosis lesions can be found anywhere in the pelvic cavity: on the ovaries, the fallopian tubes, the pelvic sidewall and the uterosacral ligaments. Other less common sites include the bladder, bowel, intestines, colon, appendix, and rectum.
These lesions, termed “endometriosis implants”, respond to female hormones like estrogen and progesterone, just like the endometrial lining does. They can even bleed in microscopic amounts just like a menstrual period. This bleeding leads to local irritation and inflammation in the sites of implantation. The inflammation causes scarring to occur which can bind-up pelvic organs to the point of dysfunction and pain. A few examples of this are:
- The fallopian tubes can become scarred to the point of blockage and prevent sperm and egg interaction. In extreme cases, reproductive organs are fused together and do not function properly.
- The ovaries can become filled up with endometriosis cysts (called an endometrioma). These are called “chocolate cysts” because the congealed blood inside looks like chocolate syrup. These can have deleterious effects on egg production and ovulation.
- Any organ that has endometriosis and scarring on it can experience pain from inflammation and adhesions to other organs.
Women with endometriosis typically present with pelvic pain, infertility or a pelvic mass (usually an endometrioma, “chocolate cyst”). The most common symptom of endometriosis is pelvic pain. The pain often correlates to the bleeding days of a menstrual period, but a woman with endometriosis may also experience pelvic pain at any time. For many women, the pain of endometriosis is so severe and debilitating that it impacts their lives in significant ways. All of these symptoms point towards endometriosis, but the only true way to diagnose the condition is through a surgical exploration of the abdominal cavity, called laparoscopic (or “minimally invasive”) surgery.
In terms of fertility, there is a strong association between endometriosis and infertility, but a true “cause-and-effect” relationship has not been firmly established. It is estimated that in untreated women with endometriosis who are trying to conceive, the monthly fecundity (chance of pregnancy each month) is 2-10%, compared to 15-20% in the general population. Some studies have suggested that 30%-50% of women with endometriosis have difficulty conceiving.
There are several proposed mechanisms for endometriosis causing infertility that include:
- The distorted pelvic anatomy from scarring and adhesions can alter the function of the fallopian tubes, ovaries and uterus.
- Inflammation in the abdominal and pelvic cavity can irritate the normal delicate environment required for fertilization and implantation.
- Hormonal disturbances from endometriosis can impair ovulation and the hormones necessary for implantation and support of the embryo in early pregnancy.
In terms of treatment, it is important to clarify your goals. Some patients do not wish to conceive and just want amelioration of their pain. If this is the case, there are medical treatments (such as anti-inflammatory medications) and hormonal manipulations such as birth control pills and injections called leuprolide acetate, (Lupron®), that can control the painful effects of endometriosis, but they will not help in conception. Surgical destruction and removal of endometriosis has also been shown to decrease pain for longer periods of time, but repeat surgery may be required in the future.
For patients wishing to conceive, the best scientific evidence points to the need for an aggressive treatment plan. This will likely include stimulating medications to induce ovulation of several eggs per month in conjunction with intra-uterine inseminations (IUI). Often patients with endometriosis need advanced treatments such as injectable medications (gonadotropins) and frequently IVF. It is the experience of many fertility specialists (called Reproductive Endocrinology & Infertility specialists) that endometriosis results in much greater fertility problems than the severity of the endometriosis suggests. This is likely due to the harmful inflammatory and immunologic effects that are hard to quantify outside research investigations.
It is important to clarify your goals. The diagnosis and care of patients with endometriosis is often a complex situation that requires specialized training, patience, and skill. Improving your quality of life, while helping you conceive and build your family, is our top concern.
For more information about endometriosis contact us.