Medical and Surgical Treatment of Endometriosis
 

What is endometriosis?

Endometriosis is disease in which the tissue that lines the uterine cavity (the endometrium) is found outside the uterine cavity, usually in the pelvis. There are several theories as to how this tissue gets into the pelvis and implants. The most accepted theory is that of retrograde menstruation. During a woman’s menstrual period it is common for menstrual blood to reflux into the fallopian tubes and into the pelvic cavity. This is called retrograde menstruation and it occurs in the majority of women. In most women the refluxed menstrual blood is cleared by the immune system and there are no ill effects. However, in women with endometriosis the refluxed menstrual blood and endometrial tissue is allowed to implant in the pelvis. It is not clear why this happens in some women and not in others. Current evidence suggests alterations in the woman’s immune system may allow this to happen.

What are the symptoms of endometriosis?

Pelvic pain is the hallmark symptom of endometriosis. This includes pain during the menstrual period, pain with intercourse, and pain at other times during the month. Pain with urination or blood in the urine may occur if the bladder is involved with endometriosis. Likewise, pain with bowel movements or blood in the stool may signify endometriosis involving the bowel. Infertility may also be a symptom of endometriosis. There is a very strong association between endometriosis and infertility. Approximately 40% of infertile women will have endometriosis. This compares to a baseline rate of endometriosis in the general female population of about 5%. Some women with endometriosis will have no symptoms.

How is endometriosis diagnosed?

The only way to definitively diagnosis endometriosis is with surgery, usually laparoscopy. The patient’s history, physical exam and ultrasound may suggest endometriosis, but surgery is the only way to establish this with certainty. Unfortunately, there is no blood test for endometriosis.

How is endometriosis treated?

Endometriosis is usually treated surgically at the time of diagnosis. This is often performed through the laparoscope. Most women will have improvement in their pain after surgical treatment. The duration of pain relief, however, is variable and eventual recurrence of pain is common. Medical treatment is also effective in reducing the pain associated with endometriosis. Various hormonal therapies including birth control pills, progestins (provera, megace), lupron and aromatase inhibitors are efficacious in treating the pain.

Treatment of endometriosis associated infertility is controversial. There is no evidence that medical treatment of endometriosis with any of the above listed hormonal therapies improves fertility. There is some limited evidence that surgical treatment of endometriosis may improve subsequent fertility. Women who fail to conceive after surgical treatment of early stage endometriosis are usually candidates for superovulation induction with intrauterine inseminations (IUI). If such therapy is undertaken, it should be performed for no more than four cycles. If pregnancy is going to occur with this therapy, it will usually occur within this time period. Very few pregnancies occur after the 4th cycle. Women who fail to conceive after superovulation/IUI should proceed with IVF. Women with surgically treated advanced stage endometriosis who fail to conceive after surgery should move directly to IVF.