Endometriosis is the presence endometrial tissue cells (i.e., the inside lining of the uterus that women menstruate every cycle) in locations outside of the uterus. Normal hormonal changes in a woman’s cycle can cause these cells to have localized bleeding and cause pain. The exact reason for the development of endometriosis is unknown. One theory is that the endometrial cells flow backwards through the fallopian tubes into the abdomen and pelvis and then implant onto other areas.
It is more common to find endometriosis in patients who are having difficulty getting pregnant. The endometrial cells can release inflammatory factors and molecules that ultimately hinder the sperm and egg from fertilizing successfully. In addition, endometriosis can cause internal scarring that makes it difficult for the tube to physically pick up the egg, or even block the tube. In cases of moderate to severe endometriosis where the pelvic environment is altered, in vitro fertilization may be necessary.
A tendency to inherit endometriosis has been identified; 8-10% of women with endometriosis have first degree relatives (mother or sister) with the disease. Women in affected families develop endometriosis at an earlier age and are more likely to have advanced disease.
On examination, your physician can sometimes feel changes in the pelvic structures suggestive of endometriosis. These changes include the presence of cysts on the ovaries, scarring around the uterus, and painful nodules around the support ligaments to the uterus.
Laparoscopy is the only definitive diagnostic tool used in making a diagnosis of endometriosis. The smallest areas of growth appear as blue-black raised lesions covering the surfaces of the internal organs. Older lesions are often puckered as a result of scarring. Larger lesions can form cysts on the ovaries called endometriomas.
Ultrasound and blood work does not always confirm the presence or absence of endometriosis.
For infertile women with endometriosis, the infertility evaluation should be completed and all potential factors contributing to infertility should be addressed. Endometriosis can be treated with either medications or surgery. A variety of different drugs have been used to treat endometriosis but they are usually not compatible with trying to conceive.
Oral contraceptive pills
Treatment with estrogen and progesterone combination therapy (birth control pill) has been used in order to create a stable hormonal environment that does not stimulate endometriosis. This can stop the endometriosis from growing and help with symptoms. In general, oral contraceptive pills are the first-line therapy.
Therapy with medication alone is most beneficial in mild to moderate disease. Pain is usually relieved and in over 75% of patients, an improvement of disease has been observed.
Other medications include Provera, Depo-Provera and Danazol. Such medications are options but not used often because of the side effects. Indications for these medications are individualized for your personal medical situation.
Leuprolide acetate (Lupron® injection or Lupron Depot®) is a hormone-like medication, usually taken as a monthly injection when being used for endometriosis. This medication causes a menopausal state and by decreasing your hormone levels, decreases the estrogen that the endometriosis can use to grow. Unfortunately, this also stops ovulation so it is usually not possible to get pregnant while taking Lupron. Also, when the treatment is stopped, ovulation resumes and higher estrogen levels can re-stimulate the endometriosis eventually.
The goal in treatment of endometriosis is to improve the associated symptoms, such as severe menstrual cramps, pain with sexual intercourse (dyspareunia), pelvic pressure and pelvic pain, and /or bowel or bladder problems. Since endometriosis is dependent on estrogen, the GnRH agonists may dissolve the spots of endometriosis and /or shrink any ovarian cyst related to this condition (endometrioma). After therapy, however, endometriosis may grow again, so follow-up examinations are necessary.
Surgical removal of areas of endometriosis involves laparoscopy, a procedure done on an outpatient basis. Medical and surgical treatments are sometimes combined in order to facilitate surgical removal of endometriosis and diminish post operative recurrence.
Despite such therapy, endometriosis can be a difficult to deal with because of its recurrence. In general, the more severe, the greater chance of recurrence.
Management of endometriosis should be strictly individualized to each patient. This concept is of great importance in treating the infertile couple and all women with endometriosis. An SRM physician will review the specific recommendations in your situation whether it is the treatment of pain or infertility due to endometriosis.
Need more information? Make an appointment with one of our Reproductive Endocrinologists at 206.301.5000.