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Endometriosis

  • by Melanie Haiken, M.A.
  • Posted March 11, 2013

What is endometriosis?

Endometriosis gets started when tissue from your endometrium, the uterine lining that nourishes a developing fetus, begins growing outside the uterus. This misplaced tissue usually turns up elsewhere within your abdominal cavity, most commonly on or around the reproductive organs (which include the ovaries, the Fallopian tubes, and the outside of the uterus). It may also grow on the bladder or on the intestines or rectum. The tissue reacts to your monthly cycle of hormones as it normally would: filling with blood, thickening, and then breaking down. But because there's nowhere for this blood and tissue to go as it sloughs off, it builds up and can cause intense abdominal pressure. Meanwhile, the immune system attacks this misplaced endometrial tissue as "foreign tissue," often resulting in adhesions and scarring. If you have endometriosis, you may suffer severe pain during your menstrual periods or during sex. In some cases, the disease can also result in scarring that interferes with pregnancy.

Up to 10 percent of all women develop endometriosis during their reproductive years. Because it's a progressive condition, the symptoms increase in severity over time. If you're diagnosed as having endometriosis while you're young and you want children, your doctor may advise you not to postpone childbearing past your early 30s.

What causes endometriosis?

Researchers aren't sure. Some physicians think a process called retrograde menstruation is to blame. The theory is that during your period, menstrual tissue flows backward through the Fallopian tubes and into the abdomen, where it takes root and grows. Many researchers now believe, however, that all women experience some menstrual backup -- mostly without adverse consequences -- and that those who develop endometriosis must have a hormonal glitch or immune-system weakness that allows the tissue to become implanted. What's more, studies of sisters reveal that endometriosis appears to run in families, which points to a genetic link.

In rare cases, endometrial tissue can travel by way of the bloodstream or lymph nodes or can be spread during abdominal surgery. Some preliminary research suggests that the rise in the incidence of endometriosis may also be related to environmental toxins. One study of rhesus monkeys found that animals exposed to dioxin and PCBs developed spontaneous endometriosis. Researchers theorize that toxins like those trigger the disease by acting as hormone disrupters.

What are the symptoms of endometriosis?

The symptom most women notice first is unusually heavy periods, often accompanied by extremely painful cramping. You may feel pelvic or abdominal pain at other times, especially right before your period, or you may notice pain during or after intercourse. Some people also suffer from intestinal discomfort, diarrhea, or painful bowel movements during their periods. In some cases, though, women experience no symptoms and don't know they have endometriosis until they have trouble getting pregnant.

How can I ease the pain?

All the time-tested remedies for menstrual cramping are worth a try: warm baths, a hot-water bottle applied to your abdomen, and over-the-counter painkillers such as ibuprofen and acetominophen. Some doctors have had good luck with Anaprox DS (naproxen), a nonsteroidal anti-inflammatory agent that you take twice daily, beginning a few days before your period. You might also try extra fiber in your diet to ease constipation or intestinal upset.

Can endometriosis affect my fertility?

The statistics are contradictory, and the answer seems to depend on how serious your condition is. In women with mild endometriosis, cumulative pregnancy rates are normal, according to recent studies. But when scar tissue has formed around the uterus and other reproductive organs, fertility can be decreased. Studies have shown that 30 to 40 percent of women with endometriosis are infertile (twice the rate in the normal population) and, conversely, that between one-fourth and one-half of all infertile women have endometriosis. Adhesions and scar tissue caused by the disease can prevent pregnancy by blocking the Fallopian tubes, wrapping around the ovaries so ovulation can't take place, or sealing off the uterus. But the good news is that once you've conceived and your egg has implanted, endometriosis will not interfere with or damage your pregnancy. In fact, your endometriosis should actually improve during pregnancy.

What are my treatment options?

At the moment, there's no sure cure for endometriosis. The options range from doing nothing to undergoing fairly invasive surgery, and your approach will depend on how severe your symptoms are and whether you're trying to get pregnant. Many women with endometriosis simply control the pain with painkillers and take birth control pills to moderate the bleeding and cramping that come with their periods. If your symptoms are severe enough so that you need to go on the offensive, though, you can go in any of several directions.

  • Drugs. Doctors can stop the menstrual cycle with drugs that mimic pregnancy or menopause, but clearly this isn't helpful for women who want to conceive. Some doctors prescribe Depo-Provera to stop menstruation altogether. Although its important to note that in 2004, the Food and Drug Administration added a black box warning -- the agency's strongest caution -- to Depo-Provera because prolonged use can lead to the loss of bone density. A common older treatment is danazol, which is a modified male androgen that can replace estrogen; unfortunately, its predictable side effects include excess hair growth, acne, decreased breast size, and a lowered voice register. Drugs belonging to the category of gonadotropin-releasing hormones (GnRH) work by inducing a pseudo-menopause and thus encouraging the endometriosis to regress, but they're only a short-term fix -- the FDA recommends limiting limits their use to six months because of concerns about long-term effects on bone density. If conception is your primary goal, several studies have shown that there's promise in the use of fertility drugs such as Clomid and Pergonal, along with artificial insemination.

    Some gynecologists use a cream containing natural progesterone as their first line of treatment. Applied twice a day, the cream works by reducing estrogen's effect on endometrial lesions. As an alternative, some doctors prescribe natural progesterone capsules.

  • Surgery. A tiny device called a laparoscope allow the doctor to see cysts and lesions, which can then be surgically removed or vaporized with a laser. The surgeon can also cut adhesions, places where organs are bound together. New developments in laser technology are making this kind of surgery faster and more accurate. If you decide to opt for it, however, choose your surgeon carefully, basing your decision on the number of procedures he or she has performed and the sophistication of the equipment that will be used. This is important, because the surgeon must remove as much of the misplaced endometrial tissue as possible to prevent its growing back, meanwhile trying to avoid any additional scarring. Studies show that this surgery significantly increases your chances of becoming pregnant.

    In the past, a hysterectomy (and sometimes removal of the ovaries as well) was a common treatment for severe endometriosis. Today most doctors consider it a last resort, reserved primarily for women who don't want to conceive or are menopausal. Keep in mind that this extreme measure doesn't guarantee a cure; some people have continued to suffer from endometriosis even after having their reproductive organs removed.

  • Alternative remedies. Fish-oil supplements have been shown to decrease menstrual cramps and are probably worth trying, since they're relatively harmless. Naturopaths or gynecologists trained in integrative medicine may also suggest a change in diet, since that can help reduce the excess estrogen your body is producing; they might recommend that you eat foods containing fatty acids (such as salmon or nuts) every day, lessen the amount of meat and dairy foods that you eat, increase your consumption of soy products and cruciferous vegetables like cabbage and broccoli, and take a multivitamin-mineral supplement.

    Some women with endometriosis report good results after turning to traditional Chinese medicine, homeopathy, massage, or allergy management (although no research has yet documented the effectiveness of these unconventional approaches). If the disease is causing you pain or disruption, and if other remedies haven't provided relief, it could certainly be worthwhile to experiment with one or more of these options. Talk with your doctor about any alternative methods you've adopted, and be sure to list all the herbal preparations or supplements you're taking; some can interfere with prescription and over-the-counter medicines.

References

Tokushige M, et al. Laparoscopic surgery for endometriosis: a long-term follow-up. J Obstet Gynaecol Res 2000 Dec;26(6):409-16.

dos Reis RM, et al. Familial risk among patients with endometriosis. J Assist Reprod Genet 1999 Oct;16(9):500-3.

Rier SE, et al. Immunoresponsiveness in endometriosis: implications of estrogenic toxicants. Environ Health Perspect 1995 Oct;103 Suul 7:151-6.

Brigham Narins, Editor. World of Health:378-9. The Gale Group 2000.

Food and Drug Administration. Alternatives to Hysterectomy: New Technologies, More Options. November 2001.

American College of Obstetricians and Gynecologists (ACOG). Management of endometriosis. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2010 Jul.

Food and Drug Administration. Black Box Warning Added Concerning Long-term Use of Depo-Provera Contraceptive Injection. November 2004.

Mayo Clinic. Endometriosis. September 11, 2010.

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