Pinky Ronen, M.D.
Endometriosis is a condition where tissue, similar to the tissue that normally grows inside the uterus, also grows outside of the uterus. The tissue inside the uterus is called "endometrium" and the tissue outside of the uterus is called "endometriosis". The most common places where endometriosis occurs are the ovaries, the fallopian tubes, the bowel, and the areas in front, in back, and to the sides of the uterus. Some women with endometriosis have few or no symptoms while others have pain or difficulty becoming pregnant. There is no cure for endometriosis, but there are several treatment options. The best treatment depends on your individual situation.
The cause of endometriosis is not known. A common theory is that some menstrual blood and endometrium flows backwards from the uterus through the fallopian tubes and into the pelvis during a menstrual period. This tissue then grows where it lands in the pelvis. This is called the retrograde menstruation theory. There are several other theories.
Some women with endometriosis have no symptoms. The most common symptom is pain in the pelvic area, especially with periods.
Pelvic pain caused by endometriosis can occur:
Pelvic pain can also be caused by many other conditions, such as pelvic infections and irritable bowel syndrome. A doctor or nurse can help to figure out if endometriosis may be the cause of your pain.
Difficulty getting pregnant: Endometriosis can make it more difficult to become pregnant. This might occur because endometriosis may cause scar tissue to develop, which can damage the ovaries or fallopian tubes. Even women with endometriosis who do not have scar tissue can have difficulty becoming pregnant.
In women who become pregnant, endometriosis does not harm the pregnancy. Symptoms of endometriosis often improve after pregnancy.
Endometriomas (chocolate cysts) — Women with endometriosis can develop ovarian cysts containing endometriosis; this is called an endometrioma. Endometriomas are usually filled with old blood that resembles chocolate syrup; thus, they are sometimes called chocolate cysts. Endometriomas are sometimes seen during a pelvic ultrasound or felt during a pelvic exam.
Your doctor or nurse might suspect that you have endometriosis based on your symptoms of pelvic pain or painful menstrual periods. However, the only way to know for sure if you have endometriosis is to have surgery.
Endometriosis is considered mild, moderate, or severe depending on what is found during surgery. Women with mild disease can have severe symptoms, and women with severe disease can have mild symptoms.
In some cases, your doctor will recommend a medicine as the first treatment for symptoms that make her suspect endometriosis. This might include a nonsteroidal anti-inflammatory medicine (ibuprofen/Advil) or hormonal birth control
If treatment does not improve your pain within three to six months, surgery is a reasonable next step
In other cases, surgery is performed to diagnose endometriosis and remove it before you take any medicine. Talk to your doctor or nurse about which treatment is right for your situation.
There are several treatment options for women with endometriosis:
The best treatment depends on your future plans to become pregnant and what symptoms are most bothersome.
Nonsteroidal antiinflammatory drugs
Nonsteroidal antiinflammatory drugs (NSAIDs) are a type of pain medicine that can help to relieve the pain caused by endometriosis. The medicine works by stopping the release of prostaglandins, one of the main chemicals responsible for painful menstrual periods. NSAIDs do not shrink or prevent the growth of endometriosis.
Most NSAIDs are available without a prescription, including:
The disadvantage of NSAIDs is that they do not always relieve endometriosis-related pain. NSAIDs probably work better when combined with another treatment, like hormonal birth control. Serious side effects from NSAIDs, although uncommon, include stomach upset, kidney problems, and worsened high blood pressure.
Hormonal birth control treatments
Hormonal birth control, including the pill, patch, and the vaginal ring are often helpful in treating pain because they reduce heavy bleeding. Injectable and implantable long-acting progestins may be very effective in managing endometriosis-related pain. A progestin-containing intrauterine device can also be very effective in treating pain. Hormonal birth control works best in women who do not have severe pain unrelated to the period.
Women with endometriosis are often advised to take hormonal birth control continuously (skipping the placebo pills) for three or more months. This allows you to have fewer periods and have less pain and bleeding during each period. This is explained in detail separately
The most common side effects of estrogen-containing hormonal birth control are:
These side effects usually improve after using the treatment for several months. Serious side effects (eg, blood clots, stroke, heart attack) are rare in women who do not smoke.
Progestins are a synthetic form of a natural hormone called progesterone. This treatment might be recommended for women who do not get pain relief from or who cannot take hormonal birth control that contains estrogen (such as smokers). Progestins are available by prescription and usually given as a pill or injection. Progestins are not used if you are trying to become pregnant. A progestin-containing intrauterine device delivers very low levels of progestin directly to the uterus and results in markedly lighter and less painful bleeding episodes with fewer systemic side effects.
Side effects of progestins can be bothersome for some women. The most common side effects include: bloating, weight gain, irregular vaginal bleeding, and rarely, worsened depression.
Gonadotropin releasing hormone agonists — Gonadotropin releasing hormone (GnRH) agonists are medicines that work by causing a temporary menopause. The treatment causes the ovaries to stop producing estrogen, which causes the endometriosis implants to shrink.
This treatment reduces pain in over 80 percent of women, including women with severe pain. GnRH agonists are not used if you are trying to become pregnant.
Examples of GnRH agonists include:
Adult women can take the full dose of a GnRH agonist for up to 12 months. There are concerns about using GnRH agonists at full strength for more than 12 months. Women who use GnRH agonists lose bone density, and this can become serious over time. One way to minimize bone loss is to take hormonal "add-back" treatment (adding very small amounts of either estrogen or a synthetic progestin) in addition to the GnRH agonist.
Taking hormonal add-back can also help to treat the most common side effects of GnRH agonists, which are menopausal symptoms (hot flashes, vaginal dryness, decreased libido, insomnia).
Surgery might be an option to treat endometriosis if you:
The goal of surgery is to remove endometriosis implants and scar tissue. More than 80 percent of women who have surgery have less pain for several months after surgery. However, there is a good chance that the pain will come back unless you take some form of treatment after surgery (like hormonal birth control).
Laptroscopy is one way to perform surgery, and is commonly used to diagnose and treat endometriosis. During laparoscopy, a doctor makes several small cuts to place instruments inside the abdomen and pelvis. One of these instruments has a light and camera, which allows the doctor to see the organs on a screen.
Treatment of an endometrioma — Medicines are unlikely to make an endometrioma go away. Surgery to remove the endometrioma if it is larger than 4 to 5 cm, symptomatic or enlarging, is usually recommended because surgery can confirm the diagnosis, prevent complications (such as rupture of the endometrioma), and treat any symptoms, such as pain.
Removal of the uterus or ovaries
Your doctor might recommend surgery to remove your uterus or ovaries or both if:
Hormone therapy after surgery
If your ovaries are removed, your doctor or nurse might recommend hormone therapy (estrogen) after surgery. This is especially true for women under age 50 who are not yet menopausal. Estrogen can help to minimize menopausal symptoms like hot flashes, night sweats, vaginal dryness, and bone loss.
There are several options for treating infertility in women with endometriosis. The best treatment depends on individual factors, including your age, if there are other fertility issues, and how severe your endometriosis is. Treatment options include: