Dra. Joana Faria

Gynecologist-Obstetrician

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Endometriosis

Endometriosis image

What is endometriosis?

Endometriosis develops when endometrial implants, comprised of tissue normally found within the uterus, are present in other areas of the body, most commonly, inside the abdominal cavity (belly). As this tissue continues to thicken, break down, and bleed during the menstrual cycle (as it happens with the endometrium- inside lining of the uterus), it becomes trapped within the body. Scar tissue and adhesions form, and this can cause organ fusion, anatomical changes and consequently, chronic pelvic pain and infertility.

Endometriosis affects around at least 15% of women in reproductive age. The percentage is even higher in infertile women.

Which are the symptoms?

Because of the difficulty in the diagnosis, there is a delay of about 7 years to make the diagnosis in the United States.

The following are the most common signs and symptoms of endometriosis:

Painful periods (dysmenorrhea): Pelvic pain and cramping may begin before your period and extend several days into your period. You may also have lower back and abdominal pain.
Pain with intercourse (dyspareunea): Pain during or after sex is common with endometriosis.
Pain with bowel movements (dyschezia) or urination (dysuria), usually, during your period.
Excessive bleeding: You may experience occasional heavy periods (menorrhagia) or bleeding between periods (menometrorrhagia).
Infertility: Endometriosis is first diagnosed in some women who are seeking treatment for infertility.
Other symptoms: You may also experience fatigue, diarrhea, constipation, bloating or nausea, especially during menstrual periods.

The severity of your pain isn't necessarily a reliable indicator of the extent of the disease. Some women with mild endometriosis may have intense pain, while others with advanced endometriosis may have little pain or even no pain at all.

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What is the cause?

Although the exact cause of endometriosis is still unknown, but there are possible explanations:

Retrograde menstruation: the menstrual blood containing endometrial cells flows back through the fallopian tubes and into the pelvic cavity instead of out of the body. These displaced endometrial cells stick to the pelvic walls and surfaces of pelvic organs, where they can grow and continue to thicken and bleed during each menstrual cycle.
Transformation of peritoneal cells (“induction theory”): it is proposed that hormones or immune factors promote transformation of peritoneal cells (the cells that line the inner side of your abdomen) into endometrial cells.
Embryonic cell transformation: Hormones, such as estrogen, may transform embryonic cells (cells in the earliest stages of development) into endometrial cell implants during puberty.
Surgical scar implantation: It can happen after a surgery (eg. hysterectomy or C-section), endometrial cells may attach to a surgical incision.
Endometrial cells transport: The blood vessels or tissue fluid (lymphatic) system may transport endometrial cells to other parts of the body.
Immune system disorder: It’s possible that a problem with the immune system may make the body unable to recognize and destroy endometrial tissue that's growing outside the uterus.

There are also some risk factors that place you at greater risk of developing endometriosis: never giving birth; starting your period at an early age; entering in the menopause at an older age; having short menstrual cycles; having higher levels of estrogen in your body or a greater lifetime exposure to estrogen your body produces; low body mass index; alcohol consumption; one or more relatives (mother, aunt or sister) with endometriosis; any medical condition that prevents the normal passage of menstrual flow out of the body; uterine abnormalities.

Endometriosis usually develops several years after the onset of menstruation (menarche). Signs and symptoms of endometriosis usually end temporarily during the pregnancy and end permanently with menopause, unless you're taking estrogen.

What is the treatment?

The treatment for endometriosis depends on the extent of the disease, your symptoms, and if you want to have children. Endometriosis symptoms may be controlled with medication- Medications that are used to treat endometriosis include pain relievers (such as nonsteroidal anti-inflammatory drugs) and hormonal medications (birth control pills, progestin-only medications, and gonadotropin-releasing hormone agonists). Hormonal medications help to slow the growth of the endometrial tissue and may keep new adhesions from forming but these medications do not get rid of endometriosis tissue that is already there. Surgery is necessary if the symptoms are not controlled with medication and to improve fertility. During surgery, endometriosis implants can be removed. After surgery, most of the women are (almost) pain-free. However, about 40–80% of women have pain again within 2 years of surgery. The more severe the disease, the more likely it is to return. Taking birth control pills or other medications after having surgery (laparoscopic surgery is the gold-standard surgery for endometriosis) may help to extend the pain-free period. You must be aware that endometriosis surgery is associated to a risk of complications, depending on the severity and localisation of the disease. Your doctor will inform you which are the potential risks and benefits.

If pain is severe and does not go away after treatment, a hysterectomy (uterus removal) may be the last option. Endometriosis is less likely to come back if your ovaries also are removed since endometriosis is hormonal-dependent disease. If you keep your ovaries, endometriosis is less likely to come back if endometriosis implants are removed at the same time you have the hysterectomy.

Nevertheless, it is important to be aware that there is a (very) small chance that some pain comes back even if your uterus and ovaries are removed. This may be due to endometriosis that was not visible or could not be removed at the time of surgery.

When to see your doctor?

If you have very painful periods or if your periods have changed from relatively pain-free to painful;
If the pain interferes with your daily activities;
if you have pain during intercourse;
If you have painful urination, blood in your urine or inability to control the urine flow;
If you have difficult defecation, blood in your stool and unexplained changes in the bowel movements