Endometriosis

Endometriosis

Defining Endometriosis

• A systemic condition where tissue that is similar to the lining of the tissue is found throughout the body. It can be found in any organ and muscle in the body.

  • These lesions have microscopic bleeding, inflammation, and fibrosis formation.

• Some women also develop adenomyosis which is where the tissue that normally lines the walls of the uterus starts to grow into the muscular walls of the uterus.

• Common symptoms include pelvic pain, dysmenorrhea, heavy or irregular bleeding, lower abdominal or back pain, etc.

• ⅓ of women are asymptomatic

• Endometriosis can cause subfertility (reduced fertility) and/or infertility.

Causes and Risk Factors

• The cause is unknown, but there are several theories.

  • Immune system may be involved

  • Metaplasia: changing from one tissue type to another type.

  • Genetics

• Risk Factors:

  • Family history

  • Early age of first period

  • Short menstrual cycles

  • Long duration of menstrual flow

  • Heavy bleeding during periods

  • Delayed childbearing

  • Defects in uterus or fallopian tubes

  • Hypoxia

  • Iron deficiency

Diagnostics

• Laparoscopy is the most accurate form of diagnosis. It is an invasive procedure that checks several sites such as the ovaries, posterior cul-de-sac, broad ligament, uterosacral ligament, rectosigmoid colon, bladder, and distal ureter. A tissue biopsy will be taken and analyzed.

  • A laparoscopy can also be used to treat endometriosis, by removing areas of endometrial tissue.

  • Laparoscopy can determine the severity of the lesions.

• Lab studies:

  • CBC w/ differential to rule out an infection

  • Urinalysis

  • Cervical gram stain and cultures to rule out STDs

• Imaging studies:

  • Ultrasonography

    • Can be done transvaginally

    • Sonohysterography: sterile saline fluid is injected into the uterus through the cervix to allow for greater detail to be observed

  • Magnetic Resonance Imaging (MRI)

  • CT scan

• Pelvic examination

Treatment Options

Medications

• Combination Oral Contraceptive Pills (COCPs)

  • These work by ovary suppression and continuous progesterone administration.

  • They slow the growth and activity of the endometrium.

  • Can be done continuously without taking a break or on a cycle, allowing for a break each month

  • Ovulation will not occur if they are taken continuously

  • Pain relief usually only lasts while taking the pills

  • Women with endometriosis are at an increased risk for epithelial ovarian cancer and COCPs prevent this

• Danazol

  • This is an older medication that inhibits follicle stimulating hormone and luteinizing hormone

  • Can be very effective, but there are lots of side effects

  • Side effects include oily skin, acne, weight gain, deepening of voice, facial hirsutism , emotional lability, hot flashes, vaginal dryness, and reversible breast atrophy.

• Progestational Agents

  • These cause the endometrium to atrophy.

  • Norethisterone acetate (NETA) is commonly used because it has the least amount of side effects

  • Can be given through different routes: orally, injection, or intrauterine

• Gonadotropin releasing hormone analogues (GnRH)

  • These down regulate the pituitary gland and send the body into a post menopausal state. They prevent ovulation, menstruation, and growth of endometriosis.

  • Treatment is restricted to monthly injections for six months. 85-100% of women experience a decrease in pain which can last for up to twelve months after the discontinuation of the medication.

  • Side effects include a decrease in bone density, hot flashes, and vaginal dryness.

  • Menopause-like side effects can be decreased by adding low-dose estrogen-replacement therapy.

• Gonadotropin releasing hormone antagonists

  • Elagolix is the only medication in this class with FDA approval.

  • This medication works quickly and can dramatically reduce pain.

  • Side effects include hot flashes and a decrease in bone mineral density.

  • It is possible to get pregnant while on this medication.

• Aromatase inhibitors

  • This class of medications suppresses endometriosis at the local level and eliminates estrogen production.

  • Ideal for women who are resistant to hormone therapy.

  • Letrozole is an example

    • Has been used in breast cancer management

    • Further studies are needed

• Selective progesterone receptor modulator

  • Proellex is an example

    • Biopsies showed that the medication was effective in promoting atrophy of the tissue

• COX2 inhibitors can be used for period pain

  • Celecoxib

• Acetaminophen and NSAIDs can be taken

  • Ibuprofen, naproxen, indomethacin, tolfenamic acid

• Mirena IUD

Surgery

• Goal: removal endometrial lesions and correct anatomical distortions

• Drainage and laparoscopic cystectomy

  • A cystectomy is better at decreasing pain and has better pregnancy rates than drainage

• Ablation can be done with a laser or electrodiathermy.

  • This is an effective method for pain relief in 87% of women who have it done, but the results may not be long lasting, depending on how deep the endometrial lesions are.

  • Destroys the lesions with intense heat and seals the blood vessels.

  • This can also remove scar tissue.

• Presacral neurectomy severs the nerve connected to the uterus.

• Laparoscopic uterine nerve ablation severs the nerves in the ligaments that secure the uterus

• Hysterectomy is the removal of the uterus.

  • This is not necessarily a cure. Endometriosis reoccurs in 15% of cases.

• Cytoreduction of pelvic endometriosis

• A total hysterectomy with a bilateral oophorectomy involves the removal of the uterus and the ovaries.

  • This is not necessarily a cure. Endometriosis reoccurs in 15% of cases.

Menopause

• Endometriosis usually ends with menopause, but this does not always occur.

• Women who have endometriosis after menopause are usually treated with an aromatase inhibitor and GnRH.

Other

• Diet

  • A gluten free diet can be beneficial for women who have GI discomfort relating to endometriosis.

  • An anti-inflammatory diet can decrease pain.

  • Curcumin and probiotics have also been known to be beneficial.

• Therapy

  • Pain Reprocessing Therapy

  • Mind-Body Medicine

• Some women benefit from yoga and cognitive behavioral therapy.

• Acupuncture can decrease pain.

• Heating pads on the abdomen

• Warm baths

• Get regular exercise

• Pelvic physical therapy

Pregnancy

• The disease and different treatment options have the potential to interfere with fertility.

• Women often need help getting pregnant with options like intrauterine insemination, superovulation, and in vitro fertilization.

• Studies have shown that women are able to get pregnant after conservative surgical approaches, and they may be even more likely to get pregnant after removal of endometrial lesions.

Current Research and Trials

• Resveratrol is a drug derived from grape wine.

  • Induces apoptosis (cell suicide) in endometrial cells.

• IPS cell-based treatment

• Gestrinone

• Botulinum toxin

• New diagnostic tool: saliva test

Resources

Endometriosis Association

Endometriosis Foundation of America

Products

The 4-Week Endometriosis Diet Plan

LILAS Menstrual Relief Patch (10 Pack)

FORICOM Hot Water Bottle for Pain Relief

Seat Cushion

Body Pillow w/ Memory Foam

Electric Heating Pad

ThermaCare Menstrual Pain Heat Wraps

Solimo Epsom Salt Soak

AUVON Rechargeable TENS unit Muscle Stimulator

The Doctor will See You Now: Recognizing and Treating Endometriosis

Know Your Endo: An Empowering Guide to Health and Hope with Endometriosis

Sources

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