- Endometriosis is a disease in which tissue similar to that of the uterine lining, called the endometrium, grows outside the uterus attaching to the exterior of the uterus, the ovaries, fallopian tubes, bowels and on tissue lining the pelvis.
- This tissue mimics normal endometrial tissue that increases in fluid and thickness during the menstrual cycle before shedding; but endometriosis can’t shed and causes irritation outside the uterus.
- Symptoms can include painful periods, excessive menstrual bleeding, spotting in between periods, pain during intercourse, constipation and bloating.
- Endometriosis is a leading cause of infertility, and 30% to 50% of women who have the disease experience infertility, primarily because it blocks the fallopian tubes with scarring or adhesions.
- There is no cure for endometriosis, but we can treat its symptoms as well as the infertility it may cause with medications, hormone therapies, surgery and infertility treatments like in vitro fertilization (IVF).
What is endometriosis, also called endo?
Endometriosis occurs when tissues like those that make up the endometrium (the lining of the uterus) grow outside the uterus, most often on the ovaries, fallopian tubes, bowels and other tissue in the pelvic lining. These tissues cause irritation because, like the tissues in the endometrium, they continue to become thick, break up and bleed during the menstrual cycle.
But unlike the tissue in the endometrium, endometriosis tissues do not shed from the body during menstruation because they are not in the uterus, but outside it. Endometriosis tissue is trapped in the pelvic area and can irritate surrounding tissue and organs. Scar tissue can develop as can adhesions, which are bands that can cause organs and pelvic tissue to stick together.
Endo affects millions of women. The disease requires medical attention, particularly when it results in pain that alters a woman’s lifestyle or infertility.
The condition is classified into four stages: minimal, mild, moderate and severe. These stages relate to the extent, location and depth of the endometriosis implants, as well as the types of adhesions and ovarian endometriomas (cysts). Most women have minimal and mild endo. Infertility is likely in the severe stage.
Endometriosis and infertility
Causes of endometriosis & risk factors
The direct cause of endometriosis is unknown. But many health officials believe it is linked to a condition known as retrograde menstruation, in which menstrual blood containing endometrial cells flows back through the fallopian tubes and into the pelvic cavity rather than out of the body.
Several risk factors give women a higher chance of developing endometriosis.
- Family history of endometriosis.
- Personal history of pelvic infections.
- Uterine or other reproductive tract abnormalities.
- Starting periods at an early age.
- Never giving birth.
- Short menstrual cycles.
- Heavy periods longer than seven days.
- Low BMI (body mass index).
Some women have no symptoms of their endometriosis. Pain and infertility are the most common symptoms. But because its symptoms are similar to other conditions and can often change, endometriosis can be tricky to diagnose. Women can have symptoms for years and not know they have endometriosis.
But recognizing the signs below can lead to an earlier diagnosis and more effective treatment.
- Pain during periods (dysmenorrhea), worse cramping than normal and increasing over time.
- Pain during or after intercourse that may change with a different position.
- Pain with urination or bowel movements, usually during menstruation.
- Pain in the lower back, pelvic area or belly, also during periods.
- Heavy periods at times or bleeding between periods.
- Digestive problems, such as constipation and diarrhea.
- Nausea or bloating.
- Difficulty conceiving.
The presence of the symptoms above may indicate endo, but our fertility specialists can’t diagnose it without further examinations and testing. We will discuss the woman’s health history and whether her mother or sister have had it.
A pelvic exam can reveal the prospect of the condition. Our physician may feel that the uterus has been affected. A nodule behind the cervix may be present, which can be tender to the touch. Sometimes an endometrial implant can be visible in the vagina or cervix. Even with such indications, surgery is the only definitive way to diagnose endometriosis.
Laparoscopic surgery enables us to see inside the pelvic cavity and look for endometriosis, using a thin camera inserted through a small incision by the navel. This allows the physician to examine the outside of the uterus, ovaries, fallopian tubes and other pelvic organs and tissue. During this laparoscopic examination, the surgeon can decide to remove the endometriosis.
Additional imaging tests may be needed in some cases involving chronic pain and infertility. A CT scan, MRI and ultrasound may be used to get a better picture of the woman’s pelvic area and evaluate ovarian cysts that may be endometrial.
Though there is no known cure for endometriosis, we can treat the pain and infertility the disease can cause. We discuss the treatment options with each woman, taking into consideration her age, the extent of her symptoms and of the disease, and her desire to have children. Treatments that focus on alleviating symptoms of pain include:
- Lifestyle modifications.
- Birth control pills and other hormone-based contraceptives.
- Hormone therapy.
- Surgery to remove endometriosis scars and adhesions to reduce pain.
Endo treatments for infertility
Our patients are most often interested in improving their infertility due to endometriosis. Before we consider treatment for infertility, we first evaluate the woman’s overall fertility. Other fertility hampering conditions could affect the success of treatment.
Laparoscopy may be recommended if no other conditions are found in women with moderate or severe endo. Laparoscopy can be accomplished by excision to remove the endometriosis or by electrosurgery, ablation, or lasers to destroy the scars or adhesions.
In cases of minimal or mild endometriosis, ASRM reports that natural pregnancy rates can be improved following laparoscopy. One study showed 29% of women achieving pregnancy, as opposed to a 17% pregnancy rate for those who do not have laparoscopy.
We usually do not recommend more than one surgery to remove endo growths if future pregnancy is desired. These can impair ovarian function, reducing the prospect of success with other treatments.
Controlled ovarian stimulation with intrauterine insemination (IUI) can be effective for minimal or mild cases. While IUI alone or using controlled ovarian stimulation alone via different drugs or hormones increases pregnancy rates, the combination of the two provides the most success.
In vitro fertilization (IVF) has the best success rates for women or couples with endo. Their success with IVF is similar to success rates for IVF used to treat other causes of infertility. IVF may follow surgery to remove endometriosis, but if hormonal therapy was used, we will wait until ovarian function returns to normal.
Risks of treatment
Surgery for endometriosis carries the same risks as any surgery. These include pain, scarring, reaction to anesthesia, and possible damage to organs and tissue. In the case of controlled ovarian stimulation with IUI, the risk of a multiple pregnancy of twins or more increases. This has health risks for the mother and child.