What is Endometriosis?

Endometriosis is a disorder in which tissue similar to the tissue forming the endometrium (inner lining of the uterus), grows outside the uterus. This disorder commonly involves ovaries, fallopian tubes and the tissue lining the pelvis. Generally women with this disorder experience a lot of pain during their menstruation days.

Endometriosis lesions, also known as the endometriosis implants, can be found anywhere in the pelvic cavity, i.e. on the ovaries, the fallopian tubes, the pelvic sidewall and the uterosacral ligaments. There are other less common sites including bladder, bowel, intestines, colon, appendix and rectum. 

These lesions respond to hormones found in females, estrogen and progesterone. They too thicken, break down and bleed in microscopic amounts with each menstrual cycle just like normal endometrial tissue. But the endometrial-like tissue does not have an exit and becomes trapped. Cysts may form known as endometriomas. Surrounding tissue can become irritated, which might develop scar tissue and adhesions. Adhesions is a condition caused by endometriosis where bands of fibrous tissue can cause pelvic tissues and organs to stick to each other.

Few examples of problems faced by women due to endometriosis are as follows:

1. The fallopian tubes can become scarred to the point of blockage and prevent sperm and egg interaction. In extreme cases, reproductive organs are fused together and do not function properly.
2. The ovaries can become filled up with endometriosis cysts (called an endometrioma). These are called “chocolate cysts” because the congealed blood inside looks like chocolate syrup. These can have deleterious effects on egg production and ovulation.
3. Any organ that has endometriosis and scarring on it can experience pain from inflammation and adhesions to other organs.

What are the Symptoms of Endometriosis?

The key symptom of endometriosis is pelvic pain, which is often associated with menstruation. With this disorder, women might experience cramps that are more painful than usual period cramps. Some other symptoms of endometriosis include the following:

• Painful periods (dysmenorrhea). Pelvic pain and cramping may begin before and extend several days into a menstrual period. women  may also have lower back and abdominal pain.
• Pain with intercourse. Pain during or after sex is common with endometriosis.
• Pain with bowel movements or urination. Women suffering from endometriosis are most likely to experience these symptoms during a menstrual period.
• Excessive bleeding. they  may experience occasional heavy menstrual periods or bleeding between periods (intermenstrual bleeding).
• Infertility. Sometimes, endometriosis is first diagnosed in those seeking treatment for infertility.
• Other signs and symptoms. Women with endometriosis may experience fatigue, diarrhea, constipation, bloating or nausea, especially during menstrual periods.

What is the connection between Endometriosis and Fertility?

The connection between endometriosis and fertility can be said to be a strong one. But the exact cause of infertility or inability to conceive due to endometriosis is still unknown. It is estimated that for women with endometriosis who are trying to conceive, the chance of pregnancy each month, or the fecundity is about 2% to 10%, compared to 15% to 20% in the general population.

Upto 30% to 50% of women suffering from endometriosis may experience infertility. 

Endometriosis can influence fertility in several ways: distorted anatomy of the pelvis, adhesions, scarred fallopian tubes, inflammation of the pelvic structures, altered immune system functioning, changes in the hormonal environment of the eggs, impaired implantation of a pregnancy, and altered egg quality. Women with severe endometriosis, which causes considerable scarring, blocked fallopian tubes, and damaged ovaries, experience the most difficulty becoming pregnant and often require advanced fertility treatment.

There are several proposed mechanisms for endometriosis causing infertility that include:

1. The distorted pelvic anatomy from scarring and adhesions can alter the function of the fallopian tubes, ovaries and uterus.
2. Inflammation in the abdominal and pelvic cavity can irritate the normal delicate environment required for fertilization and implantation.
3. Inflammation causes the production of chemicals known as cytokines. These cytokines can inhibit the sperm and egg cells, making fertilization more difficult.
4. Hormonal disturbances from endometriosis can impair ovulation and the hormones necessary for implantation and support of the embryo in early pregnancy.
5. Endometrial tissue on the ovaries can inhibit ovulation, preventing the release of an egg.

What are the Treatments available for Endometriosis?

Endometriosis can be treated through medication or surgery. Based on signs and symptoms, the doctor suggests the type of medication or surgery. Usually doctors recommend the conservative treatment approaches first, and then recommend surgery in case the initial treatment fails.

Pain medication:

Pain relievers such as the nonsteroidal anti-inflammatory drugs (NSAIDS), ibuprofen (Advil, Motrin IB, etc.) or naproxen sodium (Aleve) are beneficial in easing the painful menstrual cramps.

Hormone therapy:

Supplemental hormones might be effective in reducing the pain caused by endometriosis. It can slow down the endometrial tissue growth and prevent new implants of the endometrial tissue. But hormone therapy is not a permanent treatment. The symptoms might return after stopping the treatment. Hormone therapies include the following:

• Hormonal contraceptives: Birth control pills, patches and vaginal rings help control the hormones responsible for the buildup of endometrial tissue each month. Many have lighter and shorter menstrual flow when they’re using a hormonal contraceptive. Using hormonal contraceptives, especially continuous-cycle regimens, may reduce or eliminate pain in some cases.
• Gonadotropin-releasing hormone (Gn-RH) agonists and antagonists: These drugs block the production of ovarian-stimulating hormones, lowering estrogen levels and preventing menstruation. This causes endometrial tissue to shrink. Because these drugs create an artificial menopause, taking a low dose of estrogen or progestin along with Gn-RH agonists and antagonists may decrease menopausal side effects, such as hot flashes, vaginal dryness and bone loss. Menstrual periods and the ability to get pregnant return when you stop taking the medication.
• Progestin therapy: A variety of progestin therapies, including an intrauterine device with levonorgestrel (Mirena, Skyla), contraceptive implant (Nexplanon), contraceptive injection (Depo-Provera) or progestin pill (Camila), can halt menstrual periods and the growth of endometrial implants, which may relieve endometriosis signs and symptoms.
• Aromatase inhibitors: Aromatase inhibitors are a class of medicines that reduce the amount of estrogen in the body. The doctor may recommend an aromatase inhibitor along with a progestin or combination hormonal contraceptive to treat endometriosis.

Conservative surgery:

In this surgery the endometriosis implants are removed, while preserving the uterus and ovaries.. This surgery is helpful for those women who are trying to conceive. However, the endometriosis or the pain caused by it might return soon.

The most common way of this surgery is the laparoscopic surgery. The surgeon inserts the laparoscope through a small incision near the navel and inserts instruments to remove endometrial tissue through the small incision. After surgery, the doctor might recommend hormone medication to help with the pain.

Fertility treatment:

Women with endometriosis can face trouble while trying to conceive. This treatment is highly recommended to those women who want to conceive with endometriosis. Fertility treatment ranges from stimulating the ovaries to make more eggs to in vitro fertilization. The personal situation of the women determines the type of fertility treatment.

Hysterectomy with removal of the ovaries:

The surgery of removing the uterus, known as hysterectomy, and the surgery to remove the ovaries, known as oophorectomy, were once considered the most effective treatment for endometriosis. But the surgery nowadays focuses more on the careful removal of all endometriosis tissue.

Removal of ovaries results in menopause. Early menopause carries a risk of cardiovascular diseases, certain metabolic conditions and early deaths. The lack of hormones produced by the ovaries may improve endometriosis pain for some women. For others, endometriosis that remains after surgery continues to cause symptoms. 

Removal of the uterus can sometimes be used to treat the signs and symptoms of endometriosis, such as heavy menstrual bleeding and painful cramps. A hysterectomy with the ovaries may have a long term effect on the woman’s health, especially if the surgery is done before the age of 35.