Endometriosis at a glance
- Endometriosis is a common condition that occurs when tissue from the lining of the uterus, called the endometrium, grows outside the uterus on other organs and tissues in the pelvis.
- Individuals with endometriosis may not have any symptoms or experience symptoms of chronic pelvic pain, severe menstrual cramps, painful intercourse or infertility.
- According to the American Society for Reproductive Medicine (ASRM) endometriosis may be found in 24-50% of women experiencing infertility and in more than 20% of those who have chronic pelvic pain.
- When our fertility specialists suspect this condition, we will discuss symptoms with the patient and conduct a physical exam, though the only definitive way to diagnose endometriosis is using laparoscopy. This is a minimally invasive surgical procedure where a thin camera is inserted into the abdomen through small incisions near the navel, which may or may not be recommended, depending on the woman’s situation.
- There is no cure for this disorder, but symptoms can be managed surgically or with medication, both of which may increase the chance of pregnancy success.
- Our infertility specialists can use assisted reproductive technologies like ovarian suppression, ovarian stimulation, intrauterine insemination (IUI) and in vitro fertilization (IVF) to enhance the ability to conceive in women with endometriosis-related infertility.
What is endometriosis?
The condition occurs when the tissue that lines the uterus (endometrium) grows outside of the uterus.
Each menstrual cycle, a reproductive age woman’s endometrium prepares to accept an embryo. If this doesn’t happen (the woman doesn’t become pregnant), the tissue and blood are normally shed through the vagina during menstruation.
In all women, some of this tissue also enters the pelvis through the fallopian tubes, called “retrograde menstruation.” It is believed that retrograde menstruation along with some form of autoimmune dysfunction leads to endometriosis. In this case, the endometrial tissue often grows on or within pelvic organs such as the fallopian tubes, ovaries, vagina and cervix. These growths may also occur on the outer surface of the uterus, bowel, bladder or rectum.
Endometrial tissue outside of the uterus continues to act as if it were within the uterus and responds to the menstrual cycle hormones. This tissue growth often results in inflammatory cells responding, causing the structures where the endometrial tissue is growing to develop adhesions and scarring. Adhesions and scarring can cause pain and disrupt the anatomy, resulting in fertility problems.
Causes of endometriosis
The exact cause is not known. Researchers are also not certain why some women get the condition and others do not.
During a typical menstrual cycle the uterine lining thickens to prepare for potential pregnancy. If that doesn’t occur, the lining is shed as a menstrual period. Though most tissue exits via the cervix and vagina, some tissue exits out of the fallopian tubes and ends up in the pelvis. ASRM says some individuals may develop endometriosis because their bodies may not be able to clear this endometrial tissue from the pelvic area, where it grows on surrounding organs and tissues.
There is evidence published by the National Institutes of Health that the disorder may be hereditary. Early studies have shown that women are more likely to develop the condition if an immediate family member such as a mother or sister has it.
Who gets this disorder?
Endometriosis is most common in women of reproductive age, 15 to 44 years old. According to the U.S. Department of Health and Human Services, more than 11% of women in this age range will have the disease. Up to 50% of infertile women have it.
The condition is most likely to affect women in their 30s and 40s. It can also affect teens, young adults and individuals who have already had children.
Endometriosis and infertility
Current research shows an association between the disease and a woman’s inability to conceive naturally, even in mild cases.
It’s estimated that individuals with untreated, mild endometriosis conceive at a rate of 2 – 4.5% per month, compared with the 15 – 20% monthly fertility rate in couples with no known infertility factors.
Those women with moderate to severe cases of the disorder have a monthly pregnancy rate of less than 2%. In our experience, these rates apply to LGBTQIA individuals with female reproductive organs who may be seeking to become pregnant through reproductive assistance.
The condition may cause infertility, particularly in cases where:
- Adhesions have blocked the fallopian tubes, preventing the sperm and egg from reaching one another, or the resulting fertilized egg from reaching the uterus.
- The anatomy of the pelvis has changed due to adhesions that have developed on the reproductive organs. This can make interaction with the fallopian tubes and ovaries less likely.
- Hormone production has changed, altering egg production and quality.
- The immune system is functioning differently.
Though endometriosis is commonly associated with infertility, it’s important to note that not all patients diagnosed with the disorder will have difficulty becoming pregnant.
Symptoms of endometriosis
The severity, symptoms and complications associated with the disorder are extremely unpredictable and vary from patient to patient.
The disorder can present in a combination of three basic categories:
- Endometriomas, which are cysts of endometrial tissue within the ovary
- Adhesions (scar tissue).
Endometriosis, regardless of the severity, does not always present with symptoms. It is not uncommon for women to go undiagnosed with the condition until they experience difficulty conceiving (infertility).
Despite this, there are a number of symptoms often associated with the condition, including:
- Chronic pain in the pelvis or lower back that increases during menstrual periods
- Severe menstrual cramping, which can cause nausea, vomiting or diarrhea
- Spotting between menstrual periods
- Digestive problems such as diarrhea, constipation, bloating or nausea that worsen during menstrual periods
- Painful bowel movements, or pain during urination during menstrual periods
Pain during or after intercourse is also a common symptom.
This is described as a “deep” pain within the pelvis. This pain is more common during penetrative sex. It is thought to be the result of disturbing tender endometrial implants or nodules on the uterus or cervix, or adhesions that connect the pelvic organs to the vagina.
It has been observed that menopausal women or individuals whose estrogen has been suppressed will experience fewer symptoms.
Endometriosis versus adenomyosis
These two conditions are often confused as they are both associated with the uterine lining and have similar symptoms.
However, in adenomyosis, endometrial cells appears to be growing in the muscular walls of the uterus, whereas, in endometriosis, the endometrial lining spreads outside of the uterine cavity into other parts of the pelvis.
The progression of the disease
Endometrial tissue implants are initially small, flat patches, similar to blisters or flecks, that grow on the surface of pelvic organs or tissue lining the pelvis.
- These blisters can appear clear, white, brown, red, black, or blue in color.
- The implants may grow into larger collections, or nodules.
Endometrial tissue that enters the ovary can form a fluid and debris-filled cyst inside the ovary known as an endometrioma.
- Endometriomas can grow to be quite large, sometimes exceeding the size of a grapefruit.
- Endometriomas are sometimes referred to as “chocolate cysts” because the blood they contain darkens to a deep reddish-brown color over time.
Over time, endometriosis may irritate the surrounding pelvic tissue causing internal scar tissue known as adhesions. Adhesions can cover pelvic organs, bind neighboring organs together or block the fallopian tubes preventing sperm and egg from meeting (and therefore pregnancy).
Four stages of the condition
Endometriosis is classified into four stages:
Most women have minimal or mild cases, which typically involves minimal scarring (adhesions), and small, less invasive endometrial implants. Moderate and severe endometriosis are characterized by numerous and sizable implants and more severe scarring within the pelvic organs.
Importantly, the stage (severity) does not correlate with the presence or severity of symptoms.
Review of symptoms, and a physical exam in which endometrial nodules may be felt can help lead a physician to suspect a diagnosis.
However, if a definitive diagnosis is needed, laparoscopic surgery must be performed and biopsies taken to confirm a formal diagnosis of the disorder.
Laparoscopy is an outpatient surgical procedure. A surgeon inserts a thin camera through small incisions near the navel to examine the uterus, fallopian tubes, ovaries and other pelvic organs for endometrial implants, adhesions and ovarian cysts.
Our surgeons will use their observations to stage the endometriosis, which influences treatment options. The implants can be surgically removed at the same time of diagnosis.
Treatment of endometriosis
The treatment option chosen will depend on the specifics of the disease, cost effectiveness and the patient’s goals.
Although there is no cure for the condition, women with it have treatment options that can address symptoms and enhance prospects for pregnancy if they are infertile due to endometriosis.
Treatment for pelvic pain
- Hormonal contraceptives
- Gonadotropin-releasing hormone (GnRH) analogs (as with contraceptives, this is not an option for women looking to conceive)
- Hormone-like medicines (progestins, Danazol)
- Lifestyle factors such as exercise and relaxation
- Over-the-counter medications.
We may use the following assisted reproductive technologies to improve the chances of pregnancy in women with endometriosis:
Minimally invasive surgery
Women who may be experiencing infertility as a result of endometriosis might consider laparoscopy to remove endometrial tissue and restore the anatomy of the reproductive organs.
It is worth noting that surgery has been associated with a small improvement in natural pregnancy rates – about 29% of women who had endometriosis removed surgically conceived in nine months compared with the 17% who conceived without surgical treatment.
However, it is important to note that those with moderate to severe cases of the disorder seem to achieve the greatest improvement in pregnancy rates. It is also important to note that at any stage of the condition, no significant improvement in pregnancy rates are seen with additional surgical procedures.