Reproductive Organs. The uterus is a pear-shaped organ located between the bladder and lower intestine. It consists of two parts: the corpus (body) and the cervix (neck). When a woman is not pregnant, the body of the uterus is about the size of a fist, with its walls collapsed and flattened against each other. During pregnancy the walls of the uterus are pushed apart as the foetus grows. The cervix is the lower third of the uterus; it has a canal opening into the vagina, with an opening called the os, which allows menstrual blood to flow out of the uterus into the vagina. Leading off each side of the body of the uterus are two tubes, known as the fallopian tubes. Near the end of each tube is an ovary. The inner lining of the uterus is called the endometrium, and during pregnancy it thickens and becomes enriched with blood vessels to house and support the growing foetus and placenta. If pregnancy does not occur, the endometrium is shed as part of the menstrual flow. Menstrual flow also consists of blood and mucus from the cervix and vagina.
In women, six key hormones serve as chemical messengers that regulate the reproductive system. The hypothalamus (an area in the brain) first releases the gonadotropin-releasing hormone (GnRH). This chemical, in turn, stimulates the pituitary gland to produce follicle-stimulating hormone (FSH) and luteinizing hormone (LH). Oestrogen, progesterone, and the male hormone testosterone are secreted by the ovaries at the command of FSH and LH and complete the hormonal group necessary for reproductive health.
Endometriosis was described in medical literature more than 300 years ago and has been recognized since ancient times as a chronic, painful, and often progressive disease in women. Endometriosis develops when fragments of endometrial (uterine lining) tissue become implanted outside the uterine cavity, usually in other areas of the pelvis. The implants consist of both endometrial gland cells (which secrete hormones and other fluids) and stroma cells (which build supportive tissue). These cells contain receptors that bind to oestrogen and progesterone, which are responsible for uterine growth and thickening. Each month, these exiled endometrial implants respond to the monthly cycle, just as they would in the uterus, filling with blood, thickening, breaking down, and bleeding. The products of the process, however, cannot be shed through the vagina during menstruation. Instead, they develop into collections of blood that form cysts, spots, or patches. As the cycle continues these lesions may grow or reseed. They are not cancerous, but they can develop to the point that they cause obstruction or adhesions (web-like scar tissue) that attach to nearby organs, causing pain, inflammation, and sometimes infertility.
The endometrial lesions vary widely in size, shape, and colour. Early implants are usually very small and look like clear pimples. Over the years, they may diminish in size or disappear, but they may also grow to form cysts that range from sizes smaller than a pea to larger than a grapefruit. These cysts are called endometriomas. The implants also vary in colour; they may be colourless, red, or very dark brown. These so-called chocolate cysts are endometriomas filled with thick dark brown blood that usually appear on the ovaries.
Implants usually form in the peritoneum, the smooth lining of the abdominal and pelvic cavities and uterus and fallopian tubes. Implants can occur on or next to the ovaries, on the connective tissue that supports the uterus (called the uterosacral ligaments), in the area between the uterus and rectum (called the cul-de-sac), or on the fallopian tubes. They can also form on the cervix, vagina, and even on the bladder, bowel, and appendix. Very rarely, they have been reported in areas far from the pelvis, including the lungs and even the arms and thighs. A relatively uncommon form of endometriosis, called adenomyosis, occurs when implants invade the deep muscle layers of the uterus. What Causes Endometriosis?
In spite of the high prevalence of endometriosis in women all over the world, researchers have been unable to determine its cause. Combinations of genetic, biologic, and environmental factors appear to work together to trigger the initial process, to produce implantation, and to trigger subsequent reseeding and spread of the implants.
Theories for the Cause of Initial Development of Endometriosis
One favoured theory for dispersed uterine tissue and development of endometriosis is retrograde menstruation, in which some menstrual tissue flows backward through the fallopian tubes rather than flowing out through the vagina. This idea, however, does not go far enough; many women experience retrograde menstruation, but not all of them develop endometrial cysts. Other factors, then, must be at work to explain why uterine tissue becomes implanted and grows in areas outside the uterus.
Still another theory suggests that the peritoneal lining in some women contains cells that were left over from foetal development in the womb. These cells would remain inactive until later in life when they develop into endometrial cells.Environmental Toxins. Chemicals called organochlorines have like-like effects and are widely found in pesticides and other common products. The organochlorines, which include dioxins (such as PCBs and furans), have a particularly powerful impact on the ovary and are also associated with infertility, certain cancers, diabetes, and autoimmune disorders. These conditions are also more common in women with endometriosis than in the general population. Some studies have observed that animals exposed to some of these chemicals develop spontaneous endometriosis.
Theories for Causes of Persistence and Growth of Endometriosis
Fewer Protective Immune Factors.
One theory proposes that women with endometriosis have fewer so-called natural killer (NK) cells, which are factors in the immune system important for surveillance. In their absence, the immune system is weakened and allows endometrial tissue to invade and take root.Inflammatory Immune Factors. Other factors in the immune system, large white blood cells called macrophages, are elevated in endometriosis and produce substances, including cytokines (particularly those known as interleukins), growth factors, and prostaglandins. These substances are important players in the so-called inflammatory response, which might play some role in the symptoms and development of endometriosis.Growth Factors and Angiogenesis. Growth factors, which are produced by macrophages, are of particular interest because they play important roles in angiogenesis, a natural process by which new blood vessels form. For example, one substance of special interest is called vascular endothelial growth factor (VEGF). Endometrial cells secrete VEGF and levels increase when oxygen levels drop. This is an important normal process that serves to repair the uterus after menstruation and blood loss. Some investigators have suggested that when implants occur in the pelvis during retrograde menstruation, the cells secrete VEGF as they are deprived of blood and oxygen; this, in turn, stimulates angiogenesis and blood vessel growth. Other growth factors involved in angiogenesis that may play a role in endometriosis include transforming growth factors (such as TGF-beta), platelet-derived endothelial growth factor (PD-ECGF), and tumour necrosis growth factors.
What Are The Symptoms Of Endometriosis?
Symptoms of Endometriosis
Pain. Pain at the time of menstruation (dysmenorrhoea) occurs in nearly all girls and women with endometriosis. In fact, one study reported that endometriosis was responsible for 70% of adolescent cases of dysmenorrhoea that couldn't be relieved by using medications. Pain can also occur at other times of the month. A sharp pain during ovulation may be due to an endometrial cyst located in the fallopian tube that ruptures as the egg passes through. Large cysts in other locations can rupture and cause very severe pain at any time. Endometriosis can also cause pain during sexual activity. In a survey published by the Endometriosis Association, 71% of women reported pain within two days of a menstrual period, 47% reported pain in the middle of a cycle, 40% reported pain at other times of the month, 20% reported continual pain, and 7% said there was no pattern. About 80% reported that the pain had progressed over time. Nearly all reported pelvic pain. The pain is often experienced as severe cramping that occurs on both sides of the pelvis, radiating to the lower back and rectal area and even down the legs. Many women experience pain during intercourse. Implants can also occur in the bladder or intestine and may cause pain during urination or bowel movements.
Other Symptoms. Some women also report fatigue, diarrhoea, painful bowel movements, and bloating. Nausea, dizziness, heavy menstrual bleeding, and headaches are also reported. Conditions with Similar Symptoms
Severe Pain and Nausea. Recurrent pelvic pain associated with menstruation whose cause is unknown is called primary dysmenorrhoea (menstrual cramps). It is common in many women. In addition to endometriosis, similar symptoms are also reported under other circumstances, including use of an intrauterine device (IUD), the presence of pelvic inflammatory disease (PID), uterine fibroids, miscarriage, ectopic pregnancy, endometrial (uterine) polyps, or pelvic cancer. Severe pain in the gastrointestinal (GI) tract from endometriosis may be confused with appendicitis, inflammatory bowel disease, diverticulitis, and irritable bowel syndrome.Heavy Bleeding. Heavy or abnormal bleeding occurs in as many as 25% of all women and can be caused by a number of problems. Spotting or light bleeding between periods is common in girls just starting menstruation and in young adult women during ovulation. Women with late periods or women approaching menopause may also experience heavy bleeding. In postmenopausal women, abnormal bleeding may be due to hormone replacement therapy, infection, overgrowth of the uterine lining (i.e., polyps or endometrial hyperplasia), or cancer. Often, the reason for abnormal bleeding is unknown. In some cases it may be due to underproduction of the hormone progesterone or increased levels of prostaglandins, the substances that regulate the narrowing and dilating of blood vessels. Any abnormal bleeding should be brought to the attention of a physician.
How Serious Is Endometriosis?
Without treatment, endometriosis gets progressively worse in up to 64% of women. Even with treatment, endometriosis continues to advance in 20% of patients. Cysts and implants may grow and spread to other parts of the pelvis, and in very severe cases, to the urinary or intestinal tracts. Eventually adhesions may form. These are dense, web-like structures of scar tissue that can attach to nearby organs and cause pain, infertility, and intestinal obstruction.
The most common problem for women with endometriosis is pain. The pain experienced around menstruation can be so debilitating that up to 25% of women with the condition can be incapacitated for two to six days of each month. In severe cases, regular activities may be curtailed for up to two weeks per month. Sleeping problems have been reported in three quarters of patients, mostly due to pain.
Endometriosis accounts for up to 30% of all female infertility cases, and up to 40% of women with endometriosis are infertile. Endometriosis causes infertility in a number of ways. Endometrial cysts or implants in the ovaries or fallopian tubes are particularly likely to cause infertility. Endometrial cysts in the fallopian tubes may block the egg's passage or they may grow in the ovaries and prevent the release of the egg. Sometimes infertility occurs when adhesions form rigid webs of scar tissue between the uterus, ovaries, and fallopian tubes, thereby preventing the transfer of the egg to the tube. Endometriosis can be associated with infertility even if the condition is mild.
Some studies have observed poor egg implantation in women with endometriosis. Researchers have noted that patients with both endometriosis and infertility sometimes have unusually low levels of certain substances that enable the fertilized egg to adhere to the endometrial lining. Oddly, abnormalities in implantation are more often a factor in infertility in women with mild to moderate endometriosis than in those with severe cases. Some experts have reported fewer eggs in women with endometriosis than in women with other fertility problems, although others have not found any difference. One study found that the eggs in women with endometriosis appeared to have more genetic abnormalities than those in women without the disorder.Researchers are focusing on defects in the immune system that may cause endometriosis, and in turn, can lead to infertility. For example, immune factors that attack the endometriosis may also attack the similar, normal endometrial tissue in the uterus. In severe endometriosis, researchers have observed increased immune system activity in the fluid surrounding the uterus. They suggest that these greater numbers of infection fighters may create a hostile environment for the sperm and also interfere with implantation and development of a fertilized egg. In one laboratory test, slower sperm were noted in fluid taken from women with moderate or severe endometriosis; abnormal sperm motility was not observed in the fluid of women with mild endometriosis. Elevated levels of prostaglandins, substances produced by the immune system that stimulate blood flow and uterine contractions, are also associated with endometriosis and may also contribute to infertility.
Of great concern are studies that suggest that women with endometriosis have a higher risk for cancers, particularly for early-onset breast and ovarian cancers, non-Hodgkin's lymphomas, and melanoma. There is also a high incidence of diabetes in families of women with endometriosis. The risk for autoimmune diseases (in which the body attacks it's own cells), such as systemic lupus erythematosus, hypothyroidism, rheumatoid arthritis, and multiple sclerosis, is also higher in these patients and their families. Women with endometriosis appear to be more susceptible to other conditions including allergies and yeast and other infections.
The emotional effect of severe endometriosis can be almost as devastating as the pain. It can effect marriages and work. In one survey conducted by the Endometriosis Association, 84% of patients reported feeling depressed during periods of pain; 75% of them felt irritable, and over half reported feelings of anxiety and anger. About 20% said they felt hopeless. In one study, during the days around menstruation 30% of women with endometriosis increased their alcohol intake compared to 14% of women with other gynaecological problems and only 9.5% of women with no gynaecological disorders.
Who Gets Endometriosis?
An estimated 2% to 4% of all premenopausal adult women have detectable endometriosis, and over a third of these women experience noticeable pain. Because many women with endometriosis have no symptoms, however, the actual percentage of premenopausal women with the disorder may be as high as 15%. Even endometriosis that is too minimal to be detected by standard diagnostic procedures (such as laparoscopy) may be a cause of infertility. Endometriosis, then, should be considered in women with risk factors for this disorder in which infertility has no other known cause.
Women at risk for endometriosis include those who began menstruating after the age of 13 and whose periods at that time were heavier than normal. Menstrual cycles of less than 27 days long with periods that last more than a week appear to be associated with a higher risk of endometriosis. Approximately 40% to 60% of women with endometriosis report symptoms before age 25. Contrary to popular thought, early pregnancy is not protective, although women have relief from symptoms during pregnancy. Some women who become pregnant after surgery for endometriosis may be protected against relapse. Menopause usually brings an end to mild to moderate endometriosis, although if women with a history of endometriosis take hormone replacement therapy, the condition may be reactivated. Adenomyosis (endometrial glands in the deeper muscles layer of the uterus) is a deep form of endometriosis that usually occurs in women who have uterine fibroids who are between the ages of 40 and 50 and who have had children. Women may be at higher risk for endometriosis if they were born with uterine abnormalities that obstruct the normal outflow of blood and cause retrograde menstruation. A major study is underway to uncover the genetic factors that predispose one to endometriosis. The incidence of endometriosis in women with a mother or sister with the disorder may be seven times greater than average. A family history of endometriosis often puts women at risk for a more severe manifestation of the condition as well. Oddly, women with red hair have an increased risk for endometriosis; experts guess that the gene determining red hair might be located near other genes that make such women susceptible to endometriosis. Endometriosis is more prevalent in women with a family history of asthma and allergies, including food and skin allergies and hay fever.
Women who drink large amounts of beverages with caffeine appear to have an increased risk for endometriosis, possibly because caffeine contributes to increased levels of the oestrogen, estrone. Heavy alcohol use (which also increases oestrogen levels) is also associated with endometriosis.
How Is Endometriosis Diagnosed?
Although endometriosis is the most commonly diagnosed uterine disorder, it is often misdiagnosed or missed altogether because its symptoms vary so widely, and sometimes do not occur at all. The doctor and even the patient may not be able to determine whether menstrual pain is severe enough to indicate an abnormality. Pain in the pelvic or abdominal area can be caused by so many conditions that it is often difficult to pin down the precise cause. Some women do not know they have endometriosis until they try to become pregnant. Endometriosis frequently begins to develop in adolescence but is often not diagnosed for over a decade. In one survey, half of women with endometriosis reported that they had to visit a physician five or more times before they were diagnosed. Some experts believe that early diagnosis and treatment in young women without symptoms might prevent some cases of infertility later on, although at this time treatments for endometriosis may actually trigger symptoms in those who do not yet experience them.
The physician may be able to feel tender areas during a pelvic examination, but diagnostic laparoscopy, an invasive surgical procedure, is currently the only definitive method for diagnosing endometriosis. Laparoscopy usually requires a general anaesthetic, although the patient can generally go home the same day. The procedure involves tiny abdominal incisions through which a fibre optic tube, equipped with small camera lenses, is inserted so the physician can view the uterus, ovaries, tubes, and peritoneum (lining of the pelvis) on a video monitor. In operative laparoscopy, instruments are passed through a tube so the physician can take samples of tissue for examination. In some cases, a blue dye is flushed through the fallopian tubes; if there is an obstruction the dye will not flow through the tube. Small endometrial implants can often be removed at that time, either by excision (surgical removal) using a laser or scissors or by destroying the area with laser- or electro-cautery. Endometrial implants that are very deep or hidden by other structures, however, may be missed. In some cases, operative laparoscopy will restore fertility in women with endometriosis, even those with mild cases.
To help determine the severity of the condition, some researchers have established four stages of endometriosis (I through IV) that rank severity according to number, size, and location of endometrial implants and adhesions. A number of experts do not believe the categories are useful, however, because often they do not relate to the intensity of the symptoms or to the presence of infertility. Some experts now also categorize endometriosis as superficial versus infiltrative endometriosis (deeper than 5 to 6 mm). Such deep implants are believed to be the best indicator of progression and severity rather than the number of implants.
An ultrasound is performed in cases where other conditions are suspected, such as uterine fibroids, ovarian cysts, or ectopic pregnancy. This non-invasive imaging technique can detect endometriomas--cysts that are usually located on the ovaries and filled with thick dark blood. Ultrasound can also pick up cysts larger than 1 cm (about 1/3 in.) but will miss smaller cysts or small, shallow endometrial implants on the surface of ovaries or on the peritoneum (lining of the pelvis). Once a diagnosis is made, more sophisticated imaging techniques, such as computed tomography (CT) scanning or magnetic resonance imaging (MRI) may be used to obtain a more accurate image of severe endometriosis, but these techniques are expensive and are not useful in reaching a diagnosis of endometriosis.
Blood Tests for CA-125
Experts hope that in the near future, blood tests can be developed that will identify endometriosis by measuring high levels of specific chemical substances released by the implants. Some researchers believe that deep invasive endometriosis may be detected by using a combination of a vaginal examination during menstruation and a blood test for CA-125. This substance is elevated in women with ovarian endometriomas (cysts) and deep endometriosis. Higher levels of CA-125 occur in many other diseases, including ovarian cancer, so results using this test alone do not provide enough information for a definitive diagnosis of endometriosis. It may, however, be useful for indicating the need for more invasive tests in women who are infertile and for monitoring the effectiveness of treatments in women with severe endometriosis.
What Are The Non-Surgical Treatments For Endometriosis?
Many hormone therapies that reduce or suppress oestrogen levels have been found to relieve symptoms of endometriosis, although such treatments do not improve fertility. Such therapies are often prescribed for a period of time after surgery to help prevent recurrence. There is some evidence that some of these drugs, including GnRH agonists and danazol, also improve immune factors associated with endometriosis. None of these treatments are cures. For example, pain returns within about six months after ending treatments with GnRH or danazol. The duration of pain relief may be slightly longer with danazol than with GnRH, but not by much. Side effects can be distressing, and there is a high drop-out rate with the use of nearly all these hormonal treatments. Women who are taking GnRH agonists, danazol, or similar agents should use non-hormonal birth control methods (such as the diaphragm, cervical cap, or condoms) because these drugs can increase the risk for birth defects.Progestins. Oral contraceptives combining oestrogen and a progestin are most often used for treating endometriosis. Progestins alone may be helpful. One study reported that progestins provide temporary pain relief equivalent to the more powerful hormone drugs, such as danazol or a GnRH agonist. Some experts recommend them as the first choice for women with endometriosis who do not want to become pregnant. Injections of medroxyprogesterone (Depo-Provera) every three months have been helpful in women with endometriosis and pelvic pain. Women who choose this treatment have an absence of regular periods but often experience unpredictable spotting and other side effects, including cramping, weight gain, headache, depression, irritability, and hair loss. Norethindrone (Aygestin, Norlutate) and dienogest are other progestins under investigation for endometriosis. In one study 94% of patients achieved some pain relief from norethindrone; only 7% dropped out because of side effects. GnRH Agonists. At this time, gonadotropin releasing hormone (GnRH) agonists are the most effective hormone treatments for endometriosis. They are able to block the release of the reproductive hormones LH (luteinizing hormone) and FSH (follicular-stimulating hormone). As a result, the ovaries stop ovulating and no longer produce oestrogen. They relieve pain in most patients by the second or third month. GnRH agonists include goserelin (Zoladex), buserelin, a monthly injection of leuprolide (depot Lupron), and a nasal spray, Nafarelin (Synarel). Studies have reported that nafarelin shrank all implants and significantly relieved symptoms in 85% of patients, delayed recurrence of endometriosis after surgery, and, in comparison with leuprolide, was less expensive, had fewer side effects, and a provided better quality of life.Commonly reported side effects include hot flashes, reduced sexual drive, insomnia, headache, muscle aches, nausea and vomiting, memory loss, changes in the skin and hair, rapid heartbeat, vaginitis, burning sensations in the vaginal area, and weight changes. They can be very severe in some women. Depression is common, and may be treated with antidepressants. The side effects vary in intensity depending on the GnRH agonist. They may be more intense with leuprolide and persist after the drug has been stopped. Because oestrogen loss can lead to osteoporosis, women ordinarily should not take GnRH agonists for more than six months. Factors that increase the chance for osteoporosis include smoking, having a history of polycystic ovarian syndrome (with infrequent periods), alcohol abuse, long-term use of certain drugs (such as corticosteroids) that reduce bone density, and a family history of osteoporosis. Some studies suggest that GnRH agonists taken in very low doses may be effective against endometriosis while still producing some oestrogen so that bone density is not lost. To date, however, the most proven effective regimen for allowing long-time use of GnRH agonists and protecting against bone loss is called add-back therapy, which provides doses of oestrogen and progestin that are high enough to maintain bone density but are too low to offset the beneficial effects of the GnRH agonist. Adding a bone-protective agent called a bisphosphonate (alendronate or etidronate) may also be helpful. Other combinations with a GnRH agonist, including intermittent parathyroid hormone or tibolone may prove to be an effective alternative for preserving bone density while allowing long-term use of the hormone. Tibolone is known as a selective receptor-receptor modulator (SERM), which means it has some, but not all. effects of oestrogen.
GnRH treatments used alone do not prevent pregnancy; their use during pregnancy also increases the risk for birth defects. Women who are taking GnRH agonists or other non-contraceptive hormones, such as danazol, should use non-hormonal birth control methods, such as the diaphragm, cervical cap, or condoms while on the treatments. The risks and benefits of long-term therapy are not fully known.
Danazol (Danocrine) is a synthetic substance that resembles a male hormone. It suppresses oestrogen and menstruation and is used to reduce symptoms of endometriosis, sometimes in combination with an oral contraceptive. Studies have shown symptomatic improvement in 90% of women, but in one study, only about 58% of women expressed satisfaction with this therapy. A high drop-out rate occurs, most likely because of adverse side effects, particularly male characteristics, such as growth of facial hair, acne, weight gain, dandruff and deepening of the voice. Exercise may help reduce them. Danazol may increase the risk for unhealthy cholesterol levels. A few cases of blood clots and strokes have been reported. One study reported that taking a low dose may relieve endometrial symptoms and reduce the risk for these side effects. Pregnant women or those trying to become pregnant should not take this drug because it may cause birth defects.
Antiprogestins are promising agents for endometriosis. The most well-known is RU486, or mifepristone, also referred to as the "abortion pill" because its antiprogestin effects can induce miscarriage. In one study, mifepristone improved symptoms and reduced endometrial implants without causing menopausal side effects during the six months of the trial. Investigative Hormones. Drugs that inhibit aromatase, an enzyme that is a major source of oestrogen in postmenopausal women are being studied for effects against endometriosis. Such drugs include anastrozole, letrozole, exemestane, and vorozole. Gestrinone is an anti-oestrogen hormone that in some studies has reduced pain comparable to GnRH agonists with fewer menopausal symptoms. In one study, bone density even increased slightly. Adverse effects of gestrinone include male hormone symptoms, such as acne, and possibly the development of unhealthy cholesterol levels. A small study suggested that cyproterone acetate, a male contraceptive drug, could drastically reduce endometriosis; more research is needed.
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
In cases of heavy bleeding and cramping, nonsteroidal anti-inflammatory drugs (NSAIDs) may be tried. Aspirin is the most common NSAID, but there are dozens of others, including ibuprofen (Advil, Motrin, Rufen) and naproxen (Aleve, Anaprox, Naprosyn), both of which are often recommended for menstrual pain. Such drugs reduce inflammation, in part by their action against prostaglandins, the substances that increase uterine contractions and cause cramping and pain.
Some women report relief by avoiding dairy products and having a diet rich in fibre and low in fats. If women choose such a diet, they should be sure to have sufficient calcium from other sources.
Some women have reported relief from pelvic pain after acupuncture, Yoga and other exercises, and meditative techniques that promote relaxation. Ginger tea may help in relieving nausea. In a study of one patient, an oriental herb, keishi-bukuyogan, relieved symptoms without reducing oestrogen levels. It is certainly possible that some herbal medicines may be helpful, but patients should always be wary of unproven claims for quick cures. Until scientific studies determine actual benefits, proper doses, and side effects of nonregulated herbal products, the patient is at risk for ineffective or even harmful treatments. It is dangerous to assume that simply because a substance is "natural," it has no side effects and is completely safe. High doses of any herbal or so-called natural medicine are not necessarily safer than traditional drugs, and because of the lack of manufacturing standards and knowledge about toxicity or interactions with other drugs, they may be even more dangerous. There is absolutely no evidence that endometriosis is caused by candida (commonly called yeast infection) or allergies, so dietary remedies and allergy shots are probably not useful.
What Are The Surgical Treatments And Other Procedures For Endometriosis?
There are a number of surgical options for endometriosis. Conservative surgery removes the endometriosis implants without removing any other reproductive organs and is a good option for women who wish to become pregnant or who cannot tolerate hormone therapy. Removing only the uterus (hysterectomy) is not curative and recurrence is a risk. In fact, the only cure for endometriosis is called definitive surgical therapy, which involves hysterectomy with removal of ovaries (oophorectomy) along with all endometrial implants. It is important to note that studies have shown that endometriosis often recurs after either conservative surgery or removal of only the uterus and implants. Recurrence rates at two years range from 2% to 47%. The risk for recurrence or residual pain after any procedure increases with the severity of the condition, particularly if endometriosis has affected areas outside the uterus. In choosing between hysterectomy (with or without oophorectomy) and conservative surgeries, age and the desire for children are important factors. One study reported a greater sense of loss, more residual symptoms, and more pain in younger women (under 30) who have undergone hysterectomy than older women. In one study 37% of such younger women regretted their decision to have a hysterectomy. The physician should respect any decision the patient makes to retain as much of her reproductive system as she wants, even if she is past menopause, assuming she has been carefully instructed in all the risks and benefits of the different options. Both the patient and the physician should also be clear about the possibility of changing procedures once the operation has begun, depending on what the surgeon may observe. For example, the surgeon may find abnormalities that require more extensive surgery. Much of the success of any procedure relies on the experience of the surgeon. A woman should always ask for a doctor's track record, that is, the number of times he or she has performed the procedure in question; the more the better. Asking for complication rates may be helpful, but a patient should realize that an experienced surgeon may have a higher number of high-risk patients, and therefore, a higher complication rate than a less experienced surgeon with fewer serious cases.
General Guidelines. The goal of conservative surgery is to aggressively remove as many endometrial implants and cysts as possible without causing surgical scarring and subsequent adhesions that could cause fertility problems. Some physicians recommend surgery as soon as endometriosis is diagnosed, even if it is mild, because of the progressive nature of the disorder. An analysis of studies published between 1977 and 1996 reported that surgery improved fertility for all stages of endometriosis. It can even restore fertility in women with deep infiltrating endometriosis. If endometriosis is found on the ovaries and fallopian tubes, it is particularly important that the first surgical attempt remove all the implants; subsequent surgeries become less effective in restoring fertility. Conservative surgery, however, can miss microscopic implants that may continue to cause pain and other symptoms after the procedure. Even with very successful surgery, endometriosis usually recurs within a period of between two months and several years. In one study the risk for recurrence after conservative surgery was highest in women who have had previous surgery or who have Stage IV disease (large, endometriotic cysts). Other factors, including age, pregnancy, or the number of cysts, did not seem to influence the degree of risk. As opposed to this study, an earlier one had indicated that women who became pregnant after surgery for endometriosis had a lower risk for recurrence, although pregnancy itself does not cure endometriosis). The use of GnRH agonists after surgery may delay recurrence without affecting fertility.
Procedures: Laparoscopy or Laparotomy.
Laparoscopy is now the standard conservative surgical treatment for endometriosis and has largely replaced laparotomy, which uses a wide abdominal incision and conventional surgical instruments. In some severe cases, the physician may need a wider view of the pelvic area and will perform a laparotomy, which is more invasive and requires a longer recovery time. Pregnancy rates can range from 20% to over 50% after laparoscopy. In addition to improving fertility, in one 1997 study, 90% of surgical patients experienced symptom relief for at least a year after laparoscopy. Still, the recurrence rates for laparoscopy are no better than those with the older procedure. Laparoscopy is usually done under a general anaesthetic and requires small incisions at the navel and above the pubic bone. Carbon dioxide gas is injected into the abdomen, distending it and pushing the bowel away. The laparoscope, a hollow tube equipped with camera lenses and a fibre optic light source, is inserted through the umbilical incision. A probe is then inserted through the second incision allowing the physician to directly view the outside surface of the uterus, fallopian tubes, and ovaries. One or two additional small incisions can be made on either side of the lower abdomen through these incisions. Surgical instruments or other devices are passed through these accessory incisions to destroy or remove abnormal tissue. After laparoscopy the small wounds are minimally painful. There are small risks of bleeding, infection, and reaction to anaesthesia. Many patients experience temporary but severe discomfort in the shoulders after the operation due to residual carbon dioxide gas that puts pressure on the diaphragm.
Destroying the Endometrial Implants. The physician may destroy endometrial implants or adhesions by various methods. Superficial implants or adhesions can often be vaporized, cauterised, or coagulated using electrical or laser devises. Excision (removal of implants by cutting) is used for deep, inaccessible implants. Such infiltrating endometriosis may require laparotomy, although the less invasive laparoscopy is showing increasing effectiveness even for these deep implants. An ovary affected by endometriosis may be treated by removing the implant, draining the cyst cavity, and destroying the cyst lining using electro- or laser surgery to reduce the risk for recurrence.
Neurectomy, also called nerve resection or ablation, involves cutting the nerves that cause pain. Laparoscopic uterosacral nerve ablation (LUNA) may be used to sever nerves and relax the ligaments that attach to the bottom of the uterus. This procedure relieves pain in about 70% of women. For patients who have persistent pain in the middle of the pelvic area and who have failed LUNA, a procedure called presacral neurectomy may be beneficial. With this procedure the surgeon uses either electricity (electrocautery) or lasers to destroy tissue deep in the pelvic region that contain pain-causing nerves. Studies indicate that, regardless of the severity of the case, pain is reduced in 50% to 90% of patients and the benefit persisted for more than a year. In one study, major complications occurred in 0.6% of cases. Constipation is a very common side effect, but it is easily relieved with medication.
As many as one-third of all American women eventually have a hysterectomy by the time they are 65 years old; this is twice the rate in English women and four times the rate in French women. Nearly 600,000 hysterectomies are performed each year. Some studies report that between 6% and 14% of all hysterectomies are performed to treat extensive endometriosis not controlled by conservative surgery or drug therapies. Having endometriosis and severe symptoms, in fact, is a major risk factor for eventually requiring a hysterectomy. Total vs. Supracervical Hysterectomy. Once a decision for a hysterectomy has been made, the patient should discuss with her physician what will be removed.
The common choices are total hysterectomy, supracervical hysterectomy, or either procedure with bilateral salpingo-oophorectomy (removal or tubes and ovaries). In a total hysterectomy the uterus and cervix are removed, which eliminates the risk of uterine and cervical cancer. In a supracervical hysterectomy the uterine body is removed and the cervix is retained. Retaining the cervix helps support the pelvic floor and may help maintain full sexual sensation. The risk for cervical cancer remains. Given technical advances and growing surgical experience, a total hysterectomy may eventually be unnecessary except in special circumstances, such as when cancer is present. If a bilateral salpingo-oophorectomy is also performed, the fallopian tubes and ovaries are removed. Oophorectomy helps to reduce the risk for ovarian cancer and breast cancers. Ovarian cancer can still occur, however, from cancer cells that may develop the lining of the pelvis (the peritoneum). Ovarian cancer is very difficult to detect in its early stages and spreads rapidly. Losing ovarian function, however, imposes other risks that are higher than cancer: bone loss, heart disease, and possibly Alzheimer's disease. In addition, women sometimes experience a decrease in sexual function after oophorectomy because ovaries also produce small amounts of testosterone (the male hormone responsible for sexual drive), even after menopause. Therefore, oophorectomy in older women could interfere with the important health, sexual, and emotional benefits of this male hormone.
The Best Approach: Abdominal or Vaginal. In an abdominal hysterectomy, the surgeon removes the uterus through the abdomen and in a vaginal hysterectomy through the vagina. The abdominal hysterectomy is still used in 70% to 80% of cases, but, in some centres where experience with vaginal approach is increasing, it is only used in about 40% of cases. It is best suited for women with large fibroids, when the ovaries need to be removed, or when cancer or pelvic disease is present. It requires a wide incision to open the abdominal area, from which the surgeon removes the uterus. If possible, the incision should cut horizontally across the top of the pubic hairline (the bikini incision). This incision heals faster and is less noticeable than a vertical incision, which is used in more complicated cases. The patient may need to remain in the hospital for three to four days, and recuperation at home takes about four to six weeks. Vaginal hysterectomy requires only a vaginal incision through which the uterus is removed. Except in women who have had caesarean sections, the complication rates from vaginal hysterectomy are reported to be between half to a quarter of those from standard abdominal hysterectomy. Even in women with caesarean sections, one study observed no difference or even lower complication rates with vaginal hysterectomy. About half of vaginal hysterectomies use a procedure called laparoscopic-assisted vaginal hysterectomy (LAVH). In LAVH, the surgeon makes several small abdominal incisions, through which the attachments to the uterus and ovaries are severed. The uterus and ovaries can then be removed through the vaginal incision, as in the standard approach. Hospitalisation stays may be longer and costs are greater than with standard vaginal hysterectomy. At this time LAVH is not an alternative to standard vaginal hysterectomy but may be an alternative to abdominal hysterectomy in certain cases when a standard vaginal hysterectomy is not appropriate.
Postoperative Care. For a day or two after surgery, the patient is given medications to prevent nausea and pain killers to relieve pain at the incision site. Coughing can cause pain, which may be reduced by holding a pillow over a surgical abdominal wound or by crossing the legs after vaginal surgery. If possible, a patient should ask a family member or friend to help out for the first few days at home. Patients are advised not to lift heavy objects (including small children), not to douche or take baths, and not to climb stairs or drive for several weeks. For the first few days after surgery, many women weep frequently and unexpectedly. These mood swings may be due not only to depression about the loss of reproductive structures, but also to abrupt changes in hormones, particularly if the ovaries have been removed. As soon as the physician recommends it, usually within a day of the operation, the patient should get up and walk in order to help prevent pneumonia, reduce the risk of blood-clot formation, and to hasten recovery. Walking and slow, deep breathing exercises may help to relieve gas pains, which can cause major distress for the first few days. Light exercise, such as walking, should be started as soon as possible. The patient should discuss with the physician when more intense exercise programs can be initiated. The abdominal muscles are important for supporting the upper body, and recovering strength may take a long time. Even after the wound has healed, the patient may experience an on-going feeling of overall weakness, which can be demoralizing, particularly in women used to physical health. Some women do not feel completely well for as long as a year; others may recover in only a few weeks.
Complications Following the Procedure. Minor complications after hysterectomy are very common. About half of women develop urinary tract infections, which are usually minor and treatable. There is usually light vaginal bleeding and mild pain after the operation. If the pain continues or becomes severe, if fever occurs, or there is heavy discharge or bleeding, or if any sudden unexpected symptoms occur, a physician should be called immediately. Such symptoms could indicate infection, which occurs in 10% to 15% of patients, with the risk being higher with abdominal than with vaginal surgery. Antibiotics given at the time of surgery help to reduce this risk. Other risk factors for infection appear to be obesity, a longer than normal operative time, and low socio-economic status. Other potentially serious complications of hysterectomy include pneumonia and formation of small blood clots, usually in veins of the legs (thrombophlebitis). A sudden swelling or discoloration in the leg can indicate this condition and requires immediate medical attention. Other serious and even life-threatening complications are rare, but include pulmonary embolism (blood clots that travel to the lung), abscesses, perforation of the bowel, fistulas (a passage that bores from an organ to the skin or to another organ), or dehiscence (the opening of the surgical wound).
Long-Term Complications and Risk of Recurrence. One study reported that endometriosis reappeared in 13% of women within three years of a hysterectomy and in 40% after five years. Women who have had a total hysterectomy are at higher risk for developing muscle weakness in the pelvic area. Prolapse (descent) of the bladder, vagina, and rectum may occur if the muscle's walls are overly weakened, possibly requiring further surgery. Bowel problems may develop if adhesions (extensive scarring) have formed and obstructed the intestines, sometimes requiring additional surgery. It should be noted that such complications are uncommon, and in one 1999 study of 43 women, satisfaction was high and none reported significant problems in the bladder or intestinal tract afterward. A possible complication specific to vaginal hysterectomy is shortening of the vagina, which can cause pain during intercourse.
Menopausal Symptoms and Premature Menopause. Women may have hot flashes after surgery even if they retain their ovaries, since surgery may have temporarily blocked blood flow to the ovaries, therefore suppressing oestrogen release. If both ovaries have been removed in premenopausal women, the procedure causes premature menopause. The symptoms come on abruptly and may be more intense than those of natural menopause. Symptoms include hot flashes, vaginal dryness and irritation, and insomnia. Women should take hormone replacement therapy (HRT) after surgery if their ovaries have been removed. In premenopausal women, HRT is not needed if the ovaries are left intact. The ovaries will usually continue to function and secrete hormones, even after the uterus is removed. Their life span, however, is reduced by an average of three to five years. In rare cases, complete ovarian failure occurs right after hysterectomy presumably because the surgery has permanently cut off the ovaries' blood supply.
Psychologic and Sexual Concerns. Sexual intercourse may resume after four to six weeks. Studies are mixed with respect to the effects of hysterectomy on sexual drive. Some have reported that between 25% and 46% of women experience loss of or reduced sexuality. In one study, however, 25% of women experienced increased sexual drive after a hysterectomy, and two 1999 studies supported these findings. One reported no loss of sexual drive in women who had been sexually active, and the other found an increase in sexual relations. Exceptions are patients who have both ovaries removed; in such women sexual drive can drop significantly. Some women who had been afraid of getting pregnant are able to feel more spontaneous after a hysterectomy. A woman's emotional response to a hysterectomy also certainly plays a role. Not enough is yet known about the mechanisms of sexual response in women to accurately predict the physical effects of a hysterectomy. Many experts now believe that uterine contractions stimulated by sexual intercourse cause a so-called deep orgasm. Retaining the cervix may help to retain this sensation. If the cervix is removed, the clitoris located outside the vagina can trigger an orgasm, although some women report distress at the loss of the intense deeper sensation. If the ovaries are removed or their blood supply is cut off, male hormones (androgens) are no longer produced; such hormones appear to be important in the sexual drive of both men and women. Some women try androgen replacement therapy to restore sexuality. Occasionally oral or injection treatments can produce male characteristics such as facial hair and voice change. A slow-release pellet inserted every six months under the skin in the hip appears to reduce these side effects. Taking hormones long term almost always carries some risks, and it is not yet known what danger testosterone replacement may pose in women. Support groups and counselling can provide important help for this problem.
Surgical Procedures for Intestinal or Urinary Tract Endometriosis
If deep endometriosis causes severe symptoms in the intestines or urinary tract, surgical excision of these implants may be necessary. Sometimes the surgeon will need to remove adhesions that have joined pelvic structures, such as the vagina and rectum. If a surgeon is experienced, laparoscopy may be used to remove urinary tract or bowel obstructions caused by endometriosis or adhesions, but conventional laparotomy is often required for complete surgical removal of endometriosis in the intestine or urinary tract. Almost any intestinal surgery is major and requires careful preoperative preparation to avoid infection. The operations take a long time, are technically difficult, and pose a risk for bleeding and infection. The recovery period is often lengthy.
This content is reviewed periodically and is subject to change as new health information becomes available. The information is intended to inform and educate and is not a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional.
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