What is Endometriosis?
Endometriosis is a complex disease process that commonly results in pelvic pain and infertility. It is one of the most common female reproductive conditions, with 50% of female infertility patients estimated to have it.
The Endometrium and the Menstrual Cycle
Around the time of ovulation, the endometrium (inside lining of the uterus) grows thick with blood vessels, glands, and stored nutrients to allow a fertilized egg to implant and grow. If fertilization does not occur, the endometrial tissue sheds as menstrual flow to mark the beginning of the next cycle. Progesterone and estrogen control the growth and stabilization of the endometrial tissue. If one doesn’t produce enough of these hormones, the uterus may not maintain a pregnancy.
How Endometriosis Starts
Endometriosis most likely starts with normal menstrual flow that spills back through the tubes and into the pelvis. This tissue then becomes adherent to the pelvic walls and floor, depending on the interplay of the woman’s immune system and inflammatory response. Responding to her own hormones, the endometriosis is allowed to grow and spread on the pelvic surfaces including the ovaries and tubes, and leads to a cycle of growth and inflammation. This results in the symptoms of painful menses, pain with intercourse, generalized pelvic discomfort, chronic pain, pelvic scar tissue and infertility. Alternatively, there may be no symptoms at all. While there are no identifiable markers that would make the diagnosis detectable by a blood test, promising developments are on the horizon, attempting to interrupt the complex pathways in its development.
Presently the only way to accurately diagnose endometriosis is through direct visualization by laparoscopy. At that time, surgical removal is performed, to remove or destroy as much of the disease as possible, including cysts of endometriosis within the ovary. Ultrasound visualization of the “chocolate cyst” is the most practical means of detection, and is often associated with more advanced disease. This guides the physician to the best treatment approach, which may also utilize medications such as progestins ( synthetic progesterone- like hormones) and leuprolide acetate ( monthly injection), both alone or in combination with surgery. Laparoscopic removal may be performed by different methods, including CO2 laser, which is the method I prefer because is causes minimal effects on the surrounding normal tissue.
Each woman”s clinical situation must be evaluated by her symptoms and treatment goals in order to guide her individualized therapy. Another important point for women wishing to conceive is their ovarian reserve, determined by their hormone levels (AMH, and cycle day 2-3 FSH,LH and estradiol), as well as the antral follicle count (the number of tiny egg carrying cysts in the ovaries) visualized by transvaginal ultrasound. These factors may help the woman and her physician decide on the best treatment approach, as surgery could decrease the ovarian reserve, depending on the severity of the disease. She may wish to attempt more advanced fertility therapy, freeze her eggs, or embryos through in vitro fertilization prior to directed endometriosis treatment.