Endometriosis

What is endometriosis ? :

Endometriosis is the the growth of endometrial glands and stroma on the peritoneal surfaces of the pelvis. Endometrial glands and stroma are normally found lining the uterus. Endometriosis is abnormally located tissue of this type and can be found on the surface of the uterus, tubes and ovaries, as well as the sidewalls of the pelvis, nearby bowels and other structures. Endometriosis is hormonally responsive, just like the lining of the uterus, and secretes inflammatory chemicals such as prostaglandins. To varying degrees, depending on the patient, this inflammation can produce local tissue destruction and scarring.

The causes of endometriosis are not fully worked out, though the preeminent concept at this time is that menstruation can send endometrial tissue out the tubes as well as out of the cervix, and it implants abnormally in the pelvis.

Endometriosis FAQS:

Endometriosis affests 6-10% of women of reproductive age.

38 % of women with infertility have endometriosis

About 80% of women with chronic pelvic pain have endometriosis

There is a genetic component to endometriosis.

Risk factors for endometriosis:

Period before 11 year of age
cycle interval less than 27 days
heavy prolonged cycles.
Factors protective against endometriosis:
Higher number of births
Longer period of lactation
Regular exercise of more than 4 hours per week.

Symptoms:

abdominal and pelvic pain
painful intercourse of the deep type
heavy periods
pelvic pain during bowel movements

Symptom severity does not correlate well the amount of disease found at surgery. See photo below showing a specimen taken from an asymptomatic patient.

Workup :

While history, physical exam and imaging such as Ultrasound are important, diagnosis of endometriosis can only be made at the time of surgery and upon microscopic confirmation of a specimen sent to the lab.

At surgery lesions can appear as gelatinous and red, collections of chocolate colored liquid, dark bluish black spots, or as tight white scars. We believe these different appearances reflect different stages of the disease.

This photo is of the largest chocolate cyst I have ever removed. It is 6-7 inches in longest dimension. The patient was symptom free.

Treatment:

Medical suppressive therapy in the form of oral contraceptive pills of GnRH analogs ( i.e. LUPRON) improves pain symptoms, but recurrence rates are high after discontinuation of therapy.

Conservative surgical therapy such as lysis of adhesions, or cautery of lesions ( anything short of removal of uterus tubes and ovaries ) can produce short term improvement in pain.

Only conservative surgical therapy of endometriosis produces some increased pregnancy rates for endometriosis related infertility. ( Medical therapies do not appear to help. )

Definitive surgical therapy is the removal of uterus tubes and ovaries and can produce longer term relief of pain. Estrogen therapy after such surgery does not appear to result in a recurrence of pain.