Endometriosis
What is Endometriosis?
Endometriosis is a
condition where
endometrium (the lining of the uterus) is found
in locations outside the
uterus.
This misplaced
tissue may be found on the
ovaries, uterus,
bowel,
bladder utero-sacral ligaments (ligaments that hold the uterus in place), or
peritoneum (covering lining of the pelvis and abdominal cavity). On rare
occasions it can be found in other distant sites.
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What are the Symptoms of
Endometriosis?
Endometriosis is
typically detected through pain
which may be felt :
Endometriosis may also be found
during the investigation of infertility.
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What are the Causes of
Endometriosis?
Commonly during the menstrual period, cells can be found in the fluid behind the
uterus. The most widely held theory, retrograde
menstruation, states that
endometriosis occurs when
endometrial fragments attach to nearby
pelvic structures and grow. Other theories include tissue transplantation,
induction of changes in peritoneal lining cells, spread through uterine
veins, and direct extension through the
lymphatic system. No one theory seems to explain all cases.
As
endometrial cells are frequently seen in peritoneal fluid in all women at the
time of menses, one would expect endometriosis to develop in everyone. Obviously
this is not the case. Unfortunately, we don't really know why. Is the
immune system the cause? Immunological changes have been demonstrated in
women with endometriosis, however, it is uncertain whether these immunologic
findings are responsible for the endometriosis or are a result of the
inflammation caused by endometriosis.
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How Common is Endometriosis?
At the time of
tubal ligation 2-5% of women will have endometriosis, while between 25-50%
of infertile women have been reported to have endometriosis. Endometriosis
effects 5 million
U.S. women,
approximately 6-7% of all females, 30-40% of whom are infertile.
Staging System for Endometriosis
The American Society of Reproductive Medicine has established a grading system
to document the degree of severity of the disease. Unfortunately, this has not
been particularly helpful in predicting response to
therapy. Stage I constitutes a mild form of endometriosis whereas Stage IV is
the most severe form.
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What are the Most Common Forms of Treatment?
Surgical Treatment
Surgery can be an
effective way to control endometriosis. The one criteria is that your surgeon is
experienced and thorough. Many women have undergone multiple surgeries and still fail to find relief from their
pain. It is important that ALL the endometriosis is removed at the time of
surgery for good results. This includes endometriosis on the delicate internal
organs such as the bowel and the bladder, which requires exceptional surgical
expertise. The endometriosis can be removed by excision,
laser
ablation, vaporization, or coagulation. Many experts believe excision is the
best tool for removing the endometriosis to insure removal of the entire
lesion, as opposed to other methods which make it harder to tell if the
whole lesion has actually been removed.
The least invasive kind
of surgery, and therefore the most preferred, is called a
laparoscopy, in which a lighted
tube is inserted into the belly button of the endometriosis patient through
which the surgeon can see inside of the
abdominal cavity. Other tools for destroying endometriosis can be inserted
into other small incisions. This surgery can usually be performed on an
outpatient basis. Expert surgeons are able to perform very complicated surgeries
using laparoscopy.
A more invasive kind of
surgery is called
laparotomy, which requires hospitalization. It is considered major abdominal
surgery.
While surgery is not
considered a
cure, if it is administered by an expert surgeon, it can often provide
relief for many years. Will the endometriosis come back? Although most patients
gain long term relief, about 20% of patients will need a repeat surgery due to
recurrent symptoms of pain in the next 5 years.
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Medical Treatment
In general, the hormonal
treatments for endometriosis attempt to mimic the state of
pregnancy, that is, postpone
ovulation and thereby control the production of
estrogen in the body. Many women experience significant side effects while
taking these
hormones, some of which may be irreversible. In addition, many of these
treatments can only be taken for a short period of time, to eliminate other
significant health problems.
·
Oral
Contraceptives
Birth control pills
(usually a combination of estrogen and progesterone) were not originally created
for the treatment of endometriosis, but they are often used to keep the disease
in check. Some doctors prescribe them on a regular regime (taking a week of
placebo pills to allow your body to have a period), while others advise
their patients to take them on a continuous basis. When a woman is on continuous
birth control pills she doesn't take the sugar pills once a month that would
normally allow her body to have a period. Instead, the woman keeps taking the
hormone pills, and does not have a period. The theory is that if a woman does
not have her period, then the endometrial cells that are displaced in her
abdomen won't "bleed" either, causing pain and adhesions. Since
using birth control pills aren't officially approved for treatment of
endometriosis, no official guidelines exist in the medical literature about how
long it is safe for a woman to be on continuous birth control pills.
There is some disagreement
about the use of birth control pills for treatment of endometriosis because it
contains estrogen which is known to stimulate endometriosis. For this reason,
some doctors prescribe
progesterone only (Depo-Provera).
The side effects
associated with birth control pills are slight weight gain, break-through
bleeding, mood swings, and headaches.
Some of the brand names of
this drug include Lupron, Synarel, and Zoladex. These drugs were created
specifically for the treatment of endometriosis in 1990. It is reputed to
decrease the amount of estrogen in the body by taking control of the part of the
pituitary gland in the brain which produces the hormones that signal the
ovaries to produce estrogen. In more simple terms, these drugs force the body
into a state of
menopause.
GnRH agonists seem to be a
"wonder drug" for many women. But for others, they don't seem to work at all.
For many women, the side effects are nearly as unbearable as the symptoms of
endometriosis itself. Side effects include hot flashes, vaginal dryness,
headaches,
depression,
insomnia, and memory loss. GnRH drugs are only approved for up to 6 months
for pain relief and the recurrence rate is high. Many doctors see this drug as
useful only for buying time before trying to conceive, or before surgery (these
uses are controversial).
GnRH agonists (i.e. LUPRON)
is generally used if the patient has pain – they do not seem to help improve
patients fertility. Surgery and assisted reproductive technologies, such
as IVF, are the best
options for the treatment of
infertility due to endometriosis.
Danazol is a synthetic
testosterone derivative. It was the first drug approved for the treatment of
endometriosis, and it was widely used in the 1980's. It is similar to the GnRH
agonists in that by decreasing estrogen in the body it can shrink endometriosis
lesions and relieve pain. Danazol can also only be used for up to 6 months and
then must be discontinued.
Because Danazol acts like
the male hormone testosterone, it has many androgenic side effects. Some of
these include, acne, reduction in breast size, weight gain, abnormal facial and
body hair growth, and though rare, a deepening of the voice. Most of these are
considered temporary, but a few may be permanent.
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Alternative Treatments
Listed here are several of
the alternative methods, through which many women have found some relief.
Very few offer better relief than placebo, but some patients claim improvement.
Many women say they have
found some relief by giving up selected things in their diets. The most common
things mentioned are
caffeine, sugar, and alcoholic beverages. Women have reported good results
when following macrobiotic diets and diets which include organic vegetables and
few processed foods.
Soy is an estrogen like
herb. It is helpful in alleviating hot flashes in menopause, but may help
improve the PMS symptoms that patients with endometriosis experience.
Evening Primrose Oil.
This oil is an essential fatty acid that can be used to make prostaglandins in
our bodies. It has been theorized that women with endometriosis may have an
imbalance of prostaglandins, which are responsible for the stimulation and
inhibition of smooth muscle tissue such as is found in the uterus, the
intestines and the bladder. This has not been studied and probably doesn’t
work very well.
The B Complex Vitamins.
These vitamins have reportedly improved emotional symptoms of endometriosis and
have been scientifically linked to the breakdown of estrogen in the body.
Vitamin E & Selenium
When taken together, these two vitamins have been reported to decrease
endometriosis-related inflammation, although there are mixed feelings by
specialists about the use of Vitamin E by women with endometriosis because it
boosts the production of estrogen.
This is a traditional
chinese medicine treatment for endometriosis which involves the insertion of
very thin, long needles (or pressure) at various "energy points" on the body.
This treatment has received mixed reviews from women with endometriosis.
Techniques such as
yoga, biofeedback,
meditation, and regular exercise have all been reported to increase the
general well-being of women with endometriosis.
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Does Endometriosis
Affect Fertility?
In cases where
there is obvious distortion of the normal anatomy (i.e. blocking the fallopian
tubes), endometriosis is a known cause of fertility. In fact 30-40% of patients
with endometriosis are infertile. This is two to three times the rate of
infertility in the general population.
In patients with
endometriosis, the chance of
conception decreases by 20 – 30%. However, the long
term pregnancy rates are the same in patients with minimal endometriosis and
normal anatomy (i.e., open tubes) Studies provide contradicting information, but
the bulk of research at this time indicates that pregnancy rates are not
improved by treating minimal endometriosis.
We know that during in
vitro fertilization, endometriosis patients have normal hormonal profiles. There
is a tendency towards obtaining fewer eggs and it appears that eggs derived from
ovaries with endometriomas may have a lower fertilization rate and
implantation rate.
Immune System: The
immune system is affected by endometriosis and this may affect fertility.
Patients with endometriosis may
show decreased nature killer
cell function. In addition, complement, an immune component that breaks
apart abnormal cells, is higher in patients with endometriosis.
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Treatment of
Endometriosis-Related Infertility
Danazol, birth control pills, Lupron, Synarel, Zoladex, Depo-Provera and
Norplant have not been proven effective as either primary or adjunctive
therapy (combined with surgery) for endometriosis-related infertility. While the
use of medical treatment may decrease inflammatory reactions making surgical
correction easier and reduce endometriosis-related pain, use of these
medications in patients with minimal disease is of no proven benefit in treating
infertility.
Multiple studies have
reported a 4-5 times improvement in fecundity (monthly chance of conception)
with empirical treatment, superovulation combined with
intrauterine
insemination. (The medicines commonly used are Follistim®, Repronex®, Gonal
F® and Bravelle®.)
While complete removal
of all disease and restoration of normal anatomy should be the goal of any
surgical treatment, aggressive surgery may result in post-operative
adhesion (scar tissue) formation. The endoscopic surgeon may need to strike
a balance between excising all visible disease and limiting the risk of adhesion
formation. If surgical excision is incomplete or attempts at pregnancy are to be
delayed, it is advisable to plan continuous hormonal suppression following
surgery. (i.e. use Lupron)
In women with distorted
tubal-ovarian anatomy due to endometriosis, the first surgery is the most
effective. Repeat surgical interventions are less effective at restoring
fertility than the initial attempt, which is best performed by a skilled
endoscopist. Endometriosis is generally considered a progressive disorder and
aggressive management at the time of its discovery is appropriate.
Surgical treatment of
endometriosis consists of cautery, coagulation, excision or vaporization. As
most cul-de-sac endometriosis is generally deeper than it may at first appear,
excision should be the treatment of choice. Vaporization of adhesions on the
ovarian surface, bladder flap, and uterine peritoneum may be beneficial.
Treatment of ovarian
endometriomas has included removal of the
ovary, simple drainage, destruction of the cyst-lining with laser, bipolar
electrosurgery, monopolar electrosurgery, and excision of the ovarian
cyst. Although in many cases the cyst-lining can be stripped from inside the
ovary during laparoscopy, in approximately 30% of the cases, this cannot be
performed. In these cases, unless destruction of the lining is carried out, the
endometrioma will likely reoccur.
Pregnancy rates
following surgery generally range between 35-40% for severe endometriosis to
55-65% with milder disease. Surgical studies show that monthly pregnancy rates
are as low as 3-6% per month following surgical treatment of this disease.
Usually normal fertility can be achieved with ovulation induction and
intrauterine insemination.
In patients with normal
anatomy, it is reasonable to try 3 – 4 cycles of. If normal anatomy cannot be
restored or the patient has not been successful with ovulation and intrauterine
insemination, in vitro fertilization should be considered. In women with large
endometriomas, removal of the ovarian cyst may be necessary prior to proceeding
with in vitro fertilization.
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Developing a Treatment Plan
When determining appropriate course of treatment for this disease, it is
necessary to determine what is the most important to each patient: Improving
pain or improving fertility. Sometimes both cannot be accomplished using the
same treatment. Surgical treatment is best performed by skilled laparoscopic
surgeon who can balance your desired fertility with the need to aggressively
excise abnormal endometrial tissue, restore normal anatomy, and treat pain and
other symptoms. As this is a progressive, ongoing, long term disorder, patients
will do best to establish an ongoing relationship with a
physician who can provide appropriate care.
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Links for Endometriosis
Frequently asked
questions:
http://www.bioscience.org/books/endomet/babaknia.htm
Endometriosis association:
http://www.endometriosisassn.org/
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Date Page Last Edited:
10/06/2008
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