Endometriosis




Normal
Abnormal
  • The endometrium is the tissue located inside the uterus, as the inner lining.  Normally, the uterus is the only place this tissue should be found.  In the course of the normal menstrual cycle, the endometrium changes in size, structure, and function in direct relation to fluctuations in female hormones.  Endometriosis occurs when endometrial tissue becomes located outside the uterus.
  • The prevalent theories of the cause of endometriosis include retrograde menstruation (postulating a back flow of endometrium outside the uterus during menstruation), and the spread of endometrium via lymphatic channels (i.e., blood vessels) to other sites.  Common abnormal places for this to occur are around the ovaries, fallopian tubes (tubes that carry eggs from the ovaries to the uterus), colon, and rectum.  It rarely spreads to distant sites, such as the vagina, cervix, lungs, legs, stomach, spleen, gallbladder, and breasts.
  • Since endometrial tissue fluctuates in size and structure in the course of menstrual flow, women with endometriosis will notice a pattern of pain or bleeding that correlates with their cycle.  For example, if endometriosis occurs in the colon (bowels), then at the end of their cycle women with this condition will experience pain and Constipation caused by the tissue pushing down on the bowels.

  • Aching pain usually begins 2-7 days before menstrual period starts and increases until menstrual flow wanes (i.e., toward the end of the period).
  • Pain types include:
    1. Uterine pain
    2. Abdominal pain
    3. Rectal pain
  • Vaginal bleeding
  • Rectal bleeding
  • Infertility (inability to become pregnant)

  • Examination:
    1. May be no findings
    2. Nodules may be felt on exam
  • Testing:
    1. Ultrasound -- limited value
    2. MRI -- most helpful noninvasive test
    3. Barium Enema if rectal involvement suspected
    4. Laparoscopy -- small incision in the belly button is made for a scope to pass through.
    5. Laparotomy (open surgical exploration) is only done if laproscopy is not possible or not conclusive.

  • Medicine
    • The goal is to suppress ovulation in the menstrual cycle by manipulating hormone production. The following treatments are commonly used to achieve this end:
      1. Nafarelin nasal spray a gonadotropin-releasing hormone agonist (GnRH).
      2. Leuprolide acetate (GnRH agonist) injection
      3. Zoladex (GnRH agonist) implant.
      4. Danazol -- an androgen (male-like) drug.  Side effects that can be bothersome include acne, excess facial hair growth, weight gain, and decreased breast size.
      5. Oral birth control pills
      6. Medroxy-Progesterone acetate and oral estrogen
    • Anti-inflammatory medications-especially Anaprox or Motrin
    • Narcotic pain medications, e.g., Tylenol with codeine
    • Calcium supplementation is recommended when using GnRH therapy
  • Surgical Treatment:
    1. The endometrial tissue located in abnormal places is removed.  Surgery is usually performed if there is extensive endometriosis, infertility (problems getting pregnant), or severe pain that is not very responsive to medications.
    2. If future pregnancy is not desired, removal of the ovaries can be performed.  This is usually curative since the female hormone levels are substantially reduced.