Endometriosis

Endometriosis is a condition where endometrial tissue, which normally lines the inside of the uterus, grows outside of the uterus. The tissue then attaches to other organs in the abdominal cavity, such as the ovaries, fallopian tubes and bowel.

Throughout the menstrual cycle, this endometrial tissue abnormally positioned outside of the uterus responds to hormones the same way as the endometrial tissue inside the uterus does: it thickens, breaks down and then sheds.

When tissue outside the uterus does this it causes inflammation and scarring. The resulting scar tissue can block the fallopian tubes preventing pregnancy from occurring.

This condition can also invade one or both ovaries and cause the formation of cysts of endometrial tissue, known as endometriomas. Endometriosis and endometriomas can reduce ovarian reserve and may affect egg quality.

Patients with endometriosis often experience pelvic pain, which can occur during, after or in between menstrual periods. They also may experience abnormal menstrual bleeding, pain during or after sexual intercourse, and infertility.

Causes of endometriosis

The cause of endometriosis is not known for certain, though there are a few theories. One theory suggests that small amounts of menstrual tissue flow back into the pelvic area through the fallopian tubes in a process known as “retrograde menstruation,” rather than exiting the cervix and vagina during a menstrual period. This tissue then grows on surrounding organs and tissues within the pelvis.

Another theory indicates there could be a genetic birth abnormality where endometrial cells develop outside the uterus during fetal development. Other theories describe the spread of endometrial tissue through the bloodstream and lymphatic system. This could explain the appearance of endometriosis in areas outside the pelvic or abdominal cavity.

There is some evidence that suggests that endometriosis may be hereditary, as women are more likely to develop the condition if an immediate family member like a sister or mother also has endometriosis.

Symptoms of endometriosis

The symptoms and complications from endometriosis vary greatly from patient to patient. The stage of the condition does not correspond with the presence and intensity of symptoms.

Symptoms often associated with endometriosis include:

• Chronic pain in the lower back or pelvis that gets worse during menstrual periods.
• Severe menstrual cramping.
• Diarrhea, constipation, bloating or nausea that worsens during menstruation.
• Painful urination or painful bowel movements during menstrual periods.
• Deep pain within the pelvis during sex.
• Spotting between menstrual periods.

Some individuals with endometriosis may experience problems getting pregnant naturally.

Endometriosis and infertility

Not all women with this condition will experience infertility, whereas others may be diagnosed with endometriosis after experiencing difficulty becoming pregnant. Endometriosis may contribute to infertility in several ways, including:

• Adhesions have blocked the fallopian tubes, preventing the sperm from reaching the egg and fertilizing it.
• Adhesions have changed the shape of the pelvic organs, in some cases causing them to stick together, making conception more difficult.
• Changes to egg production, number, and quality.
• The immune system is functioning differently, preventing pregnancy.

Diagnosing endometriosis

A review of symptoms, family history and pelvic exam can often lead a physician to an endometriosis diagnosis. Ultrasound imaging may also be used to find ovarian cysts.

But a formal and definitive diagnosis requires laparoscopic surgery. The surgeon will also be able to identify the stage or severity of the endometriosis via laparoscopy.

The condition can present in three basic categories: implants (areas of endometrial tissue that have attached to organs or muscle outside the uterus), endometriomas, and adhesions (scar tissue). The stage of the condition depends on the combination of implants, endometriomas and adhesions found during surgery. The staging criteria were established by the American Society for Reproductive Medicine and are as follows: Stage 1 (minimal), Stage 2 (mild), Stage 3 (moderate), Stage 4 (severe).

Most women have minimal or mild endometriosis, which involves small endometrial implants and minimal scarring. Patients with moderate and severe staging have a high number of large implants and more severe scarring on their pelvic organs.

Treatment 0ptions

Based on the stage of endometriosis and the goals of the woman, the provider will work to develop a treatment plan that works in her best interest. Common treatments include:

• Hormone-suppressing medications.
• Surgery. 
• Lifestyle changes.
• Ovulation induction medications.
• Intrauterine insemination.
• In vitro fertilization.

Treatment plans may include a combination of options to address symptoms and improve fertility.