Women's Services Encyclopedia

Endometriosis

The uterus (womb) contains a lining which is referred to as the endometrium. This special lining grows in the uterus each month for the purpose of nourishing a fertilized egg. The endometrium also provides nourishment for the developing fetus. The endometrium grows in the uterus each month in response to a complex cycle of hormones. If the endometrium is not used (egg is not fertilized), then it will be shed through menstruation.

Symptoms:

Common symptoms include recurrent abdominal pain with menses, and abnormally heavy or prolonged vaginal bleeding during the cycle. Infertility is common among these patients.

Diagnosis:

Evaluation of endometriosis will include a history and physical examination. Pelvic examination is helpful in ascertaining the exclusion of other problems that can cause the same symptoms as endometriosis.

The most efficient way to diagnose endometriosis is through direct inspection of the reproductive organs. This can be accomplished through a fiberoptic procedure known as laparoscopy. Treatment is variable and must be based on the patient’s age, desire for childbearing, and severity of the disease. Patients close to menopause can be treated conservatively (symptoms will stop with menopause).  

• Women with pelvic pain which has not responded after 3 months of nonsteroidal antiinflammatory drugs (NSAIDs), and/or 3 months of oral contraceptives.
• Patients under 35 years of age with infertility of more than one year duration with clinical findings consistent with endometriosis should undergo laparoscopy, regardless of symptoms (remember, around 30% of patients with endometriosis have no symptoms).
• Patients over 35 should undergo laparoscopy after 6 months of infertility, since their “ovarian reserve” may not allow more prolonged “expectant” therapy.
• Advanced stages of endometriosis should always be suspected in premenopausal patients undergoing laparoscopic evaluation of an ovarian mass.

Using excisional techniques, individual endometriotic implants or nodules are carefully and completely removed. These implants will not recur or ?come back.” New implants may grow in the same anatomic area, but this normally requires significant passage of time. Repeated laparoscopic surgeries to treat endometriosis that seems to “come back” every few months almost always reflects incomplete removal or inadequate surgical treatment.

Laparotomy is an appropriate approach only when the surgeon does not have the requisite skills or facilities to perform these very complex and tedious surgical procedures via laparoscopy.

Treatment:

In order to develop a long term treatment plan for the patient with endometriosis, the gynecologist must carefully and thoroughly evaluate many factors, including:

• The patient’s age
• Severity of symptoms
• Type and extent of disease
• Plans for future pregnancy
• Physical findings
• Lifestyle of the patient

She may be a teenager desiring future pregnancy, a woman planning immediate pregnancy, or a woman who has completed her childbearing and/or does not desire future pregnancy.

Treatment options include no treatment, and/or limited use of analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs). Medical therapy can also consist of oral contraceptives, progestatives, or release hormons agonists (such as lupron). Oral contraceptives can be given cyclically (the patient has a monthly menses) or continuously (the patient has no menses during treatment). After 7 to 10 days, these drugs produce a menopausal state which is fully reversible. This produces amenorrhea (no menses), which permits regression of endometriosis and relief of symptoms.

In the infertile patient, laparoscopic therapy is almost always conservative, consisting of excision, laser vaporization, or electrosurgical desiccation of endometriosis. Every attempt should be made to conserve as much ovarian tissue as possible in these patients.

Remember, symptoms may be as much a result of the implants of endometriosis as from the uterus or ovaries.

Our most important rule:

A comprehensive long-range treatment approach must be individualized for each patient. An obstetrics and gynecology specialist is the expert in the diagnosis and management of this difficult problem.

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