Endometriosis

Endometriosis key concepts

• Endometriosis is a condition where tissue similar to the uterine lining grows outside the uterus, attaching to areas in the lower abdomen like the ovaries, fallopian tubes and the pelvic lining.
• This misplaced tissue behaves like normal endometrial tissue, thickening and bleeding during the menstrual cycle, but without an exit, it causes inflammation, pain and scar tissue formation.
• Symptoms of endometriosis can include severe menstrual pain, excessive bleeding, spotting between periods, pain during intercourse, constipation, bloating and infertility.
• Although there is no proven cause or cure for endometriosis, its symptoms and associated infertility can be managed with a combination of pain relievers, hormone therapies, surgical treatments and infertility interventions such as intrauterine insemination (IUI) or in vitro fertilization (IVF).

What is endometriosis?

Endometriosis is a chronic condition where tissue similar to the lining inside the uterus, known as the endometrium, begins to grow outside the uterus. These growths, referred to as endometrial lesions or implants, commonly attach to the ovaries, fallopian tubes, the outer surface of the uterus and other parts of the pelvic cavity.

Despite being located outside the uterus, the misplaced endometrial tissue responds to the menstrual cycle similarly to the uterine lining. This means it builds up, breaks down and bleeds each month. But unlike menstrual blood from the uterus, which exits the body, the blood from these external implants has no way to leave. This can lead to inflammation, pain and the formation of scar tissue around the implants.

Although the exact cause of endometriosis remains unknown, it exclusively affects menstruating women, roughly 10% (190 million) of reproductive age women and girls across the globe, often leading to infertility.

Related reading: When To See a Fertility Specialist

Endometriosis and fertility

The Center for Disease Control and Prevention notes that in the United States, infertility affects 13.4% of women ages 15-49 and 15.4% of women ages 25-49. The American Society for Reproductive Medicine adds that 30% to 50% of these women are diagnosed with endometriosis. The scarring or blockages it often causes in the fallopian tubes, where fertilization occurs, can prevent the egg and sperm from meeting. Treatments to improve fertility in those with endometriosis include:

• Laparoscopy: Minimally invasive surgery to diagnose then remove or destroy endometrial growths.
• In vitro fertilization (IVF): The most successful treatment for women with endometriosis, similar in success rates to treating other infertility causes.
• Controlled ovarian stimulation and intrauterine insemination (IUI): Sometimes effective for mild cases.

Related reading: IUI vs IVF: What’s Better for Me?

Endometriosis symptoms

Symptoms of endometriosis can vary widely, with typical indicators including pain, infertility and abnormal menstrual bleeding. The pain associated with endometriosis can be severe and occur at different times during the menstrual cycle, yet some women with severe endometriosis may not experience any discomfort at all. Research shows that 20% to 25% of women with the condition are asymptomatic.

The condition is particularly tricky to diagnose because its symptoms often resemble those of other ailments and can change over time, leading many women to endure symptoms for years without knowing they have endometriosis.

Common symptoms include:

• Infertility.
• Painful periods (dysmenorrhea) with severe cramping that worsens over time.
• Pain during or after intercourse.
• Pain with bowel movements or urination, particularly during menstruation.
• Excessive menstrual bleeding or bleeding between periods.
• Digestive issues such as constipation, diarrhea, bloating and nausea.
• Lower back and pelvic pain.

Recognizing symptoms can lead to an earlier diagnosis and more effective treatment.

Endometriosis causes and risk factors

The exact cause of endometriosis is unknown, but several theories exist. One common theory is retrograde menstruation, where menstrual blood flows backward through the fallopian tubes into the pelvic cavity. Another is exposure to environmental toxins like chemicals found in some plastics, personal care products and household cleaners, which can affect hormone levels. Additional risk factors include:

• Family history of endometriosis.
• Early onset of menstruation.
• Has not yet given birth.
• Heavy menstrual periods.
• Short menstrual cycles.
• Low body mass index (BMI).
• Reproductive tract abnormalities.

Diagnosing endometriosis

Accurate diagnosis is crucial regardless of pain severity, as even mild cases can impair fertility through organ damage, problems with embryo implantation, increased white blood cells in the abdominal area and stress on the immune system. While pelvic or ultrasound exams might suggest endometriosis, a definitive diagnosis requires direct inspection via laparoscopy.

Laparoscopy involves the insertion of a thin, lighted instrument through a small incision below the navel. This allows the surgeon to view and, if necessary, treat endometrial implants or other pelvic conditions. During this procedure, the surgeon can also remove or biopsy any suspicious tissue for further analysis.

Endometriosis treatment

While there is no cure for endometriosis, several treatments can help manage its symptoms and improve fertility.

Surgical treatment

Surgical options range from minimally invasive to more extensive procedures.

• Laparoscopy: Used for diagnosis and to remove or destroy endometrial implants and scar tissue.
• Laparotomy: A more extensive surgery with a larger incision, used for severe cases or when implants are inaccessible via laparoscopy.
• Hysterectomy: In severe cases, removing the uterus and ovaries may be considered. This results in permanent infertility.

Pain management

Treating endometriosis with pain management is essential to alleviate severe discomfort and improve the quality of life for those affected by the condition.

• Nonprescription pain relievers: Aspirin, acetaminophen or ibuprofen for mild to moderate pain.
• Prescription pain medication: For severe pain not relieved by over-the-counter drugs.
• Alternative therapies: Acupuncture, biofeedback, meditation and exercise may provide additional relief.

Hormone therapy

Hormone therapy aims to reduce or eliminate menstruation, which can shrink endometrial lesions and prevent new ones from forming. It is important to note that the hormone therapies that follow do not cure endometriosis, and symptoms often return after treatment stops.

• Oral contraceptives: Estrogen and progestin combinations.
• Danazol: A synthetic hormone that reduces estrogen levels.
• Gonadotropin-Releasing hormone (GnRH) agonists: Suppress ovulation temporarily.

Lifestyle changes and home remedies

Simple lifestyle modifications and home remedies can help manage symptoms and improve the quality of life for those with endometriosis. Patients should always consult with a healthcare provider before making significant changes to their lifestyle or treatment plan.

• Diet and nutrition: Increase fiber intake and follow an anti-inflammatory diet minimal in red meat, processed foods, and caffeine and alcohol to decrease estrogen levels and inflammation.
• Exercise: Engage in low-impact exercise and stretching (strength training may be appropriate for some as well) to alleviate stress, pain and tension.
• Stress management: Practice mindfulness and meditation and take part in cognitive behavioral therapy to manage stress levels.
• Better sleep: Stick to a consistent sleep schedule and relaxing bedtime routine to reduce stress and provide your body with time to heal.
• Heat therapy: Safely apply heat to the lower abdomen to help relax muscles and reduce pain.
• Supplements: Take physician-approved supplements including omega-3 fatty acids, vitamin D and magnesium to reduce inflammation and menstrual cramps as well as improving immune and muscle function.
• Alternative therapies: Attend regular acupuncture sessions for pain relief and learn how to practice biofeedback to control bodily functions.

Support groups and counseling

Connecting with others in endometriosis and/or infertility support groups can provide emotional support and practical advice. Professional therapy can also help manage the emotional and psychological impact of living with a chronic condition.