Endometriosis is a somewhat mysterious but increasingly common condition. While the lining of the uterus (endometrial lining) normally grows inside the uterine cavity, if it is affected with endometriosis, this tissue grows in other areas of the pelvis, even outside the pelvis entirely. The cause of endometriosis is not completely known, although some factors are extremely important indicators. A family history of endometriosis may suggest genetic factors. Some deformities of the uterus such as obstruction, as well as uninterrupted menstruation for long periods of time may also predispose an individual to develop endometriosis.

Symptoms of endometriosis are painful intercourse, rectal pressure and pain with bowel movements. Besides pelvic pain, endometriosis can be associated with infertility and abnormal menstrual cycles. "Among patients with infertility there is a very high prevalence of endometriosis," says Sherif G. Awadalla, M.D., Alliance Center for Reproductive Health. "Some studies have shown that 30 - 50 percent of individuals presenting with infertility have endometriosis."

Because symptoms vary a great deal from woman to woman and mimic other medical conditions, endometriosis is often misdiagnosed.

"Endometriosis is diagnosed through careful history-taking and physical examination," Dr. Awadalla says. "On pelvic examination there can be clues to the presence of endometriosis based on the consistency of the tissue. Also, irregularity in the tissue behind the uterus, or cul-de-sac, can be a tip."

Ultrasound is also effective in diagnosing severe endometriosis. However, a firm diagnosis is usually made only after laparoscopy. In this procedure, a lighted scope is inserted into the pelvic cavity through a small incision around the naval, allowing the physician to actually view the condition. When endometriosis cannot be viewed, a biopsy may be done during the laparoscopy.

The American Fertility Society has established criteria for classifying endometriosis based on where the tissue is growing, whether it is on or buried beneath an organ’s surface, and whether filmy or dense adhesions are found. Based on these factors, a doctor may classify the disease as minimal, mild, moderate or severe. Tests also may be done to determine if fertility has been affected.

Treatment of endometriosis depends on a woman’s symptoms, pregnancy plans and age, as well as the extent of the disease. The most common treatment for endometriosis is hormone therapy. These drugs act on the pituitary gland to make a woman temporarily menopausal, thereby allowing the endometriosis to regress by stopping the hormonal stimulation. When hormone levels are decreased, symptoms often disappear and the disease becomes inactive. But when the drugs are stopped, the disease usually returns.

"The advantage of medical therapy is the elimination for the need for surgical intervention," states Dr. Awadalla. "However, medical therapy generally suppresses ovulation for six to nine months. For the patient who wishes to conceive, this may be an unacceptably long time to defer attempts at conception."

Surgery is usually necessary for moderate to severe stages of endometriosis, which is characterized by patches of tissue larger than two inches in diameter, significant adhesions in the lower abdomen or pelvis, or endometrial tissue that obstructs one or both fallopian tubes or that is causing extreme pain unrelieved by drugs. Sometimes electrocautery (the use of an electrical current to produce heat) or laser is used to remove endometrial tissue. Again, the tissue may regrow after surgery. Dr. Awadalla suggests this method of treatment for patients who wish to conceive because it allows them the opportunity to immediately attempt conception.  Only the surgical removal of both ovaries prevents endometriosis from recurring.

According to Dr. Awadalla, there is a suspicion that we are seeing more endometriosis now than years ago. With the increasing availability of oral contraceptives and with a generally increasing trend from women to work longer before attempting their first childbirth, it is suspected that perhaps this is allowing for more uninterrupted menstruation, a risk factor for endometriosis.

"While endometriosis is probably most commonly diagnosed in the mid to late thirties, we are seeing an increasing number of women in their twenties with moderate to severe endometriosis," Dr. Awadalla states. "This poses a significant threat to their future reproduction."

If you have any questions about endometriosis consult your gynecologist or physician. Please call 513-585-4400 or 513-585-2355 for information or to schedule an appointment for the Alliance Center for Reproductive Health.