What is the Zika virus?

There's been much in the news lately about the Zika Virus, especially its effects on pregnant women.  Already, I've been receiving calls in my office about whether it's safe to travel.  Here, I hope to explain a little more about what's going on...

On Friday last week, the Centers for Disease Control (CDC) released an official health advisory urging all pregnant women to avoid travel to certain areas to avoid infection with the Zika virus....

Today, I want to explain what this is, where it is, and how it can affect people, especially during pregnancy.

The Zika (pronounced ZEE-kuh) virus was first reported in Brazil in May of last year.   Prior to that, it was found only in Africa, Southeast Asia, and the Pacific Islands. Over the past several months, the virus has spread to a larger area, now including Mexico, Central America, and much of South America.

Zika virus is transmitted through the bite of an infected mosquito.  As of now, the United States does NOT have infected mosquitoes.  There are reports of pregnant women in the U.S. who are affected by Zika but they had recently traveled to areas where it is prevalent.  The virus is NOT spread through human contact.

Not everyone who gets infected gets symptoms.  Only about 20% of infected people notice things such as fever, rash, joint aches, or pink eye, which typically start about 2 weeks after being exposed.  Usually symptoms are mild and last for up to a week.  Most people recover fully without problems.  

The big problem is that if a pregnant woman gets the virus, it can cause miscarriage.  It can also cause the baby to have microcephaly, which means that its head is too small.

Microcephaly can be associated with seizures, developmental delays, problems with vision, hearing, movement, and intellectual disability.

The only way to prevent Zika virus infection at this time is to avoid traveling to areas where the disease is present.  For this reason, the CDC has recommended that pregnant women or women who are trying to become pregnant not travel to areas where the disease is prevalent.  For now, this includes Mexico, Puerto Rico, Haiti, Martinique, El Salvador, Guatemala, Honduras, Panama, Brazil, Colombia, French Guiana, Paraguay, Suriname, and Venezuela.  

If travel is necessary,  you should do everything possible to prevent mosquito bites.  This includes using insect repellants, wearing long sleeved shirts and long pants, keeping windows closed or open with a screen, using mosquito nets, and remove any standing water from around you.

At this time, there is no commercial testing available for the virus.  Testing can be done through the CDC if infection is suspected.

There is no treatment for Zika.  Supportive care, including rest, fluids, and use of acetaminophen (Tylenol) is recommended.  Most people recover fully and hospitalization is usually not necessary.

If you are pregnant or planning to become pregnant soon, the best bet for avoiding infection is to stay away from those areas where Zika has been found in mosquitos.

Much more information can be found at the following sites:

Centers for Disease Control 

Travel Notices

Information on microcephaly

Protection against mosquitoes

Cervical cancer screening

One topic that I discuss on a daily basis is cervical cancer screening.  After all, this is the reason that most of us go to the gynecologist.

For years, women have been told that they needed annual Pap smears.  This was an arbitrary recommendation, not based on scientific evidence, when Pap smears were initially done in the 1940s.  Since scientists and doctors did not understand at the time what caused cervical cancer, and what the risk factors were, it was thought that once a year should be adequate to pick up precancerous changes on the cervix before they turned into cancer.  For an interesting read on the development of the Pap test, click here:

Dr. George Papanicolaou's discovery

Fast forward about 70 years...so much more is known now about cancer in general, and specifically cervical cancer.  With the knowledge we now have, it is possible to prevent cervical cancer, and even minimize risk factors for its development.   Unfortunately, cervical cancer still exists, mostly for women who have not been adequately screened, or have not been appropriately treated.  In 2011, over 12,000 women were diagnosed with cervical cancer in the United States, and about 1/3 of them died from it. 

It has been known for many years now that cervical cancer almost always arises from infection with the human papilloma virus (HPV).  There are nearly 100 strains of HPV.  Some can cause annoying warts on the hands, feet, or genitalia.  Some "high-risk" strains can cause cancer of the cervix, vagina, vulva, throat, penis, and anus.  These high-risk strains are sexually transmitted, and it's been stated that 80% of sexually active people become infected with some strain of HPV.

The good news is that our immune systems frequently clear this virus.  Most of the time, people do not get cancer from HPV.  People can get cancer from HPV if their immune systems do not clear the virus. Any coexisting condition which causes the immune system not to work well (such as smoking, HIV infection, some immunosuppressive medications) also increase the risk of HPV not being cleared.

This rationale is the basis for the development of the vaccine for HPV (Gardasil or Cervarix).

We offer Gardasil in our office, which is a quadrivalent vaccine, meaning that it vaccinates against 4 strains of HPV.  Types 16 and 18 cause about 70% of cervical cancer, and cause the most rapid changes to cervical cells after infection.  Types 6 and 11 are responsible for the development of external genital warts.  This is the first cancer that can be prevented by vaccination!  Gardasil is now recommended for boys and girls ages 9-26, and is best given before the onset of sexual activity.  See my HPV vaccine blog for more info...

This HPV vaccine podcast details a personal story of why HPV vaccination is important.

So...back to screening.  Of course I recommend the HPV vaccine, but that's only only one piece of the puzzle.

Because it takes many years (5-10) after HPV infection to cause cervical cancer, it is not recommended to screen women until 21 years of age.  Often there are other reasons to see a gynecologist before that age, but not for routine Pap tests.

If a woman's Pap is negative at age 21, screening is repeated every 3 years.  Why not every year?

This goes back to the fact that most often, our immune systems clear HPV.  If someone has been infected with HPV, sometimes it can cause transient mild changes to the Pap that eventually resolve.  If we screen annually, we are more apt to pick up those small changes. We then feel compelled to act on it, requiring biopsies, and potentially freezing or excising part of the cervix.  These treatments are likely unnecessary, as mild abnormalities usually resolve on their own.  If we screen every 3 years, we are less likely to find these inconsequential changes, and more likely to pick up PERSISTENT changes.  These are the abnormalities we need to act on.

However, if the Pap is not normal at age 21, we do follow more closely, with more frequent Pap tests, occasional biopsies and treatments.  We are not ignoring changes, just acting on those more likely to be harmful.

At age 30, the recommended approach is to add testing for high-risk HPV to routine Pap screening.  Why don't we do it earlier?

Because most sexually-active women become infected with HPV, and the infection is frequently cleared, we would find a lot of high-risk HPV in the younger population that will be eventually cleared.  However, if it is still present by age 30, that signifies a more likely persistent infection, which is more likely to cause pre-cancerous changes.

If the Pap and high-risk HPV test are both negative after age 30, women can safely go 5 years until their next screen.  The risk of high-grade precancerous changes or cervical cancer in 5 years in this population is roughly 0.1%.

If women have had consecutive negative screens, Pap tests can be safely discontinued at age 65.  Cervical cancer is different than other cancers.  Because it's sexually transmitted, and takes at least 5-10 years from infection to severe changes or cancer, its peak incidence is in a woman's 30s and 40s.  It is rare to diagnose cervical cancer in women over age 50 who have had adequate prior screening.

Remember that these guidelines apply to women who have had negative screening.  If any abnormal result is found, we follow more closely, either with repeat Pap tests or biopsies.

Even though the Pap does not generally need to be done every year, it is still important to see your doctor annually.  Much more is done at the annual well-woman exam, including breast exam, pelvic exam, check of blood pressure, height and weight, and preventive health counseling.

Much more information can be found by clicking these links:

American College of Obstetricians and Gynecologists

American Cancer Society

Centers for Disease Control

Nutrition during pregnancy

I've been into learning about nutrition lately.  It's something we learn very little about during medical school, only skimming the surface.  We all know "healthy foods" vs. "junk foods" but how do we optimize our health with diet?  If you think about it, food is a type of medicine, and very definitely affects how our bodies function.  I plan to write a series about nutrition, and thought it best to start with nutrition during pregnancy.  I get asked on at least a weekly basis "Can I eat _______?" 

To start off, it's important to talk about weight gain during pregnancy.  It's good to know whether you're at a healthy weight at the beginning of your pregnancy, and your doctor/provider can then advise on a recommended amount to gain.  For women of normal weight (i.e. body mass index (BMI) 18.5-24.9), a 25-35 pound total weight gain is recommended.    If you're underweight (BMI less than 18.5), plan on 28-40 pounds.  If you are overweight (BMI 25-29.9), shoot for 15-25 pounds, and if you're obese (BMI greater than 30), minimal weight gain to a maximum of 20 pounds.   Most of your weight gain should come in the second half of pregnancy.

If you're pregnant with twins and are of normal weight, 37-54 pounds of weight gain is recommended.  This decreases to 31-50 pounds for overweight women, and 25-42 pounds for obese women.

Of course, it is impossible to control exactly how much weight you gain during pregnancy, but being aware of these guidelines and paying attention to how much weight you've gained to try to stay within these ranges can decrease your risk of complications such as gestational diabetes, preeclampsia, and gestational hypertension.  Gaining too much weight also increases your risk for c-section, and having a large infant.

 

In general, pregnant women should follow the same food guidelines as before pregnancy.  You should take in more calories, but only about 300 more than usual. 
Click the link to learn more about Healthy Food Choices During Pregnancy and calculate your BMI.

The most important nutrients you need to pay attention to during pregnancy are:

Folic acid - helps to prevent neural tube defects (problems with development of the baby's brain and spine), and ideally should be supplemented before pregnancy
Iron - protects against anemia as your blood volume increases during pregnancy
Calcium - helps to protect your bone health

When it comes to specific foods, there are certain food-borne illnesses that can cause birth defects or other problems during pregnancy.  One specific issue that I get asked about frequently is listeriosis.  Listeria is a type of bacteria that can be present in unpasteurized dairy products and undercooked meat, however there was a listeria outbreak in 2011 as a result of unwashed cantaloupe.  Listeria usually causes flu-like symptoms such as fever, abdominal pain, and diarrhea, but can be passed to the fetus through the placenta and has been linked to miscarriage, stillbirth, and preterm delivery.  This is a very rare infection (about 0.3 cases per 100,000 people per year), but in order to avoid these issues, make sure you only drink milk and eat cheese that has been pasteurized.  You don't need to avoid deli meats and hot dogs, but make sure they are heated until steaming hot.  Make sure you wash all produce before you cut it or eat it. 

Another concern is mercury exposure.  Mercury can be present in high levels in certain types of fish.  High levels of methylmercury in a pregnant woman can cause problems with development of a baby's nervous system, causing altered memory, attention deficity-hyperactivity disorder, or problems with language development and coordination.  It is advised to avoid eating shark, swordfish, king mackerel, and tilefish during pregnancy, as these have the highest levels of mercury.  Fish does have great nutritional value, however, so you should not cut it out entirely.  Recently, the FDA and the American College of OB/GYN released a statement encouraging pregnant women to eat 8-12 ounces of low-mercury fish each week.  Click here to read:  FDA recommendation on fish consumption during pregnancy.

 

 

Of course, fish should be cooked well, so avoid raw sushi.

 

A good source of information if you have any questions about what is safe to eat during pregnancy can be found by clicking the following link:

FDA food safety guidelines

 

In general, the most important things to remember are to eat a variety of foods, avoid excessive salt and sugar intake, cook your meat thoroughly and wash all produce well.    These simple steps will help to ensure the safest pregnancy for you and your baby.

 

 

 



Long-acting reversible contraception

After a year-long hiatus, I'm back...

I find myself talking to many patients every day about contraceptive options.  Contraception has been quite a hot topic in the news lately, mostly related to insurance coverage mandates.  It is and has always been something important to discuss, as roughly half of all pregnancies are unintended in the United States.  Pregnancy is a "natural" state, but should be planned to minimize risk to both mother and fetus.

There are so many options for contraception, including hormonal, non-hormonal, short-acting, long-acting, pharmaceutical, natural - each with its own pros/cons and efficacies.

Today, though, I'd like to focus in on long-acting reversible contraceptives (LARCs).  LARCs include the intrauterine devices (IUDs) and contraceptive implant.  These are highly-effective long-term birth control options that have been gaining popularity over the past few years.

 

LARCs can be used by women of any age.  For many years, health providers discouraged use of IUDs in women who have never had children, but this is no longer the case.  We are now frequently using the contraceptive implant as well as IUDs in young women or women who have never been pregnant.  There really are very few women who cannot use LARCs.

One of the best features of LARCs is their effectiveness.  Pregnancy occurs less than 1 in 100 users.  That's over 99% effective.  LARCs have been found to be just as effective as tubal ligation, but are immediately reversible.  In fact, many women who may otherwise have undergone tubal ligation are now choosing to use this most effective birth control and avoiding surgery.

The IUD is a small T-shaped device that is placed into the uterus during a simple office procedure.  There are 2 different types of IUDs.  One is non-hormonal.  It is made of copper and lasts for up to 10 years.  The other contains progestin, a hormone that acts locally within the uterus to thin the uterine lining.  One advantage of this type of IUD is that over time, a woman's menstrual periods become very light or go away completely because the lining gets so thin.    Many women choose the hormonal IUD for this reason.  Because it keeps the uterine lining from becoming thick, it also decreases the risk of uterine cancer. One hormonal IUD lasts for 3 years, the other lasts for 5 years.

The IUDs are thought to work mostly by inhibiting the sperm from reaching the egg.  The hormonal IUD also thickens the cervical mucus, making it difficult for sperm to even enter the uterus.  In the case of the hormonal IUD, the thin lining of the uterus is also likely less receptive to implantation of a fertilized egg.  Fertility normally returns immediately after removal of the device.

Placing the IUD involves placing a speculum in the vagina and cleaning the cervix with Betadine. A small clamp is placed on the cervix to hold it steady.  The uterus is then "sounded" - a thin rod is placed through the cervix until it touches the top of the uterus to measure the length of the uterine cavity.  This is important because the IUD applicator is then set to that length to be sure the IUD is placed right at the top of the uterus.  The arms of the IUD are drawn into the applicator, and it is then advanced into the uterus.  Once inside, the arms are released, the IUD is advanced to the top, and the applicator is removed.  The strings on the end of the IUD are then trimmed to about 1" outside the cervix.  The clamp and speculum are removed, and it's done!  The entire procedure takes only about 2 minutes.  Most women experience a cramping sensation during the procedure, but it is temporary, and can be lessened by taking ibuprofen before the office visit.

As with any medication or procedure, there can be side effects or risks.  With the hormonal IUD, it is common to have unpredictable bleeding for up to 6 months after insertion.  The nonhormonal IUD can result in slighly heavier periods for up to 6 months.  There is a chance the IUD can be expelled from the uterus.  During placement, the uterus can be perforated, resulting in a chance of the IUD being placed into the abdominal cavity.  This happens only about 1 per 1,000 insertions.  If this occurs, it can only be removed surgically, usually with an outpatient procedure.  It is rare to have any long-term complications.  Although pregnancy is very rare with an IUD, there is a chance that if pregnancy does occur, it will implant within the fallopian tube, resulting in an ectopic pregnancy, which may require surgery. 

All of this sounds scary, but is exceedingly rare.  The IUD is an excellent form of contraception, and it's no coincidence that most of the female OB/GYNs I know use an IUD.  It is easy to use, extremely effective, and readily reversible.

The implant is a small plastic tube containing a progestin that is placed just under the skin of the upper inner arm.  With this device, the progestin hormone acts systemically, meaning through your whole body.  It acts mainly by stopping ovulation.  It, like the hormonal IUD, also thickens the cervical mucus and thins the uterine lining, making fertilization and implantation less likely. 

Placing the implant is also a simple office procedure.  The inside of the upper arm is injected with a local anesthetic.  The arm is cleaned with Betadine, then using a sterile applicator, the implant is injected under the skin.  After placement, you can feel the implant under the skin, but it is difficult to see.  A bandage is placed over the site.

The most common side effect of the implant is unpredictable bleeding.  For many women, this improves over time.  Complications can include bleeding or bruising during insertion, and difficulty with removal.

The benefits of long-acting reversible contraception greatly outweigh risks for most patients.  Their ease of use and efficacy make them a good choice for almost anyone.  It's important to note that these forms of birth control do not protect you against sexually-transmitted disease.

Women should discuss pregnancy prevention with their health care providers and determine the best method to allow a planned low-risk pregnancy when the time is right.

Check out these links for more information:

Mirena IUD official website

Skyla IUD official website

Paragard IUD official website

Nexplanon insert official website

Balance

 

Usually I put my education to use on this blog, writing about health issues that affect women.  My mother-in-law recently told me that she got her Tdap vaccine, so at least someone is reading it.  Anyway, this time I'm blogging about something from which we can all benefit, finding that elusive balance between work and personal life.

After a particularly brutal 24 hours of call on Monday, I found myself feeling a little burned out.  There were several trips through the night, in the cold, to different hospitals, and I was getting paged roughly every hour.  I was tired.  This time of year, it's always that way for me.  I usually chalk it up to a lack of sunshine, ingestion of too many carbohydrates, and decreased physical activity.  But, I had an epiphany yesterday.  I hadn't found balance.

Don't get me wrong, I absolutely LOVE what I do.  I have spent 4 years of undergraduate education, 4 years of medical school, and 6 1/2 years of residency to get me to where I am today.  All of this recently culminated in the completion of my board certification in OB/GYN.  For the past 18 months, I have been preparing for the oral board exam.  This required travel to board prep courses, studying, and sitting before board examiners while they picked my brain about how I practice medicine.  It was associated with a significant amount of anxiety.  My family and I sacrificed a lot during this time, but it was all worth it. 

There's nothing more gratifying and humbling than helping a new life come in to this world safely.  As I was introducing myself to one of my partner's patients the other night, she asked me how many babies I'd delivered (she thought I looked too young to be a doctor, LOVE that!).  Anyway, I was thinking it's got to be close to 2000!  For those of you who have witnessed a birth, it really is a miracle.   It still doesn't get old for me.  I have an incredible career.

So, why do I feel unsatisfied sometimes? 

On Saturday afternoon, I took my daughter to see "Les Miserables" at the movie theater.  Yes, I know, that movie came out a long time ago, but I hadn't made time to see it, and I was making a mad dash to see at least a few movies before the Oscars on Sunday.  Wow.  I found myself tearing up as Eponine sang "A Little Fall of Rain".  That's what life's about.  Feeling.  I love that musical.

In my younger years, I was kind of "artsy". I used to play piano, sing, dabbled in theater, and danced. I even considered a double major in music and biology in college, right up until I figured out it would take at least 6 years to graduate. But because I have been so focused in on my family, training, and career, I have let that part of me disintegrate.

That's when it struck me.  The "scientist" and "artist" are not two distinct aspects of me, but instead compliment each other perfectly.   If I let one part dwindle, the other suffers too.  For a sense of well-being, I must find that balance. 

Now that the boards are over, I plan to brush up on my piano-playing skills.  I'll spend more time with my kids, and really listen to them.  I'm going to participate in the Metro Omaha Medical Society's music parody show "The M.E.S.S. Club" in April.  (I'll also work on being more physically active, and stop eating so many darn carbs). 

This is one of my all-time favorite quotes:

I hope to be able to continue to find that perfect balance between work and personal life.  I hope to be able to teach my children to do it too.  Take some time to find it for yourself.  Figure out what it is that makes you feel joy, a sense of accomplishment, or just relaxation.  Don't let only one aspect of your life take over.  Life is too short.

Tdap vaccine

Wow, it's almost been a year since my last post!  I've survived the oral boards, and am now board certified in OB/GYN, and a Fellow of the American College of OB/GYN!  I hope to resume more regular posts now that that's behind me...

One topic that I discuss almost daily is immunization for Tetanus, diptheria, and acellular pertussis (Tdap).  What the heck is it, and why do you need it?

Every adult should be immunized against tetanus at least once every 10 years.  Tetanus is an infection caused by the bacteria Clostridium difficile.  You get tetanus by transmission of inactive spores (often found in dirt) into an open wound.  The bacteria then enter the nervous system, causing severe painful muscle spasms.  This is why tetanus used to be called "lockjaw".  The muscle spasms can be severe enough to cause muscles to tear, bones to fracture, and respiratory problems.  Without treatment, one in four people die, but the disease is less than 10% fatal when treated.  Because of the increased risk of infection with open wounds, tetanus immunizations are routinely given in the emergency room when a patient presents with a laceration or other wound.

Diphtheria is a respiratory infection, caused by the bacteria Corynebacterium diphtheriae.  You should be immunized against this at least every 10 years also.  This disease is spread by droplets from the sneeze or cough of an infected person, or by ingestion of contaminated food.  It causes thick secretions which can block the airways, and bacterial toxins can also affect other organs, causing heart problems, and paralysis if it attacks the nervous system.  Thankfully, due to the effectiveness of the vaccine, diphtheria is very rare in the U.S.

The most important reason to receive this immunization, though, is to protect yourself and those around you from pertussis, or whooping cough.  Pertussis is an infection caused by the bacteria Bordetella pertussis.  It is transmitted by infected droplets from a cough or sneeze.  At first, the symptoms of the disease are no different than that of the common cold, but worsen into a terrible cough that sometimes causes the person to make a "whoop" noise when they try to breathe between coughs.  The severe cough can sometimes lead to vomiting or loss of consciousness, especially in infants.  Infected infants have the highest rate of death from this infection, generally due to respiratory failure.  Infants less than 6 months old are infected most often, because they have not been fully vaccinated.  During 2012 and the first few months of 2013, pertussis cases have been increasing throughout the U.S., thought to be due to waning immunity to pertussis.  The immunizations most adults received when they were infants are no longer effective.

For that reason, the Tdap vaccine is recommended for everyone aged 11 or older, one time, to prevent pertussis infection.  The Td (tetanus/diphtheria) vaccine should then be given every 10 years after Tdap.  This is especially important for anyone who will be around very small infants, who will not be fully immunized, and therefore very susceptible to infection.  The Tdap vaccine was recently approved for use in pregnant women, after 20 weeks gestation.  The advantage of giving it during pregnancy is that maternal antibodies to pertussis can then cross the placenta, and protect her infant from the time of birth.

In October 2012, the Advisory Committee on Immunization Practices (ACIP) recommended that every pregnant woman, irrespective of previous Tdap vaccination status, should receive Tdap between 27-36 weeks gestation, to optimize transplacental passage of maternal antibodies against pertussis to every infant.

Getting the Tdap vaccine is not harmful.  It generally causes you to have a sore arm for a day or two after, but side effects are otherwise rare.  Some people have reported chills, nausea, body aches, headaches, or rash related to getting the vaccine.  The only people who should NOT have the vaccine are those who have had a severe allergic reaction to the vaccine or any of its components, or those who have had a seizure or gone into a coma within 7 days of previously receiving the vaccine.

Tdap vaccine is available at most physician offices, county health departments, and many pharmacies.

I hope that you consider getting the Tdap vaccine, not only to protect yourself, but others around you.

Here are some helpful links for more information:

Tdap vaccine and pregnancy

Vaccine Information Statement

CDC pertussis website

Endometriosis - Dr. Raymond Schulte

This week one of my partners, Dr. Ray Schulte, is the guest blogger...here's some great info on a common gynecologic disease.

Endometriosis is one of the most common causes of pain in the female pelvis.  It is one of the more undiagnosed conditions leaving a lot of women to suffer from cyclic pain, as well as a myriad of other symptoms until finally the diagnosis is made.  Endometriosis is a condition wherein cells that are identical to the lining of the uterus, the endometrium, grow outside of the uterus.  This can be and is most commonly in the pelvis, in the cul-de-sac, the space behind the uterus, and in the fallopian tube and ovary.  However, it may also involve the appendix, bowel, and even more widespread areas in the body in small spaces.  It is also frequently found in a cesarean section incisional scar causing cyclic symptoms.  The endometriosis causes its problems because tissue that normally would drain out as a period is isolated in areas where it is impossible for the degenerating cells to drain from the body.  They go through the same cycle as the lining of the uterus, stimulated by ovarian hormones, but when they degenerate, instead of being shed, the body starts an inflammatory process to digest and devour these cells with the enzymes contained in inflammatory white blood cells.

This inflammation leads to a lot of localized symptoms.  The symptoms typically reflect the effects of endometriosis by causing cyclic pain with the cyclic pain being most typically pain around ovulation for a few days and then easing up and gradually worsening as you approach the menstrual period and lasting throughout the period with only the week after the period ends being relatively free of pain. As the disease progresses it may get to where the pain is continuous.  It may worsen but it does not ever diminish.  This pain frequently radiates to the back in the sacroiliac joint down low in the pelvis as frequently the implants are in the uterosacral ligaments and the nerves run to that area.  In addition to this most typical pain pattern, various patterns can emerge with pain after the period, severe pain throughout the period, and  deep dyspareunia.  Dyspareunia is defined as pain with intercourse, and in the setting of endometriosis, is usually with deep penetration.  The deep penetration pain will also follow the normal cyclic pattern of endometriosis, worse at ovulation and in the time leading up to the period and through the period.

Endometriosis also causes some effects that are less recognized.  It will frequently cause a decrease in the amount of progesterone produced after ovulation.  This may shorten the time from ovulation to the start of the period, which is normally 14 days.  It may also cause the periods to be much heavier, with clots and passage of more blood than just degenerative endometrial tissue as a normal period would be.  Along with this relative deficiency of progesterone, women will frequently have premenstrual symptoms which may be pain, depression, fatigue, irritability, and sometimes an acute urge to wipe out anyone close to them.  This can make work fairly difficult and makes home life difficult too, in that people are using all their coping skills putting up with the pain and have fewer coping skills because of the effect of decreased progesterone levels on the central nervous system causing depression and irritability.

Endometriosis may also cause cyclic symptoms with the bladder and bowel.  Again in the same pattern, women may have frequent urination or diarrhea in the week prior to the period and during the period.

Endometriosis also is associated with infertility.  There are several different ways that this occurs.  The most obvious mechanical cause is scarring of the tube and ovary which does not allow the tube to pick up an egg.  Sometimes the tubes are totally occluded by being scarred down behind the ovary, or the ovary is scarred against the side wall of the pelvis.  It may have an effect also from the inflammatory process on the normal motility of the tube which would normally move a fertilized egg through to the uterine cavity to implant about six days after ovulation and fertilization of the egg.  With the inflammatory process, the movement may be accelerated, and a fertilized egg may arrive in the cavity of the uterus too early, and fail to implant to create a pregnancy.  There also is the effect of the decreased progesterone causing the lining of the uterus not to grow and mature as it normally should to allow implantation.  One other effect it may have is that in some people, because of the white blood cells devouring these degenerating endometrial cells, the immune system may start forming antibodies against the endometrial cells.  Even if everything is corrected hormonally, the normal endometrial cells have antibodies that attach to them, keeping them from responding appropriately and growing to allow implantation.

Endometriosis has two main types of treatment.  This first is medical treatment, which can be done with several medications but with the same final results.  All of them decrease the frequency of cycles so there are fewer times that the endometrial cells are degenerating and feeding into the inflammatory process.  Probably the simplest, cheapest, most able to be used for long-term treatment is a birth control pill used in at least 12 week cycles.  This limits a woman to about four periods a year, and the continuous progestin regulates the growth of endometrial cells both in the uterus and in endometrial implants.  There are two other medications commonly used for endometriosis.  The first is Depo-Lupron which causes a sort of menopausal state to occur.  This allows the inflammatory process some time to cool down and stops the growth of the endometrial cells, but the associated side effects are menopausal in nature.  The other medication is danazol, which is an androgenic or male-type hormone.  This also interferes with the menstrual cycle, but has side effects including increased muscle mass leading to weight gain, and it may cause acne to flare.  These last two medications are generally used for a six month time period in someone who has endometriosis to cool it down to have a window of opportunity for conception.  Neither are suitable for long-term suppression.

Surgical treatments are also possible and can range from separating adhesions that are caused from inflammatory changes to excision of the endometriosis to simply destroying the endometriosis with cautery of laser.  Any of these may be of considerable help in increasing fertility and relieving the symptoms, but all of these medical or surgical treatments are only temporary.  They will only work as long as suppression is continued or, in the case of surgery, until the endometriosis grows back, which nearly always occurs.

If someone has cyclic pelvic pain and the other symptoms described in this article, it would do you well to consult with a gynecologist who is experienced in making the diagnosis and treating endometriosis.

Here's some links to great sites for more information:
Womens Health - US Department of Health and Human Services Endometriosis Fact Sheet
WebMD overview of endometriosis, with visual guide