Endometriosis

Little is commonly known or understood about Endometriosis. What is known is that it can strike between 10 and 20 percent of American Women of childbearing age.

The name Endometriosis comes from the word “endometrium”, the tissue that lines the inside of the uterus. Normally, this tissue builds up and is shed each month and is discharged as menstrual flow. In case of Endometriosis, a small piece of this endometrial tissue is “misplaced” and is found outside the normal lining of the uterus. It may be located on ovaries, tubes, intestines, walls of abdomen and pelvis or the ligaments supporting the uterus.

Unlike menstrual fluid, which is discharged during menstruation, blood from the misplaced uterine lining causes the surrounding tissue to become inflamed or swollen. This may produce scar tissue (adhesions) in the area of endometriosis or can develop into what is commonly called “implants”, “lesions”, “nodules”, or “growths”.

What causes endometriosis?

We do not fully understand why endometrial tissue grows outside of the womb in some women, but not others. It probably has something to do with genetic factors, since endometriosis frequently runs in families. We do know that the female hormone estrogen makes the problem worse. Women have high levels of estrogen during their childbearing years. It is during these years (from the 20s into their 40s), that women have endometriosis. Estrogen levels drop when menstrual periods stop (menopause) and then symptoms usually go away.

The Mystery of Endometriosis is that while some women have severe pain, others who have the condition have no symptoms at all!

Symptoms

Pain is the most common symptom of endometriosis. Some women have severe cramps during their periods. Women that have progressively more painful periods with age usually have endometriosis. Other women have pain during intercourse or during urination or bowel movements.

Infertility occurs in about 30-40 percent of women with endometriosis.

Ovarian cysts filled with endometriotic material (dark, chocolate-colored substance) may be detected with ultrasound. However, these are present in less than 20% of women with endometriosis.

Diagnosis

Accurate Diagnosis – Requires Extensive Experience

Diagnosis of endometriosis remains a big problem. We can seldom diagnose this disease through the use of the present tools such as ultrasound, blood tests, or doctor exams. The only accepted diagnosis can be made by visual examination of the lesions. This of course requires a surgical procedure, with laparoscopy (laser surgery) being the most precise.

There are more than 100 documented appearances of endometriosis. Because the appearance of these lesions can be highly variable, some surgeons may fail to make an accurate diagnosis. Unless a surgeon is experienced in working with this disease, a patient with severe pain or infertility may go incorrectly diagnosed even after undergoing surgery.

Treatment – The Whole Body Approach

Our goal is to avoid surgery whenever possible. However, laparoscopy offers the only definitive diagnosis of endometriosis. Furthermore, the only laparoscopy with laser ablation or excision of endometriosis offers the best chances of restored fertility.

Treatment with medicines does not cure endometriosis. Medicines are also generally not recommended if infertility from endometriosis is your main problem. However, therapy can reduce pain and bleeding. Hormone therapy with birth control hormones, a gonadotropin-releasing hormone agonist (GnRH-a), progestin, or danazol can shrink endometriosis and reduce pain.

Birth control hormones and NSAID therapy are usually recommended first. Unlike other hormone therapies, they are least likely to cause serious side effects and can be used on a long-term basis.

Medication Choices

• Anti-inflammatories (NSAIDs) reduce pain and inflammation.
• Birth control hormones (patch, pills, or ring) create hormone levels in the body that are similar to pregnancy. This stops monthly ovulation and the growing, shedding, and bleeding that makes endometriosis painful. Birth control hormones improve endometriosis pain for most women. And birth control hormones are the hormone therapy that is least likely to cause bad side effects. For this reason, many women can use them for years. Furthermore, we sometimes suggest taking the hormones continuously. Other hormone therapies can only be used for several months to 2 years.
• GnRH agonist therapy, such as Lupron injections, lowers estrogen, triggering a menopause-like state. This shrinks implants and reduces pain for most women. This relief usually lasts for 6 to 12 months after ending GnRH-a therapy. GnRH agonist therapy may cause side effects such as headaches, hot flashes, and weight gain. Sometimes if the patient responds to the therapy, we can give her low doses of hormones (add-back therapy) to minimize the side effects.
• Progestin (pills or Depo-Provera shot) creates progestin levels in the body that are similar to pregnancy. This stops ovulation and lowers estrogen, shrinking endometriosis growths and reducing pain for most women.
• Danazol therapy lowers estrogen levels and raises androgen levels, triggering a menopause-like state. This shrinks endometriosis implants and reduces pain for most women. This relief usually lasts for 6 to 12 months after treatment. But danazol side effects can be significant including weight gain, undesired hair growth, and even voice deepening.
• Aromatase inhibitors stop estrogen production. In small studies, aromatase inhibitors have been shown to reduce pain and the chance of endometriosis growths coming back. Aromatase inhibitors may help women with endometriosis who have not had relief with hormonal treatments. Aromatase inhibitors are used in combination with hormonal treatment (such as birth control hormones or progestin). Long-term use of aromatase inhibitors may cause bone loss. More research needs to be done before it is known how well this treatment works and what the side effects are.

Surgical Treatment of Endometriosis

Laparoscopic Removal/Ablation

Endometriosis can be diagnosed and treated at the same time with the laparoscopic approach. During laparoscopy, a camera is inserted through a small incision inside the belly button and a Carbon dioxide laser is used to ablate (zap) the lesions of endometriosis. If a patient has infertility her best chances of getting pregnant are in the six months following the procedure. Pain is usually controlled for years. In fact, after a laparoscopy when the pelvis is “clean” is usually an opportune time to begin hormonal therapy if the patient so wishes. Although hysterectomy with or without oophorectomies does result in treatment and potential “cure” for endometriosis in our center we seldom take this approach, In our center, we prefer the minimally invasive treatment and usually can control symptoms without removing any organs.

Our doctors have the highest skill level of surgically removing the Endometriosis using CO2 Laser.