THE MAJORITY OF chronic pelvic pain is caused by endometriosis. Endometriosis is a disease affecting women in their reproductive years. It was widely undiagnosed until the 1980s. The name, as you’ve probably guessed, comes from the word endometrium. The clinical definition of endometriosis is an “abnormal growth of endometrial cells.” Between 2 and 22 percent of women with endometriosis don’t have any symptoms and may not know they have it; 40 to 60 percent of women with painful periods have endometriosis, while 20 to 30 percent of women who are having difficulty conceiving have endometriosis.
An endometrioma is a non-cancerous mass of tissue that contains shreds of endometrial tissue. Endometriomas most frequently occur in the ovary in a part of the peritoneum (sac around the internal organs) between the rectum and uterus, the wall (septum) between the rectum and vagina, and the outside of the uterus. Several surgical treatments are available for endometriomas, including:
Simple puncture – Fluid is drained from the cyst. Endometriomas have been shown to recur in about fifty percent of the patients treated with simple puncture; however, a more aggressive surgical approach-such as cutting away the mass-can cause extensive adhesions (scar tissue) that may prevent the ovary from releasing an egg.
Ablation – The cyst is drained and then its base removed with a laser or electro-surgery.
Cutting away of the cyst wall – is the procedure of choice to greatly diminish risk of the disease recurring. This procedure can also damage the outer layer of the ovary that contains the eggs.
Draining, drug therapy, and surgery – Endometriomas can also be drained, treated with medication, and later removed by surgery. Endometriomas recur in eight percent of the patients treated with this procedure. Results from several different studies have reported pregnancy rates of fifty percent over three years.
The most challenging surgery by laparoscopy is the management of advanced endometriosis within the pelvic cavity and the rectum and vagina. Laparoscopy and laparotomy are equally effective in relieving pain and improving fertility. Patients who undergo laparoscopy, however, experience a more rapid and less painful recovery. Preventive treatments can be used during surgery to help prevent adhesions from forming. These include rinsing the pelvic cavity with special solutions and placing a piece of protective material into the pelvic area to serve as a barrier. The barrier keeps the surfaces from rubbing together after surgery, preventing adhesion formation. The barrier dissolves and is absorbed when it is no longer needed. The advancement of laparoscopic surgery and the development of new preventive treatments have reduced the chances of adhesion formation.
Roughly 5.5 million women throughout North America have endometriosis. Endometriosis was at one time coined “husbanditis” because the pain that characterizes endometriosis was seen as a woman’s excuse to get out of her marital duties. In the past, treating women who complained of pelvic pain ranged from tranquilizers to hysterectomies. Unfortunately, many women today are still being told that their symptoms are “in their heads” when, in fact, endometriosis is a physical disease causing real physical symptoms. What happens is that endometrial tissue forms outside the uterus in other areas of the body. This tissue then develops into small growths, or tumors. (Doctors may also refer to these growths as nodules, lesions, or implants.) These growths are usually benign (noncancerous) and are simply a normal type of tissue in an abnormal location. Cancers that arise in conjunction with endometriosis appear to be very rare. Endometriosis is sometimes referred to in the medical literature as a pseudocyst endometrioma.
The most common location of these endometrial growths is in the pelvic region, which affects the ovaries, the fallopian tubes, the ligaments supporting the uterus, the outer surface of the uterus, and the lining of the pelvic cavity. Some 40 to 50 percent of the growths are in the ovaries and fallopian tubes. Sometimes the growths are found in abdominal surgery scars, on the intestines, in the rectum, and on the bladder, vagina, cervix, and vulva. Other locations include the lung, arm, thigh, and other places outside the abdomen, but these are rare.
Since these growths are in fact pieces of uterine lining, they behave like uterine lining, responding to the hormonal cycle and trying to shed every month. These growths are blind – they can’t see where they are and think they’re in the uterus. This is a huge problem during menstruation; when the growths start shedding, there’s no vagina for them to pass through, so they have nowhere to go. The result is internal bleeding, degeneration of the blood and tissue shed from the growths, inflammation of the surrounding areas, and formation of scar tissue. Depending on where these growths are located, they can rupture and spread to new areas, cause intestinal bleeding or obstruction (if they’re in or near the intestines), or interfere with bladder function (if they’re on or near the bladder). Infertility affects about 30 to 40 percent of endometriosis sufferers, and as the disease progresses, infertility is often inevitable.
The most common symptoms of endometriosis are pain before and during periods (much worse than normal menstrual cramps), pain during or after intercourse, and heavy or irregular bleeding. Other symptoms may include fatigue, painful bowel movements with periods, lower back pain with periods, diarrhea and/or constipation with periods, and intestinal upset with periods. If the bladder is involved, there may be painful urination and blood in the urine with periods. Irregular menstrual cycles and heavier flows are also associated with endometriosis, but women with severe endometriosis usually continue to have regular, albeit painful, periods. Some women with endometriosis may have no symptoms at all. It’s important to note that the amount of pain is not necessarily related to the extent or size of the growths. Tiny growths, called petechiae, have been found to be more active in producing prostaglandins, which may explain the significant symptoms that seem to occur with smaller growths.
Endometriosis can vary in terms of severity. Like other diseases, it is categorized into four stages-the higher the number, the more severe the endometriosis. Stage I is when your endometriosis is minimal and still very thin and “filmy,” hence easier to treat. Stage II is mild endometriosis; the endometriosis is still on the thin side but is situated more deeply into your surrounding tissues. Stage III is moderate endometriosis; here, your endometriosis is denser, mixed with some stage I or stage II symptoms. Stage IV means severe endometriosis. In this case, the endometriosis is dense and deep, a bad combination.
