OBG(why)N: What is Endometriosis?

Simply put, Endometriosis is when endometrial tissue implants outside the uterus.

Every month when your uterus cycles, you shed your endometrium and you have a bleed. The endometrial tissue that is outside your uterus also cycles and bleeds. Endometriosis occurs in 10% of all women and 40% of infertile women.

What are the symptoms of Endometriosis?
The most common symptoms are: cyclical pelvic pain, pain with intercourse (dyspareunia), and menstrual pain (dysmenorrhea).

Some scary symptoms (which are VERY RARE):
Coughing up blood, urinating blood or passing blood when you have a bowel movement during your period. This happens because you have uterine tissue which cycles and bleeds in places you shouldn’t, like your stomach, bladder or rectum.

How is Endometriosis diagnosed?
The most important piece in diagnosing endometriosis is by a patient’s history. It is often times the description of cyclical symptoms which will lead us down the right path. If endometriosis causes ovarian cysts called endometriomas, these are easily seen on an ultrasound. However, endometriosis can also be very small, referred to as endometrial implants and not visible on an ultrasound at all. The only way to confirm the diagnosis is surgery. Even then, it must be a skilled gyn surgeon who has experience with endometriosis as the disease varies significantly and the size, shape and appearance of implants vary so much that they can easily be missed. Interestingly enough, some women may have large endometriomas and feel no pain while other women can have tiny implants and suffer from debilitating pain. The pain is not related to the amount of endometriosis but rather to the depth of endometriosis.

How is endometriosis treated?
The treatments for endometriosis depend on the situation. If we are treating to alleviate symptoms of pain, than NSAIDS (non steroidal anti inflammatory drugs) like Advil, Motrin or Alleve are the first choice. Birth control pills are also helpful and extended cycle pills are usually the best choice. If you are only getting one period every 3 months, there is less opportunity for the implants to grow and more time for them to shrink. Another option is a GNRH agonist called Lupron. This is an injection which puts you into a temporary menopause. This treatment has many side effects for young women and is reserved for cases that have failed other medical mangement.

If we are treating for infertility, then medical management usually doesn’t work and surgery is the next step. Careful excision of endometrial implants and endometriomas have been shown to improve fertility treatment outcomes. Surgical excision is also used for the rare cases we mentioned above when women have endometriosis in their stomach, bladder or rectum. A complete hysterectomy with removal of both ovaries is reserved for severe cases which have failed all other treatment options. Studies have shown that the use of hormone replacement therapy does not cause endometriosis to come back in these patients and is safe to use.

Let’s review:

• Cyclical pain is the most common sign of endometriosis.
• It is very common for doctors to treat with NSAIDS or Oral Contraceptives based on history and lack of findings on sonogram.
• Medical management is a firstline treatment for pain.
• Surgical excision may be a better treatment option for infertility patients.
• Removal of the uterus and ovaries is reserved for the most severe cases which have failed all other treatment options.

The most important thing you can do in advocating for yourself when seeing your doctor is to give a good medical history. A good history can lead to an accurate diagnosis and save you from unnecessary testing and failed treatments. Keeping track of your cycles, symptoms and severity of your symptoms will help your doctor to help you.