Endometriosis – Causes, Symptoms, Treatments

What is Endometriosis?

Endometriosis is a condition where tissue similar to the lining of the womb (uterus) grows outside the uterus. This tissue responds to hormonal changes in the menstrual cycle, just like the lining inside the uterus. It can cause pain, particularly during menstruation, and also lead to fertility problems.

Endometriosis is a relatively common condition, particularly among women of reproductive age. However, it often goes undiagnosed or misdiagnosed due to its varied symptoms and lack of awareness among both patients and healthcare providers.

Endometriosis is a fairly common condition, affecting an estimated 5% to 10% of women and adolescents of reproductive age (15-49 years old), according to Yale Medicine. That’s roughly 10% or more than 190 million women worldwide who have endometriosis, based on figures from the World Health Organization (WHO).

Stages of Endometriosis

Doctors classify endometriosis into stages based on the extent of the endometrial tissue growth outside the uterus. The most widely used system is from the American Society of Reproductive Medicine (ASRM) which assigns points based on various factors. 

Stage 1: Minimal Endometriosis (1-5 points)

• Few small implants or lesions on the surface of the pelvic organs or lining of the pelvis/abdomen.
• Little to no scar tissue present.
• Symptoms may be mild or absent.

Stage 2: Mild Endometriosis (6-15 points)

• More implants than stage 1, with some deeper implants present.
• Early signs of scarring might be visible.
• Pain symptoms may become more noticeable.

Stage 3: Moderate Endometriosis (16-40 points)

• Deep implants throughout the pelvic cavity.
• Small ovarian cysts (endometriomas) may be present.
• Scarring and adhesions become more evident.
• Pain can be more severe during menstruation, ovulation, or intercourse.

Stage 4: Severe Endometriosis (over 40 points)

• Extensive implants with deep infiltration into pelvic tissues and organs like the bowels.
• Larger endometriomas on the ovaries are common.
• Significant scarring and adhesions are likely.
• Pain can be chronic and debilitating.

Causes of Endometriosis

The exact cause of endometriosis is unknown, but there are a few theories. One theory is that during menstruation, endometrial tissue sheds and travels backwards through the fallopian tubes and into the pelvic cavity, where it implants and grows. 

Dysfunction in the immune system may make the body unable to recognize and destroy endometrial-like tissue growing outside the uterus. Exposure to environmental toxins, such as dioxins, may also increase the risk of developing endometriosis.

Endometriosis is an estrogen-dependent condition, and hormonal imbalances may contribute to its development. High levels of estrogen or low levels of progesterone may promote the growth of endometrial tissue outside the uterus. Endometrial cells may also attach to surgical incision sites after procedures such as hysterectomy or Cesarean section.

Additionally, this condition has been noted to run in families, suggesting a genetic predisposition. Certain genetic mutations may make some women more susceptible to developing the condition.

Symptoms of Endometriosis

Endometriosis can manifest with a wide range of symptoms, which may vary in severity from person to person. One of the most common symptoms is pelvic pain, which can be chronic and debilitating. This pain often intensifies during menstruation but can also occur throughout the menstrual cycle and may radiate to the lower back or legs. 

Many individuals with endometriosis also experience dysmenorrhea, or extremely painful periods, which can interfere with daily activities. Additionally, pain during sexual intercourse, known as dyspareunia, is another common symptom. 

Some persons may also experience pain during bowel movements or urination, especially during menstruation, if endometrial implants affect the bowel or bladder. Other symptoms of endometriosis can include heavy menstrual bleeding, fatigue, gastrointestinal issues such as bloating, diarrhea, or constipation, and infertility.

Long-term Complications of Endometriosis

Endometriosis, if left untreated, can cause several long-term complications. Endometriotic lesions can grow and spread over time, leading to progressively worse pain during menstruation, ovulation, intercourse, and even bowel movements or urination if the lesions involve nearby organs.

Endometriosis can affect fertility by impacting egg quality, implantation, or blocking fallopian tubes. The severity of endometriosis often correlates with the degree of fertility problems. Surgeries to remove endometriosis can also lead to scar tissue formation (adhesions) which can cause pain and bowel or bladder problems in some women.

Chronic pain and challenges related to endometriosis can take a toll on mental well-being, potentially leading to anxiety or depression. Research also suggests a possible link between endometriosis and a higher risk of developing conditions like endometriosis-associated ovarian cancer, cardiovascular disease, and autoimmune disorders, though more study is needed.

Impact on Fertility

Endometriosis can affect fertility in women in several ways, making it more difficult to conceive. 

• Distorted Pelvic Anatomy: Endometriotic implants, particularly around the ovaries and fallopian tubes, can distort the pelvic anatomy and hinder the egg’s journey to the uterus for fertilization. Scar tissue (adhesions) from endometriosis can further complicate this process.
• Inflammation: The chronic inflammation associated with endometriosis can disrupt the delicate hormonal environment needed for ovulation and implantation. This inflammatory response can also negatively impact sperm health and egg quality.
• Blocked Fallopian Tubes: Endometriosis can directly block the fallopian tubes, preventing the sperm from reaching the egg or the fertilized egg from traveling to the uterus.
• Impaired Implantation: The endometrial tissue growing outside the uterus can interfere with the lining’s ability to properly accept a fertilized egg for implantation.
• Altered Egg Quality: Studies suggest that endometriosis might affect egg quality, potentially impacting their ability to be fertilized or develop into a healthy embryo.

The severity of endometriosis often plays a role. Women with more extensive endometriosis (stage 3 or 4) tend to have a higher chance of fertility problems compared to those with milder stages (stage 1 or 2).

How is Endometriosis Diagnosed?

Diagnosing endometriosis can be a bit challenging because there’s no single definitive test. 

Your doctor will discuss your medical history in detail, including menstrual cycles, pain patterns, and any fertility concerns. They’ll inquire about the severity, location, and timing of your pain to understand how it aligns with potential endometriosis symptoms.

A pelvic exam allows the doctor to manually assess your pelvic organs for tenderness or abnormalities. While it can’t definitively diagnose endometriosis, it can identify potential signs like tenderness or the presence of ovarian cysts (endometriomas). 

Imaging tests like ultrasounds (abdominal or transvaginal) or magnetic resonance imaging (MRI) may be used to visualize the pelvic organs and surrounding tissues. While they can’t directly detect endometriosis, they can help identify abnormalities like endometriomas or rule out other conditions with similar symptoms.

Laparoscopy is a minimally invasive surgical procedure and is considered the most accurate way to diagnose endometriosis. During a laparoscopy, a small incision is made in the abdomen, and a laparoscope (a thin tube with a camera) is inserted to view the pelvic cavity directly. This allows the doctor to visualize and confirm the presence of endometrial implants and scar tissue, as well as assess the extent of the disease. Biopsy samples can also be taken during laparoscopy to confirm the diagnosis under a microscope.

How is Endometriosis Treated?

Endometriosis treatment focuses on managing symptoms and improving quality of life. The specific approach depends on factors like your age, symptom severity, and desire for future pregnancy. 

1. Pain Management:

• Over-the-counter pain relievers: Medications like ibuprofen or acetaminophen can help alleviate mild to moderate pain during menstruation or flare-ups.
• Prescription pain medication: Stronger pain relievers may be prescribed for severe pain, but their use should be monitored by a doctor due to potential side effects.
• Hormonal birth control: Birth control pills, patches, or rings can regulate menstrual cycles and reduce endometrial tissue growth, thereby lessening pain and bleeding.
• Gonadotropin-releasing hormone (GnRH) agonists or antagonists: These medications suppress ovulation and hormone production, leading to a temporary “menopause-like” state that can significantly reduce endometriosis pain. However, long-term use can cause side effects like bone loss, so they’re typically used for a limited duration.

2. Treatment to Address Endometriosis Tissue:

• Surgery (laparoscopy): The same minimally invasive surgical procedure used for diagnosis can also be used for treatment. During laparoscopy, the surgeon removes or destroys visible endometrial implants and scar tissue. This can provide significant pain relief, particularly for women with moderate to severe endometriosis.
• Excision vs. Ablation: There are two main surgical techniques used to remove endometriosis: excision (cutting out the lesions entirely) and ablation (destroying the lesions with heat, laser, or electrical current). Excision is generally preferred as it reduces the risk of recurrence.

What Medications are Most Often Prescribed for Endometriosis?

Two main categories of medications are typically prescribed for endometriosis.

Pain Management:

• Over-the-counter pain relievers: These are often the first line of defense for mild to moderate pain, particularly during menstruation or flare-ups. Common examples include:
  • Ibuprofen (Advil, Motrin)
  • Acetaminophen (Tylenol)
• Prescription pain medication: For more severe pain, stronger medications may be prescribed by your doctor. These should be used with caution and monitored due to potential side effects like addiction or stomach ulcers.

Hormonal Therapy:

This type of medication targets the underlying hormonal imbalance that contributes to endometriosis. Here are the most commonly prescribed ones:

• Hormonal birth control: Birth control pills, patches, or vaginal rings are a popular option. They work by suppressing ovulation and regulating menstrual cycles. This can significantly reduce endometrial tissue growth, leading to less pain and bleeding. Examples include:
  • Combined oral contraceptive pills (containing estrogen and progestin)
  • Progestin-only pills
  • Vaginal rings
  • Contraceptive patches
• Gonadotropin-releasing hormone (GnRH) agonists or antagonists: These medications work by essentially putting your body into a temporary menopause-like state. They suppress the production of hormones that stimulate ovulation, causing the endometrial tissue implants to shrink and reduce pain. Some examples include:
  • Leuprolide (Lupron)
  • Goserelin (Zoladex)
  • Elagolix (Orilissa) (This is a GnRH antagonist).