A common and ‘befuddling’ disease
If you have chronic, painful periods accompanied by other symptoms such as constipation, diarrhea, nausea, fatigue, you may have endometriosis. It occurs when the tissue lining (endometrium) of the uterus becomes displaced, creating growths and lesions in the abdomen or pelvic area.
“It is probably one of the more common diseases that affect women,” said David Elmer, MD, a gynecologist with Women’s Wellness in Hyannis.
According to a 2011 study by the National Institute of Child Health Human Development (NICHD), this disease affects more than five million women in the United States. It is usually seen in women between their 20s and 40s.
During a normal menstrual cycle, the hormone, estrogen, builds up the lining of the uterus in preparation for a pregnancy. When a pregnancy does not occur, the lining of the uterus is normally sloughed off and expelled with the menstrual flow through the vagina.
With endometriosis, the endometrial tissue can be found outside the uterus on the fallopian tubes, ovaries, bowel and bladder. It has been found in the lungs, arm, thigh and other locations according to the Endometriosis Association.
Endometriosis responds to the changes in hormones during the menstrual cycle just like the lining of your uterus. Because it can’t be sloughed off with the menstrual flow through the vagina, as the tissue breaks down, it can cause bleeding, inflammation, scar tissue in your abdomen or pelvis, depending on its location.
Dr. Elmer said one of the things he learned and never forgot was “endometriosis can cause almost anything and be anywhere.” One of the oddest places he heard of it being found was in a brain tumor.
No Known Cause
One theory of how the disorder occurs is women who have an obstructed cervix are not able to have a normal menstrual blood flow because the cervix is blocked. This builds up so much pressure that it comes out through the fallopian tubes and if there is a live endometrial cell in the menstrual fluid, it can land anywhere and start to grow.
“This is supported by the finding that most endometriosis is found where gravity would tell it to go, in the bottom of the pelvis or the cul-de-sac (the pouch of Douglas located between the rectum and the uterus),” Dr. Elmer said.
Another theory is endometrial cells can travel through the bloodstream as well as the lymphatic stream system and spread that way.
There are many “befuddlements” with endometriosis according to Dr. Elmer. They include:
- The cause is unknown.
- You can be diagnosed with endometriosis at any age.
- Many women who have the worst pain only have a few spots of endometriosis
- Women who have it everywhere throughout the pelvis often have no pain at all.
- There are daughters who have mothers with a history of endometriosis and may not get it themselves.
- There are women who have no endometrial tissue because they are born without a uterus, but they still get endometriosis.
Diagnosis and Treatment
While a definitive diagnosis can only be made with laparoscopy (a type of surgery using a laparoscope with a tiny camera) and areas of endometriosis can be cauterized during the procedure, there can still be some areas in the deeper tissue of the abdomen and pelvis that can’t be seen or removed.
Many practitioners, including Dr. Elmer, prefer to initially use a therapeutic trial of medication instead of laparoscopy because the procedure is expensive and requires anesthesia.
“If the trial of hormonal treatment takes the pain away, a presumptive diagnosis that it’s endometriosis can be made,” he said.
The drug of choice is Lupron-Depot, an injection given monthly or every three months. It puts you hormonally into temporary menopause and shrinks the endometriosis. It can be successful in suppressing the endometriosis for those who can tolerate the side effects of menopausal symptoms. They include hot flashes, sleeplessness, and pain during intercourse from vaginal dryness.
“If you have one injection, can’t tolerate the side effects and refuse another injection, then it’s not enough to make the diagnosis,” said Dr. Elmer. Laparoscopy is then still an option, he said.
Another option is a long-term, low- dose birth control pill that will cause the endometrium to shrink.
“Anything that impedes the growth of the endometrium may impede the growth of the endometriosis,” said Dr. Elmer. “For many women, that’s the first thing to try; take the pill for three months and if things are no better, come back and we will talk about the next step.”
If it does work to relieve the pain, then the patient can continue it until they choose to stop in order to get pregnant. Dr. Elmer also recommends Ibuprofen or Aleve, in addition to the hormonal treatment, to help control the pain.