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Endometriosis is a painful disorder in which tissue similar to the endometrium, which normally lines the inside of your uterus, grows outside your uterus. Endometriosis most commonly affects the ovaries, fallopian tubes, and pelvic tissue. Endometrial-like tissue can occasionally be found outside of the pelvic organs.
Endometrial-like tissue behaves similarly to endometrial tissue, thickening, breaking down, and bleeding with each menstrual cycle. However, because this tissue cannot leave your body, it becomes trapped. Endometriomas can form when endometriosis affects the ovaries. Surrounding tissue can become irritated, leading to the formation of scar tissue and adhesions — bands of fibrous tissue that can cause pelvic tissues and organs to stick together.
Endometriosis can cause severe pain, particularly during menstruation. Fertility issues may also arise. Fortunately, there are effective treatments available.
WHAT ARE THE SYMPTOMS OF ENDOMETROSIS?
The most common symptom of endometriosis is pelvic pain, which is frequently associated with menstruation. Although many women experience cramping during their menstrual periods, those who have endometriosis typically report far worse menstrual pain than usual. Pain may also worsen over time.
Endometriosis is characterized by the following signs and symptoms:
- Period pain (dysmenorrhea): Pelvic pain and cramping can start several days before and last several days after a menstrual period. You might also experience lower back and abdominal pain.
- Pain with intercourse: Endometriosis frequently causes pain during or after sex.
- Pain during bowel movements or urination: These symptoms are most likely to occur during a menstrual period.
- Excessive bleeding: You may have heavy menstrual periods or bleeding between periods on occasion (intermenstrual bleeding).
- Infertility: Endometriosis is sometimes discovered in women seeking infertility treatment.
- Other symptoms and signs: During your menstrual cycle, you may experience fatigue, diarrhea, constipation, bloating, or nausea.
Your pain level may not be a reliable indicator of the severity of your condition. Endometriosis can be mild with severe pain or advanced with little or no pain.
Endometriosis is frequently confused with other conditions that cause pelvic pain, such as pelvic inflammatory disease (PID) or ovarian cysts. It is sometimes mistaken for irritable bowel syndrome (IBS), a condition that causes diarrhea, constipation, and abdominal cramping. Endometriosis can be accompanied by IBS, complicating the diagnosis.
WHAT ARE THE CAUSES OF ENDOMETRIOSIS?
Although the exact cause of endometriosis is unknown, some theories include:
Embryonic cell transformation: During puberty, hormones such as estrogen can transform embryonic cells — cells in their early stages of development — into endometrial-like cell implants.
Surgical scar implantation: Endometrial cells may attach to a surgical incision after a hysterectomy or C-section.
Endometrial cell transport: Endometrial cells may be transported to other parts of the body via blood vessels or the tissue fluid (lymphatic) system.
Immune system disorder: A problem with the immune system may prevent the body from recognizing and destroying endometrial-like tissue that develops outside the uterus.
Retrograde menstruation: Menstrual blood containing endometrial cells flows back through the fallopian tubes and into the pelvic cavity rather than out of the body during retrograde menstruation. These endometrial cells adhere to the pelvic walls and organ surfaces, where they grow, thicken, and bleed throughout the menstrual cycle.
Transformation of peritoneal cells: According to the "induction theory," hormones or immune factors promote the transformation of peritoneal cells — the cells that line the inner side of your abdomen — into endometrial-like cells.
WHAT ARE THE RISK FACTORS FOR ENDOMETRIOSIS?
Several factors increase your chances of developing endometriosis, including:
- Never having children
- Beginning your period at a young age
- Experiencing menopause at a later age
- Menstrual cycles that are shorter than 27 days
- Menstrual cycles that last more than seven days
- Higher estrogen levels in your body or a greater lifetime exposure to estrogen produced by your body
- Low BMI (body mass index)
- One or more family members (mother, aunt or sister) with endometriosis
- Any medical condition that prevents blood from leaving the body during menstruation.
- Reproductive system disorders
Endometriosis usually appears several years after menstruation begins (menarche). Endometriosis symptoms may improve temporarily during pregnancy and disappear completely during menopause, unless you are taking estrogen.
WHAT ARE THE COMPLICATIONS OF ENDOMETRIOSIS?
Infertility
The primary complication of endometriosis is infertility. Endometriosis prevents one-third to one-half of all women from becoming pregnant.
An egg must be released from an ovary, travel through a neighboring fallopian tube, be fertilized by a sperm cell, and attach to the uterine wall to begin development in order for pregnancy to occur. Endometriosis can obstruct the tube, preventing the egg and sperm from combining. However, the condition appears to have an indirect effect on fertility, such as by causing sperm or egg damage.
Despite this, many women with mild to moderate endometriosis can conceive and carry a pregnancy to term. Doctors sometimes advise endometriosis patients not to put off having children because the condition can worsen over time.
Cancer
Ovarian cancer occurs at higher than expected rates in endometriosis patients. However, the overall lifetime risk of ovarian cancer is already low. Endometriosis may increase that risk, according to some studies, but it remains relatively low. Although uncommon, endometriosis-associated adenocarcinoma can develop later in life in people who have had endometriosis.
HOW IS ENDOMETRIOSIS DIAGNOSED?
Your doctor will ask you to describe your symptoms, including the location of your pain and when it occurs, in order to diagnose endometriosis and other conditions that can cause pelvic pain.
The following tests are used to look for physical signs of endometriosis:
Pelvic exam: During a pelvic exam, your doctor feels (palpates) areas of your pelvis for abnormalities such as cysts on your reproductive organs or scars behind your uterus. Small areas of endometriosis are often difficult to detect unless a cyst has formed.
Ultrasound: This test generates images of the inside of your body using high-frequency sound waves. A transducer is either pressed against your abdomen or inserted into your vagina to capture the images (transvaginal ultrasound). To get the best view of the reproductive organs, both types of ultrasound may be used. A standard ultrasound imaging test will not tell your doctor whether you have endometriosis, but it will detect cysts associated with the disease (endometriomas).
Magnetic resonance imaging (MRI): An MRI is a test that uses a magnetic field and radio waves to create detailed images of your body's organs and tissues. An MRI can assist your surgeon with surgical planning by providing detailed information about the location and size of endometrial implants.
Laparoscopy: Your doctor may refer you to a surgeon in some cases for a procedure that allows the surgeon to see inside your abdomen (laparoscopy). While you're sedated, your surgeon makes a small incision near your navel and inserts a thin viewing instrument (laparoscope) to look for signs of endometrial tissue outside the uterus.
A laparoscopy can reveal the location, extent, and size of the endometrial implants. A tissue sample (biopsy) may be taken by your surgeon for further testing. Often, with proper surgical planning, your surgeon can treat endometriosis completely during the laparoscopy, requiring only one surgery.
WHAT ARE THE TREATMENTS FOR ENDOMETRIOSIS?
Endometriosis is typically treated with medication or surgery. The approach you and your doctor take will be determined by the severity of your signs and symptoms as well as your desire to become pregnant.
Doctors usually advise trying conservative treatment methods first, then deciding on surgery if that fails.
Medication for pain
To help relieve painful menstrual cramps, your doctor may recommend that you take an over-the-counter pain reliever, such as ibuprofen (Advil, Motrin IB, and others) or naproxen sodium (Aleve).
If you are not trying to conceive, your doctor may recommend hormone therapy in conjunction with pain relievers.
Hormone therapy
Supplemental hormones can sometimes help to alleviate or eliminate endometriosis pain. Endometrial implants thicken, break down, and bleed as hormone levels fluctuate during the menstrual cycle. Hormone therapy may slow endometrial tissue growth and prevent new endometrial tissue implants.
Hormone therapy is not a cure-all for endometriosis. You may experience a recurrence of your symptoms after discontinuing treatment.
Endometriosis therapies include:
- Progestin therapy: Progestin therapies, such as an intrauterine device containing levonorgestrel (Mirena, Skyla), a contraceptive implant (Nexplanon), a contraceptive injection (Depo-Provera), or a progestin pill (Camila), can stop menstruation and the growth of endometrial implants, potentially alleviating endometriosis signs and symptoms.
- Aromatase inhibitors: Aromatase inhibitors are medications that lower the amount of estrogen in your body. To treat endometriosis, your doctor may prescribe an aromatase inhibitor in conjunction with a progestin or a combination hormonal contraceptive.
- Hormonal contraceptives: Birth control pills, patches, and vaginal rings help to regulate the hormones that cause endometrial tissue to accumulate each month. When using a hormonal contraceptive, many women experience lighter and shorter menstrual flow. In some cases, using hormonal contraceptives, particularly continuous-cycle regimens, may reduce or eliminate pain.
- Gonadotropin-releasing hormone (Gn-RH) agonists and antagonists: These medications prevent menstruation by inhibiting the production of ovarian-stimulating hormones. Endometrial tissue shrinks as a result of this. Because these drugs induce menopause, combining a low dose of estrogen or progestin with Gn-RH agonists and antagonists may reduce menopausal symptoms such as hot flashes, vaginal dryness, and bone loss. When you stop taking the medication, your menstrual cycle and ability to become pregnant return.
Conservative surgery
If you have endometriosis and are trying to conceive, conservative surgery to remove the endometriosis implants while preserving your uterus and ovaries may improve your chances of success. If you have severe endometriosis pain, surgery may help; however, endometriosis and pain may return.
In more severe cases, your doctor may perform this procedure laparoscopically or, less commonly, through traditional abdominal surgery. Even in severe cases of endometriosis, laparoscopic surgery can usually cure it.
Your surgeon inserts a slender viewing instrument (laparoscope) through a small incision near your navel and instruments to remove endometrial tissue through another small incision during laparoscopic surgery. Your doctor may advise you to take hormone medication after surgery to help alleviate pain.
Fertility treatment
Endometriosis can make it difficult to conceive. If you're having trouble getting pregnant, your doctor may suggest fertility treatment under the supervision of a fertility specialist. Fertility treatment options include everything from stimulating your ovaries to produce more eggs to in vitro fertilization. Your personal situation will determine which treatment is best for you.
Hysterectomy with removal of the ovaries
The removal of the uterus (hysterectomy) and the ovaries (oophorectomy) was once thought to be the most effective treatment for endometriosis. Endometriosis specialists, on the other hand, are shifting away from this approach, instead focusing on the careful and thorough removal of all endometriosis tissue.
Menopause is caused by having your ovaries removed. Endometriosis pain may be relieved by a lack of hormones produced by the ovaries for some, but for others, endometriosis that remains after surgery continues to cause symptoms. Early menopause is also associated with an increased risk of heart and blood vessel (cardiovascular) disease, certain metabolic conditions, and premature death.
In those who do not want to become pregnant, removal of the uterus (hysterectomy) can sometimes be used to address signs and symptoms associated with endometriosis, such as excessive monthly bleeding and painful menses due to uterine cramping. Even if the ovaries are left in situ, a hysterectomy can have a long-term impact on your health, especially if performed before the age of 35.
Finding a doctor with whom you feel at ease is critical in the management and treatment of endometriosis. You should seek a second opinion before beginning any treatment to ensure that you are aware of all of your options and the potential implications.