Exploring Endometriosis with Dr. Carla Nicholson Daley

What is Endometriosis?

Endometriosis is a disorder in which tissue similar to the lining of your uterus grows outside of your uterine cavity. The lining of your uterus is called the endometrium.

Endometriosis occurs when endometrial tissue grows on your ovaries, bowel, and tissues lining your pelvis. It’s rare for endometrial tissue to spread beyond your pelvic region, but it’s not impossible. Endometrial tissue growing outside of your uterus is known as an endometrial implant.

The hormonal changes of your menstrual cycle affect the misplaced endometrial tissue, causing the area to become inflamed and painful. This means the tissue will grow, thicken, and break down. Over time, the tissue that has broken down has nowhere to go and becomes trapped in your pelvis.

This tissue trapped in your pelvis can cause:

• irritation
• scar formation
• adhesions, in which tissue binds your pelvic organs together
• severe pain that occurs during the menstrual cycle
• fertility problems

Endometriosis symptoms

The symptoms of endometriosis vary. Some people experience mild symptoms, but others can have moderate to severe symptoms. The severity of your pain does not indicate the degree or stage of the condition. You may have a mild form of the disease yet experience agonizing pain. It’s also possible to have a severe form and have very little discomfort.

It’s important to note that you may not experience any symptoms.

Pelvic pain is the most common symptom of endometriosis. You may also have the following symptoms:

• painful periods
• cramps 1 or 2 weeks around menstruation
• heavy menstrual bleeding or bleeding between periods
• infertility
• pain during sexual intercourse
• discomfort with bowel movements
• lower back pain that may occur at any time during your menstrual cycle

It’s important that you get regular gynecological exams, which will allow your gynecologist to monitor any changes. This is particularly important if you have two or more symptoms.

Endometriosis treatment

Understandably, you want quick relief from pain and other symptoms of endometriosis. This condition can cause challenges in your day-to-day activities if it’s left untreated. Endometriosis has no cure, but its symptoms can be managed.

Medical and surgical options are available to help reduce your symptoms and manage any potential complications. Your doctor may first try conservative treatments. They may then recommend surgery if your condition does not improve.

Everyone reacts differently to these treatment options. Your doctor will help you find the one that works best for you.

Treatment options include:

Pain medications

You can try over-the-counter pain medications such as ibuprofen but be advised that these aren’t effective in all cases.

Hormone therapy

Taking supplemental hormones can sometimes relieve pain and stop the progression of endometriosis. Hormone therapy helps your body regulate the monthly hormonal changes that promote the tissue growth that occurs with endometriosis.

Hormonal contraceptives

Hormonal contraceptives decrease fertility by preventing the monthly growth and buildup of endometrial tissue. Birth control pills, patches, and vaginal rings can reduce or even eliminate the pain in less severe endometriosis.

The medroxyprogesterone (Depo-Provera) injection is also effective in stopping menstruation. It stops the growth of endometrial implants. It relieves pain and other symptoms. This may not be your first choice, however, because of the risk of weight gain, decreased bone production, and an increased incidence of depression in some cases.

Gonadotropin-releasing hormone (GnRH) agonists and antagonists

People take what are called gonadotropin-releasing hormone (GnRH) agonists and antagonists to block the production of estrogen which stimulates the ovaries. An example of a GnRH agonist is Lupron Depot, an injectable, while Elagolix, which is taken orally, is an antagonist. Both can suppress estrogen production.

Estrogen is the hormone that’s mainly responsible for the development of sexual characteristics in people assigned female at birth. Blocking the production of estrogen prevents menstruation and creates artificial menopause.

GnRH therapy has side effects like vaginal dryness and hot flashes. Taking small doses of estrogen and progesterone at the same time can help to limit or prevent these symptoms.

Getting a diagnosis and starting treatment options early in the disease can be challenging. Thinking about — or coping with — symptoms like fertility issues and pain coupled with fear possibly setting in about getting relief can be stressful.

It’s important to address your mental wellness as part of your overall well-being. Consider finding a support group and educating yourself more on the condition. Taking these steps can be helpful in creating a well-balanced approach to managing your condition.

Other drugs are being studied that may improve symptoms and slow disease progression.

Conservative surgery

Conservative surgery is typically used for people who want to get pregnant or who experience severe pain and hormonal treatments are not working. The goal of conservative surgery is to remove or destroy endometrial growths without damaging the reproductive organs.

Laparoscopy, a minimally invasive surgery, is used to both visualize and diagnose endometriosis. It is also used to remove the abnormal or displaced endometrial tissue. A surgeon makes small incisions in the abdomen to surgically remove the growths or to burn or vaporize them.

Lasers are now commonly used to destroy this “out of place” tissue.

Last-resort surgery (hysterectomy)

Your doctor may recommend a total hysterectomy as a last resort if your condition does not improve with other treatments.

During a total hysterectomy, a surgeon removes the uterus and cervix. They also remove the ovaries because these organs make estrogen, and estrogen can cause the growth of endometrial tissue. Additionally, the surgeon removes visible implant lesions.

Two other types of hysterectomies are performed based on the condition a person is being treated for.

A subtotal — also referred to as partial or supracervical — hysterectomy removes the upper part of the uterus, leaving the cervix in place.

A radical hysterectomy is typically performed when cancer is present. It removes the entire uterus, cervix, and the top part of the vagina.

While a hysterectomy can treat endometriosis it is not a cure. You’ll be unable to get pregnant after a hysterectomy. If you’re thinking about starting a family, get a second medical opinion before agreeing to surgery.

What causes endometriosis?

During a regular menstrual cycle, your body sheds the lining of your uterus. This allows menstrual blood to flow from your uterus through the small opening in the cervix and out through your vagina.

The exact cause of endometriosis isn’t known. There are several theories regarding the cause, although no one theory has been scientifically proven.

One of the oldest theories is that endometriosis occurs due to a process called retrograde menstruation, which 90 percent of women experience, according to research. This happens when menstrual blood flows back through your fallopian tubes into your pelvic cavity instead of leaving your body through the vagina.

Another theory is that hormones transform the cells outside the uterus into cells similar to those lining the inside of the uterus, which are known as endometrial cells.

Others believe the condition may occur if small areas of your abdomen convert into endometrial tissue. This may happen because cells in your abdomen grow from embryonic cells, which can change shape and act like endometrial cells. It’s not known why this occurs.

These displaced endometrial cells may be on your pelvic walls and the surfaces of your pelvic organs, such as your bladder, ovaries, and rectum. They continue to grow, thicken, and bleed over the course of your menstrual cycle in response to the hormones of your cycle.

It’s also possible for the menstrual blood to leak into the pelvic cavity through a surgical scar, such as after a cesarean delivery, also commonly called a C-section.

Another theory is that the endometrial cells are transported out of the uterus through the lymphatic system. Still another theory purports it may be due to the immune system not working properly in destroying errant endometrial cells.

Some believe endometriosis might start in the fetal period with misplaced cell tissue that begins to respond to the hormones of puberty. This is often called Mullerian theory.

The development of endometriosis might also be linked to genetics or even environmental toxins.

Endometriosis stages

Endometriosis has four stages or types. It can be any of the following:

• minimal
• mild
• moderate
• severe

Different factors determine the stage of the disorder. These factors can include the location, number, size, and depth of endometrial implants.

Stage 1: Minimal

In minimal endometriosis, there are small lesions or wounds and shallow endometrial implants on your ovaries. There may also be inflammation in or around your pelvic cavity.

Stage 2: Mild

Mild endometriosis involves light lesions and shallow implants on the ovaries and the pelvic lining.

Stage 3: Moderate

Moderate endometriosis involves many deep implants on your ovaries and pelvic lining. There can also be more lesions.

Stage 4: Severe

The most severe stage of endometriosis involves many deep implants on your pelvic lining and ovaries. There may also be lesions on your fallopian tubes and bowels.