What Is Endometriosis?

When a woman has endometriosis, tissue that looks and acts like the lining of the uterus starts growing in places other than the inside of the uterus. The most common locations for these growths — called endometrial implants — are the outside surface of the uterus, the ovaries, the fallopian tubes, the ligaments that support the uterus, the intestines, the bladder, the internal area between the vagina and rectum, and the lining of the pelvic cavity.
It is not known exactly how many women have endometriosis, but it is believed that more than 5 million American women, including teen girls, are affected. It's not always diagnosed right away in teens because at first they or their doctors assume that their painful periods are a normal part of menstruating, or that their abdominal pain is due to another problem. But continuing, excessive pain that limits activity isn't normal and should always be taken seriously. Because severe endometriosis can make it harder for a girl to have children in the future, it's a good idea to get medical help for endometriosis and not wait too long.
To understand why endometriosis causes problems, it helps to have a basic understanding of how the monthly menstrual cycle works: During the course of each cycle, the lining of a woman's uterus builds up with blood vessels and tissue. This happens because the uterus is getting ready to receive the egg that will be released from one of the ovaries. If the egg isn't fertilized by sperm, the uterus sheds the tissue and blood; this is the menstrual period. This entire process is controlled by the female sex hormones and usually takes about 28 to 30 days.
Because the abnormal growths associated with endometriosis are made up of the same kind of tissue and blood vessels found in the uterine lining, any endometrial implants will act just like the endometrium in the uterus. That means they respond in the same way to the hormonal changes of the menstrual cycle.
However, in the uterus, if the egg isn't fertilized, the extra tissue and blood leave a girl's body in the form of menstrual fluid. With endometriosis, though, there's nowhere for the accumulating blood and tissue to go once the implants start to break down. This causes irritation of the surrounding body parts, which can cause pain. With continued build up and irritation, the symptoms of endometriosis tend to become more painful over time.

• Painful periods (dysmenorrhea). Pelvic pain and cramping may begin before and extend several days into your period and may include lower back and abdominal pain.
• Occasional heavy periods or bleeding between periods (menometrorrhagia).
• Pelvic pain during ovulation.
• Sharp pain deep in the pelvis during intercourse.
• Pain during bowel movements or urination.
• Infertility. Endometriosis is first diagnosed in some women who are seeking treatment for infertility.

• Abdominal pain
• IBS
• Infertility, female
• Infertility, male
• Painful periods

• constipation
• Diarrhea
• Irritable bowel syndrome (IBS)

A process called retrograde menstruation is a likely explanation for endometriosis. In retrograde menstruation, menstrual blood containing endometrial cells flows back through the fallopian tubes and into the pelvic cavity instead of out of the body. These displaced endometrial cells stick to the pelvic walls and surfaces of pelvic organs, where they grow and continue to thicken and bleed over the course of the menstrual cycle.
Retrograde menstruation alone may not cause endometriosis, though. Instead, the condition may develop when one or more small areas of the abdominal lining turns into endometrial tissue. This is possible because the cells lining the abdominal and pelvic cavities are descended from embryonic cells with the potential to specialize and take on the structure and function of endometrial cells. What activates that potential remains unknown.

• Infertility, female
• Infertility, male
• Ovarian cancer
  
  
  
  

  How is endometriosis diagnosed?

  Endometriosis can be suspected based on symptoms of pelvic pain and findings during physical examinations in the doctor's office. Occasionally, during a rectovaginal exam (one finger in the vagina and one finger in the rectum), the doctor can feel nodules (endometrial implants) behind the uterus and along the ligaments that attach to the pelvic wall. At other times, no nodules are felt, but the examination itself causes unusual pain or discomfort.
  Unfortunately, neither the symptoms nor the physical examinations can be relied upon to conclusively establish the diagnosis of endometriosis. Imaging studies, such as ultrasound, can be helpful in ruling out other pelvic diseases and may suggest the presence of endometriosis in the vaginal and bladder areas, but still cannot definitively diagnose endometriosis. For an accurate diagnosis, a direct visual inspection inside of the pelvis and abdomen, as well as tissue biopsy of the implants are necessary.
  As a result, the only accurate way of diagnosing endometriosis is at the time of surgery, either by opening the belly with large-incision laparotomy or small-incision laparoscopy.
  Laparoscopy is the most common surgical procedure for the diagnosis of endometriosis. Laparoscopy is a minor surgical procedure done under general anesthesia, or in some cases under local anesthesia. It is usually performed as an out-patient procedure (the patient going home the same day). Laparoscopy is performed by first inflating the abdomen with carbon dioxide through a small incision in the navel. A long, thin viewing instrument (laparoscope) is then inserted into the inflated abdominal cavity to inspect the abdomen and pelvis. Endometrial implants can then be directly seen.
  During laparoscopy, biopsies (removal of tiny tissue samples for examination under a microscope) can also be performed for a diagnosis. Sometimes biopsies obtained during laparoscopy show endometriosis even though no endometrial implants are seen during laparoscopy.
  Pelvic ultrasound and laparoscopy are also important in excluding malignancies (such as ovarian cancer) that can cause symptoms that mimic endometriosis symptoms.
  
  

  Treatments and Pharmacology

  Treatment for endometriosis is usually with medications or surgery. The approach you and your doctor choose will depend on the severity of your signs and symptoms and whether you hope to become pregnant.
  Generally, doctors recommend trying conservative treatment approaches first, opting for surgery as a last resort.
  Pain medications
  Your doctor may recommend that you take an over-the-counter pain reliever, such as ibuprofen (Advil, Motrin, others), to help ease painful menstrual cramps. However, if you find that taking the maximum dose doesn't provide full relief, you may need to try another treatment approach to manage your signs and symptoms.
  Hormone therapy
  Supplemental hormones are sometimes effective in reducing or eliminating the pain of endometriosis. That's because the rise and fall of hormones during a woman's menstrual cycle causes endometrial implants to thicken, break down and bleed.
  Hormonal therapies used to treat endometriosis include:
  
• Hormonal contraceptives. Birth control pills, patches and vaginal rings help control the hormones responsible for the buildup of endometrial tissue each month. Most women have lighter and shorter menstrual flow when they're using a hormonal contraceptive. Using hormonal contraceptives — especially continuous cycle regimens — can reduce or eliminate the pain of mild to moderate endometriosis.
• Gonadotropin-releasing hormone (Gn-RH) agonists and antagonists. These drugs block the production of ovarian-stimulating hormones. This action prevents menstruation and dramatically lowers estrogen levels, causing endometrial implants to shrink. Gn-RH agonists and antagonists can force endometriosis into remission during the time of treatment and sometimes for months or years afterward. These drugs create an artificial menopause that can sometimes lead to troublesome side effects, such as hot flashes and vaginal dryness. Taking a low dose of estrogen or progestin along with Gn-RH agonists and antagonists may decrease such side effects. If Gn-RH agonists don't relieve your pain, it's unlikely that endometriosis is responsible for your symptoms.
• Danazol. Another drug that blocks the production of ovarian-stimulating hormones, preventing menstruation and the symptoms of endometriosis, is danazol. In addition, it suppresses the growth of the endometrium. However, danazol may not be the first choice because it can cause unwanted side effects, such as acne and facial hair.
• Medroxyprogesterone (Depo-Provera). This injectable drug is effective in halting menstruation and the growth of endometrial implants, thereby relieving the signs and symptoms of endometriosis. Its side effects can include weight gain, decreased bone production and depressed mood.
• Aromatase inhibitors. Although not specifically approved for the treatment of endometriosis, studies suggest that aromatase inhibitors may significantly reduce endometriosis-related pain. Aromatase inhibitors work by blocking the conversion of hormones such as androstenedione and testosterone into estrogen and by blocking the production of estrogen from endometrial implants themselves. This deprives endometriosis of the estrogen it needs to grow. To reduce the risk of side effects, such as bone loss and follicular cysts, aromatase inhibitors must be taken in combination with a Gn-RH agonist or an oral estrogen-progestin contraceptive.

Hormonal therapies aren't a permanent fix for endometriosis. It's possible that you could experience a recurrence of your symptoms after stopping treatment.
Conservative surgery
If you have endometriosis and are trying to become pregnant, surgery to remove endometrial implants may increase your chances of success. If you have severe pain from endometriosis, you may also benefit from surgery.
Conservative surgery removes endometrial growths, scar tissue and adhesions without removing your reproductive organs. Your doctor may do this procedure laparoscopically or through traditional abdominal surgery in more extensive cases. In laparoscopic surgery, a slender viewing instrument (laparoscope) is inserted through a small incision near your navel. Guided by the laparoscope, your doctor inserts other instruments through another small incision to remove endometrial implants. Such instruments might include a laser, small surgical instruments or a cautery — an instrument that destroys tissue with heat.
Assisted reproductive technologies to help you become pregnant are sometimes preferable to conservative surgery, and doctors often suggest these approaches if conservative surgery is ineffective.
Hysterectomy
In severe cases of endometriosis, surgery to remove the uterus and cervix (total hysterectomy) as well as both ovaries may be the best treatment. Hysterectomy alone is not effective — the estrogen your ovaries produce can stimulate any remaining endometriosis and cause pain to persist. Surgery is typically considered a last resort, especially for women still in their reproductive years. You can't get pregnant after a hysterectomy.


REFERENCES:
eMedicine.com. Endometriosis.
<http://emedicine.medscape.com/article/271899-overview>
Van Gorp T; Amant F; Neven P; Vergote I; Moerman P. Endometriosis and the development of malignant tumours of the pelvis. A review of literature. Best Pract Res Clin Obstet Gynaecol 2004 Apr;18(2):349-71.