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