Endometriosis

Definition
Endometriosis is a painful and often debilitating condition that affects over 5.5 million women in the United States and Canada, and millions more worldwide. There are many theories about the cause of endometriosis however the precise cause remains unknown.

Endometriosis can have a devastating affect on a woman's fertility and reproductive health, often making it difficult to become pregnant and causing severe menstrual abnormalities. This condition strikes women of all ages, according to the results of a 1998 Endometriosis Association survey 38% of endometriosis patients reported symptoms that occurred before the age of 15, many times occurring in girls as young as 11 or 12.

Endometriosis usually occurs when tissue that is normally found inside the uterus is found outside in the pelvic region. Endometriosis is most often found on the reproductive organs, bladder, bowel, intestines, colon and appendix; although it is also found on surgical scars, uterosacral ligaments, diaphragm, cul- de- sac (area behind the uterus), and pelvic sidewalls.

Symptoms
Most women who have endometriosis, in fact, do not have symptoms. Of those who do experience symptoms, the common symptoms are pain (usually pelvic) and infertility. Pelvic pain usually occurs during or just before menstruation and lessens after menstruation. Some women experience painful sexual intercourse (dyspareunia) or cramping during intercourse, and or/pain during bowel movements and/or urination. Even pelvic examination by a doctor can be painful. The pain intensity can change from month to month, and vary greatly among women. Some women experience progressive worsening of symptoms, while others can have resolution of pain without treatment.

Pelvic pain in women with endometriosis depends partly on where the implants of endometriosis are located.

• Deeper implants and implants in areas with many pain-sensing nerves may be more likely to produce pain.
• The implants may also produce substances that circulate in the bloodstream and cause pain.
• Lastly, pain can result when endometriosis implants form scars. There is no relationship between severity of pain and how widespread the endometriosis is (the "stage" of endometriosis).

Endometriosis can be one of the reasons for infertility for otherwise healthy couples. When laparoscopic examinations are performed for infertility evaluations, endometrial implants can be found in some of these patients, many of whom may not have painful symptoms of endometriosis. The reasons for a decrease in fertility are not completely understood, but might be due to both anatomic and hormonal factors. The presence of endometriosis may involve masses of tissue or scarring (adhesions) within the pelvis that may distort normal anatomical structures, such as Fallopian tubes, which transport the eggs from the ovaries. Alternatively, endometriosis may affect fertility through the production of hormones and other substances that have a negative effect on ovulation, fertilization of the egg, and/or implantation of the embryo.

Other symptoms related to endometriosis include:

• lower abdominal pain,
• diarrhea and/or constipation,
• low back pain,
• irregular or heavy menstrual bleeding, or
• blood in the urine.

When to see a doctor
No two individuals will have the same symptoms for Endometriosis, and the variety and severity of symptoms may vary over the course of the disease. Any one suffering severe and reoccurring pain that interferes with daily functioning should seek diagnosis and treatment from a skilled physician. Couples experiencing fertility problems should consult a physician to screen for endometriosis.

Causes
The cause of endometriosis is unknown. One theory is that the endometrial tissue is deposited in unusual locations by the backing up of menstrual flow into the Fallopian tubes and the pelvic and abdominal cavity during menstruation (termed retrograde menstruation). The cause of retrograde menstruation is not clearly understood. But retrograde menstruation cannot be the sole cause of endometriosis. Many women have retrograde menstruation in varying degrees, yet not all of them develop endometriosis.

Another possibility is that areas lining the pelvic organs possess primitive cells that are able to grow into other forms of tissue, such as endometrial cells. (This process is termed coelomic metaplasia.)

It is also likely that direct transfer of endometrial tissues during surgery may be responsible for the endometriosis implants sometimes seen in surgical scars (for example, episiotomy or Cesarean section scars). Transfer of endometrial cells via the bloodstream or lymphatic system is the most likely explanation for the rare cases of endometriosis that develop in the brain and other organs distant from the pelvis.

Finally, some studies have shown alternations in the immune response in women with endometriosis, which may affect the body's natural ability to recognize and destroy any misdirected growth of endometrial tissue.

Diagnosing Endometriosis
Endometriosis can be suspected based on symptoms of pelvic pain and findings during physical examinations in the doctor's office. Occasionally, during a rectovaginal exam (one finger in the vagina and one finger in the rectum), the doctor can feel nodules (endometrial implants) behind the uterus and along the ligaments that attach to the pelvic wall. At other times, no nodules are felt, but the examination itself causes unusual pain or discomfort.

Unfortunately, neither the symptoms nor the physical examinations can be relied upon to conclusively establish the diagnosis of endometriosis. Imaging studies, such as ultrasound , can be helpful in ruling out other pelvic diseases and may suggest the presence of endometriosis in the vaginal and bladder areas, but still cannot definitively diagnose endometriosis. For an accurate diagnosis, a direct visual inspection inside of the pelvis and abdomen, as well as tissue biopsy of the implants are necessary.

As a result, the only accurate way of diagnosing endometriosis is at the time of surgery, either by opening the belly with large-incision laparotomy or small-incision laparoscopy.

Laparoscopy is the most common surgical procedure for the diagnosis of endometriosis. Laparoscopy is a minor surgical procedure done under general anesthesia, or in some cases under local anesthesia. It is usually performed as an out-patient procedure (the patient going home the same day). Laparoscopy is performed by first inflating the abdomen with carbon dioxide through a small incision in the navel. A long, thin viewing instrument (laparoscope) is then inserted into the inflated abdominal cavity to inspect the abdomen and pelvis. Endometrial implants can then be directly seen.

During laparoscopy, biopsies (removal of tiny tissue samples for examination under a microscope) can also be performed for a diagnosis. Sometimes biopsies obtained during laparoscopy show endometriosis even though no endometrial implants are seen during laparoscopy.

Pelvic ultrasound and laparoscopy are also important in excluding malignancies (such as ovarian cancer) that can cause symptoms that mimic endometriosis symptoms.

Preparing for your appointment
Because many of the symptoms of this disease vary with the patient’s menstrual cycle, and possibly with bowel, bladder and sexual activity, keeping a diary of the discomfort and pain will be important information to share with your doctor.

• Write down the symptoms you're experiencing, including any that may seem unrelated to the reason for wh