Endometriosis is the presence and growth of endometrial cells, identical to the lining of the uterus, in other locations throughout the body. Endometrial implants have been found in areas as distant as the lung and brain.
Endometriosis symptoms include pelvic pain, painful menstruation, pain when urinating or having bowel movements, pain during intercourse and infertility.
Endometriosis's exact cause(s) remains unknown. Although there are several theories to explain its presence, no single theory adequately explains the broad-ranged manifestations of this disease.
The most popular theory is that endometriosis results from implantation of endometrial tissue fragments secondary to the back flow of blood into the pelvic cavity during menstruation. It is more common in women with cycle intervals less than 27 days in length, i.e., every 21 days vs. 28 days, and menses lasting longer than 7 days, as well as in women with partial outflow blockages of the genital tract. These findings have been documented by numerous clinical studies.
Endometriosis has been found in the pelvic lymph nodes of women with this disease. Pulmonary endometrial implants and the presence of disease at other distant sites are best explained by lymphatic or vascular transmission of the disease.
Virtually all women experience retrograde
menstruation yet only some develop endometriosis.
These findings lend credence to the theory that some women
have an immune defect which allows endometrial cells to implant
and thrive.
Women with a family history of endometriosis have a 7-fold increased risk of developing this disease than women with a negative family history. Furthermore, women with a positive family history in first degree relatives have a tendency to develop the disease earlier in life and have more advanced disease than women with a negative family history. The inheritance is likely transmitted by multiple factors, perhaps involving the immune system.
The true incidence of the disease is unknown because formal diagnosis requires a surgical evaluation. While 30% of asymptomatic (no pain) patients undergoing laparoscopy for infertility are found to have the disease, 40% of patients undergoing surgical evaluation for pelvic pain (not all with infertility) are found to have endometrial implants. Furthermore, it was found in 2% of fertile, asymptomatic patients undergoing laparoscopy for elective tubal ligation.
Certainly advanced endometriosis causes infertility with adhesions and distortion of pelvic anatomy, leading to mechanical interference (tubal obstruction). This a known cause of infertility,however, the role of minimal or mild endometriosis in infertility is less certain.
Medical treatments (birth control pills, progestins, or Lupron) are sometimes recommended for pain, but not given solely for infertility. For many patients with infertility associated with mild disease, laparoscopy with ablation of endometrial implants, may improve long-term pregnancy rates if IVF is not a viable option.
- Sometimes the infertility specialist can feel endometrial implants on pelvic examination, best performed on first day of menses.
- Ovarian enlargement.
- Mulberry spot - a vaginal or cervical bluish discoloration secondary to endometriosis.
Endometriosis management may be performed in the following ways: expectant management, medical treatment, surgical treatment, or any combination thereof. The type of treatment is dependent upon many factors including the severity of the symptoms, the type of symptoms (pain and/or infertility), the location of the disease, and the stage of the disease at the time of diagnosis.
Examples of medical management include the use of birth control pills, progestins (synthetic progestational agents), Lupron and aromatase inhibitors. Surgical therapy is generally employed for treatment of pelvic pain or infertility. In many cases this surgery should be performed by a fertility specialist especially if the laparoscopy is being done for infertility. Since the diagnosis must be made laparoscopically, it can often be treated by a fertility specialist during the diagnostic procedure. Therefore, a second laparoscopy for treatment is not required.
In conclusion, medical and surgical options for management of women with endometriosis allow a variety of approaches that may be tailored individually to the patient, her desires for fertility, and the physician's experience. There is no one therapy or combination of therapies that is right for all women. Nonetheless, the infertility specialist should have a thorough knowledge of the potentials and limitations for each therapeutic modality.
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