Endometriosis -- The Silent Invader
from the book How to Have a Baby:
by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD.
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Endometriosis is a common disorder that affects women of reproductive age. It
occurs when normal endometrial tissue (the lining of the uterus) grows outside
the uterus. This misplaced tissue may implant itself and grow anywhere within
the abdominal cavity.
Many specialists feel that severe endometriosis is more likely to be found in
infertile women who have delayed pregnancy - and for this reason, the condition
is sometimes labeled a "career woman's disease".
Endometrial tissue, whether it is inside or outside the uterus, responds to
the rise and fall of estrogen and progesterone produced by the ovaries during
the reproductive cycle. Under the influence of the hormones, the misplaced
tissue swells ; and when hormonal levels drop, the tissue may bleed. Unlike the
normally situated endometrium, which is shed from the body as menstrual
discharge, this blood and tissue has no outlet. It remains to irritate the
The disease is highly unpredictable. Some women may have just a few isolated
implants that never spread or grow, while in others the disease may spread
throughout the pelvis. Endometriosis irritates surrounding tissue and may
produce web like growths of scar tissue called adhesions. The scar tissue can
bind the pelvic organs and even cover them entirely. Many women who have
endometriosis experience few or no symptoms. However, in some women,
endometriosis may cause severe menstrual cramps, pain during intercourse, and
It is a disease which has been called an "enigma wrapped inside a
mystery ", and there is a lot about it that we do not understand as yet.
What causes endometriosis?
Several theories exist as to how endometriosis begins. One possibility is
retrograde menstruation, the backward flow of the menstrual discharge through
the fallopian tubes into the pelvis. According to this theory, the endometrial
cells may implant on the ovaries or elsewhere in the pelvic cavity.
What does it look like?
Early implants look like small, flat dark patches or flecks of blue or black
paint ( "powder-burns" ) sprinkled on the pelvic surfaces. The small
patches may remain unchanged, become scar tissue or spontaneously disappear over
a period of months. Endometriosis may invade the ovary, producing blood filled
cysts called endometriomas. With time, the blood darkens to a deep, reddish
brown or tarry color, giving rise to the description "chocolate cyst."
These may be smaller than a pea or larger than a grapefruit.
In some cases, bands of fibrous tissue called adhesions may bind the uterus,
tubes, ovaries, and nearby intestines together. The endometrial tissue may also
grow into the walls of the intestine - but although it may invade neighboring
tissue, endometriosis is not a cancer.
Fig 1. Schematic, showing a chocolate cyst (endometrioma)
in the right ovary; and peritubal adhesions because of endometriosis
Fig 2. Laparoscopy, showing minimal endometriosis, in the
form of " powder-burn" deposits.
Fig 3 . Laparoscopy, showing a small chocolate cyst in the
left ovary. This can be very easy to miss, so a careful multiple puncture
laparoscopy is essential to make an accurate diagnosis of endometriosis.
What are the symptoms?
Progressively increasing dysmenorrhea (periods pains or menstrual cramping)
may be a symptom of endometriosis. These are caused by contractions of uterine
muscle initiated by prostaglandins released from the endometrial tissue. A
puzzling feature of endometriosis is that the degree of pain it causes is not
related to the extent of the disease. Some women with extensive disease feel no
pain at all. A woman with endometriosis may notice that as the disease
progresses her periods become more painful or that the pain begins earlier or
Endometriosis can cause pain during intercourse, a condition known as
dyspareunia. The thrusting motion of the penis can produce pain in an ovary
bound by scar tissue to the top of the vagina or in a tender nodule of
endometriosis. Most women who have endometriosis report no bleeding
irregularities. Occasionally, however, the disease is accompanied by vaginal
bleeding at irregular intervals; or by premenstrual spotting.
How does endometriosis cause infertility? The relationship between mild
(early) endometriosis and infertility is controversial. The most recent theories
regarding the endometriosis-infertility link focus on the fact that
endometriosis may lead to a form of mild inflammation within the pelvis. In some
women with mild endometriosis, the levels of certain chemicals called cytokines
( released in response to inflammation) are increased in the abdominal cavity,
and these hormones may have a negative effect on follicle and egg development,
egg-sperm binding and fertilization, normal tubal function, and even
implantation. Sometimes, the endometriosis may be coincidental and unrelated to
the fertility problem. In these patients, other factors may be involved in a
couple's infertility, such as poor quality sperm or ovulation disorders- and the
endometriosis is a "red herring". Some women who have the condition
are able to conceive, while others may be infertile due to endometriosis or a
combination of factors.
The disease may hinder conception in various ways - especially when it is
severe. Endometriosis may inflame surrounding tissue and spur the growth of scar
tissue or adhesions. Bands of scar tissue may bind the ovaries, fallopian tubes,
and intestines together and thus interfere with the release of eggs from the
ovaries or the ability of the tube to pick up the egg. Rarely, severe
endomteriosis may cause the tubes to become blocked. The presence of chocolate
cysts in the ovary may also impair ovulation.
Endometriosis cannot be diagnosed from symptoms alone. While a physician may
suspect the disease if an infertile woman complains of severe menstrual cramps
or pain with intercourse, many patients with the condition have no discomfort at
all. The diagnosis can be confirmed only by a laparoscopy
Laparoscopy enables the doctor to look inside the pelvis and inspect the
reproductive organs to confirm the presence of endometriosis. In fact, since
endometriosis is often without symptoms, many doctors advise laparoscopy as part
of the diagnostic study for all infertile women.
Looking through the laparoscope the surgeon can see the surface of the
uterus, tubes, ovaries, and other pelvic organs. He can visually confirm the
presence of the endometriosis and gauge its extent. If desired, a small piece of
tissue can be removed for microscopic examination (biopsy). It is easy to miss
early endometriosis if the laparoscopy is not performed carefully. The entire
ovary should be inspected carefully; and if it is enlarged, it should be
punctured to look for "chocolate" cysts.
In most cases, the surgeon will treat the endometriosis during laparoscopy.
If so, he makes other small abdominal incisions through which additional
instruments are introduced for operative laparoscopy. The surgeon may vaporize
the lesions with a laser beam , or destroy them with an electric current called
diathermy. Ovarian cysts can be excised ( removed) or opened and drained (
marsupialised) and their inner lining destroyed.
Fig 4. Operative laparoscopy, for removal of a chocolate
cyst of the ovary (endometrioma)
Other imaging technologies, such as ultrasound, computerized tomography or
magnetic resonance imaging may be used to get more information about the extent
of the disease. These procedures are useful only for identifying endometriotic
cysts in the ovary.
The goal of hormonal treatment is to simulate pregnancy or menopause, two
natural conditions known to inhibit the disease. In each case, the normal
endometrium is no longer stimulated to grow and regress with each monthly cycle,
and menstruation ceases. The growth of misplaced endometrial tissue usually will
suppressed as well.
To simulate the hormonal environment of pregnancy, birth control pills are
prescribed. To be effective against endometriosis, the pills must be taken
continuously without pausing for withdrawal bleeding. This state is sometimes
The hormone derivative danazol is the medication most frequently used to
treat endometriosis. During treatment with danazol, estrogen levels are reduced
to the low levels characteristic of natural menopause. This state is sometimes
called pseudomenopause. Danazol is an expensive medication which is usually
prescribed for six months or more. Unfortunately, large endometriotic cysts of
the ovary are generally resistant to the drug.
Analogues of GnRH, the gonadotropin releasing hormone, are the newest class
of hormones used for endometriosis treatment. These analogues switch off
production of FSH and LH from the pituitary, thus inducing a menopausal state.
These analogs can be given in the form of special injections called depot
preparations, which release small quantities of the drug daily, allowing
administration at monthly intervals.
Medical therapy used to be prescribed in the hope that it would cause the
endometriosis to shrink sufficiently so that it would no longer interfere with
conception after the treatment is stopped. However, since pregnancy cannot occur
during the medical therapy of endometriosis, and because the treatment has been
shown not to be helpful in improving fertility, medical therapy for
endometriosis is no longer advised for infertile patients.
Treating endometriosis with medicines has definite limitations. Medication
usually controls mild or moderate pain and may eliminate small patches of the
disease. But large chocolate cysts in the ovary are less likely to respond, and
drugs cannot remove scar tissue. This is why surgery may be needed to improve
fertility by removing adhesions, lesions, nodules or endometriomas.
As described earlier, laparoscopy can be used as a therapeutic tool. For
example, fluid can be drained ; adhesions freed; and patches of endometriosis
destroyed using a laser or electrical current. Even large endometriomas can be
removed through the laparoscope by a skilled surgeon, so that today most cases
can be successfully treated through the laparoscope. Open surgery (laparotomy)
is needed only very rarely.
Treatment cannot "cure" endometriosis - but it can control it. If
an infertile woman with endometriosis fails to conceive even after surgical
treatment, the next option is superovulation with intrauterine insemination,
since the fallopian tubes in these patients are usually open. If this fails,
then IVF ( in vitro fertilization ) can be very useful. However, the ovarian
response in some of these patients can be poor, especially if they have large
chocolate cysts, or have had surgery for these cysts. Fertilisation rates in
some patients with endometriosis can be a little lower than for other patients,
perhaps because of an intrinsic oocyte abnormality.
Endometriosis is a disease affecting millions of women throughout the world.
For many, the condition goes unnoticed. But for others it demands professional
attention, especially when fertility is impaired. The best strategy to maximize
chances of conception is to select a specialist who is familiar with the latest
developments in endometriosis management.
by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD.
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