Endometriosis (en-doe-me-tree-O-sis) is an often-painful disorder in which tissue that normally lines the inside of your uterus, the endometrium grows outside your uterus. Endometriosis most commonly involves your ovaries, fallopian tube and the tissue lining your pelvis. Rarely, endometria tissue may spread beyond pelvic organs.
With endometriosis, displaced endometrial tissue continues to act as it normally would, it thickens, breaks down and bleeds with each menstrual cycle. Because this displaced tissue has no way to exit your body, it becomes trapped.
When endometriosis involves the ovaries, cysts called endometriomas may form. Surrounding tissue can become irritated, eventually developing scar tissue and adhesions, abnormal bands of fibrous tissue that can cause pelvic tissues and organs to stick to each other.
Endometriosis can cause pains, sometimes severe, especially during your period. Fertility problems also may develop. Fortunately, effective treatments are available.
Symptoms
The primary symptom of endometriosis is pelvic pain, often associated with your menstrual period. Although many women experience cramping during their menstrual period, women with endometriosis typically describe menstrual pain that’s far worse than usual. They also tend to report that the pain increases over time.
COMMON SIGNS AND SYMPTOMS OF ENDOMETRIOSIS MAY INCLUDE:
- Painful periods (dysmenorrhea). Pelvic pain and cramping may begin before your period and extend several days into your period. You may also have lower back and abdominal pain.
- Pain with intercourse. Pain during or after sex is common with endometriosis.
- Pain with bowel movements or urination. You’re most likely to experience these symptoms during your period.
- Excessive bleeding. You may experience occasional heavy periods (menorrhagia) or bleeding between periods (menometrorrhagia).
- Endometriosis is first diagnosed in some women who are seeking treatment for infertility.
- Other symptoms. You may also experience fatigue, diarrhoea, constipation, bloating or nausea, especially during menstrual periods.
The severity of your pain isn’t necessarily a reliable indicator of the extent of the condition. Some women with mild endometriosis have intense pain, while others with advanced endometriosis may have little pain or even no pain at all.
Endometriosis is sometimes mistaken for other conditions that can cause pelvic pain, such as pelvic inflammatory disease (PID) or ovarian cysts. It may be confused with irritable bowel syndrome (IBS), a condition that causes bouts of diarrhoea, constipation and abdominal cramping. IBS can accompany endometriosis, which can complicate the diagnosis.
When to see a doctor
See your doctor if you have signs and symptoms that may indicate endometriosis.
Endometriosis can be a challenging condition to manage. An early diagnosis, a multidisciplinary medical team and an understanding of your diagnosis may result in better management of your symptoms.
CAUSES
Although the exact cause of endometriosis is not certain, possible explanations include:
- Retrograde menstruation. 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 each menstrual cycle.
- Transformation of peritoneal cells. In what’s known as the “induction theory,” experts propose that hormones or immune factors promote a transformation of peritoneal cells that line the inner side of your abdomen into endometrial cells.
- Embryonic cell transformation. Hormones such as oestrogen may transform embryonic cells in the earliest stages of development into endometrial cell implants during puberty.
- Surgical scar implantation. After a surgery, such as a hysterectomy or C-section, endometrial cells may attach to a surgical incision.
- Endometrial cells transport. The blood vessels or tissue fluid (lymphatic) system may transport endometrial cells to other parts of the body.
- Immune system disorder. It’s possible that a problem with the immune system may make the body unable to recognize and destroy endometrial tissue that’s growing outside the uterus.
RISK FACTORS
Several factors place you at greater risk of developing endometriosis, such as:
- Never giving birth
- Starting your period at an early age
- Going through menopause at an older age
- Short menstrual cycles for instance, less than 27 days
- Having higher levels of oestrogen in your body or a greater lifetime exposure to oestrogen your body produces
- Low body mass index
- Alcohol consumption
- One or more relatives (mother, aunt or sister) with endometriosis
- Any medical condition that prevents the normal passage of menstrual flow out of the body
- Uterine abnormalities
Endometriosis usually develops several years after the onset of menstruation (menarche). Signs and symptoms of endometriosis end temporarily with pregnancy and end permanently with menopause unless you’re taking oestrogen.
COMPLICATIONS OF ENDOMETRIOSIS
- Fertilization and Implantation
Infertility
The main complication of endometriosis is impaired fertility. Approximately one-third to one-half of women with endometriosis has difficulty getting pregnant.
For pregnancy to occur, an egg must be released from an ovary, travel through the neighbouring fallopian tube, become fertilized by a sperm cell and attach itself to the uterine wall to begin development. Endometriosis may obstruct the tube and keep the egg and sperm from uniting. But the condition also seems to affect fertility in less-direct ways, such as damage to the sperm or egg.
Even so, many women with mild to moderate endometriosis can still conceive and carry a pregnancy to term. Doctors sometimes advise women with endometriosis not to delay having children because the condition may worsen with time.
- Ovarian Cancer
Ovarian cancer does occur at higher than expected rates in women with endometriosis. But the overall lifetime risk of ovarian cancer is low, to begin with. Some studies suggest that endometriosis increases that risk, but it’s still relatively low. Although rare, another type of cancer — endometriosis-associated adenocarcinoma — can develop later in life in women who have had endometriosis.
How Does Endometriosis Affect Fertility?
Endometriosis and infertility are closely related. According to some studies, between 30-50% of women with endometriosis also experience difficulty conceiving. For a woman with untreated endometriosis who is trying to get pregnant, her chance of conceiving each month (known as the monthly fecundity rate) is only 2-10%, which can be very discouraging when you compare it to the monthly fecundity rate of the general population, which is 15-20%.
Exactly how endometriosis is causing a patient’s infertility can sometimes be unclear, and depends on the stage and severity of the disease. One or more factors may contribute to the problem, including:
- Tube blockages
Endometrial deposits can cause obstructions in the fallopian tubes which block the egg from traveling through the tubes during normal ovulation. This physical blockage can prevent fertilization.
- Ovarian cysts
The “chocolate cysts” which endometriosis can cause in the ovaries may interfere with normal ovulation, can block egg transport, and may even damage the ovaries, resulting in decreased ovarian reserve, in such cases we recommend the use of a DONOR EGG
- Toxicity in the pelvic (intraperitoneal) environment from endometriotic deposits
Infertility can occur even in relatively mild cases of endometriosis where there are no physical blockages or adhesions that prevent normal ovulation. Exactly how endometriosis causes infertility in these cases is not completely clear, but studies have indicated that the presence of endometriosis changes the intraperitoneal environment. Either the endometrial cells themselves or the body’s immune response produce biochemical substances such as prostaglandins which have anti-fertility effects and may make it more difficult to conceive.
Compounding the fertility problem is the fact that many treatments designed to combat the pain and heavy periods caused by endometriosis are incompatible with pregnancy: birth control pills and other hormonal treatments may halt the progression of the disease, but these medications work largely by suspending menstruation and the natural ovulation cycle. A woman who wants to become pregnant will have to suspend these endometriosis treatments, which ultimately results in the return of her symptoms. In these cases, time is of the essence: getting pregnant before severe symptoms return is the best-case scenario.
Laparoscopic surgery to remove endometrial lesions is a useful treatment, but depending on the size and location of the lesions and the age of the patient, it can have a detrimental effect on ovarian reserve. For younger patients with advanced endometriosis, surgery to remove large endometriomas can improve fertility, and may be indicated before beginning an IVF cycle. For older patients, proceeding directly to IVF is usually a better course of action.
Is IVF A Good Treatment Option for Women with Endometriosis?
IVF is usually the best plan for infertility patients with endometriosis, and the prognosis is surprisingly good. We find that IVF patients with this diagnosis generally do just as well as our patients who do not have endometriosis. IVF can provide hope for women who have been struggling with this disease for a long time and worried they would never be able to achieve a healthy pregnancy. You may need some special monitoring and careful management of fertility medications, which can temporarily aggravate endometriosis symptoms, but your chances of success are good. Getting pregnant often brings relief from the pain of endometriosis for the duration of the pregnancy, though once the baby is born you will probably need to resume treatment for your symptoms.
Suffering from endometriosis can be debilitating. When you add the heartbreak of infertility to that pain, it can be an especially isolating experience. If you have endometriosis or suspect that you might, it is important to find a medical team that understands this disease and can guide you through your options for treatment and for fertility.
Even if you are not ready to conceive right now, it is important to seek help: untreated endometriosis can get progressively worse, and you may wish to take proactive steps to PRESERVE YOUR FERTILITY. With the right support, endometriosis does not need to stand between you and your dreams of building a family.