To understand the disease known as Endometriosis,
it is important to understand that the normal version of this type of tissue
is the innermost lining of the uterus (womb) that sloughs away with each
period. It's all part of the normal cycling in what is a monthly
preparation for implantation of a fertilized egg. When conception
doesn't occur, the cycle begins anew by casting off the old layer so as
to build up a new one. This innermost lining is called "endometrium,"
from which the actual disease of endometriosis gets its name.
The disease of endometriosis is when endometrium
or endometrium-like tissue is in other places besides the uterus.
Since it is a very hormonally reactive tissue, and since it isn't discarded
away on a tampon to the outside world, it can sit in a woman's pelvis and
thicken and shrivel cyclically with no way out. It is a fairly bloody
substance, and since blood is very inflammatory to the lining of the abdomen,
it causes pain and scarring that can cause adhesions (things meant to be
floating free sticking together). Besides the bloody inflammation,
there are other chemical irritants that not only contribute to the inflammation,
but also can retard the normal conception process.
Infertility is one of the big tip-offs of
endometriosis. Although pain is a famous component, some cases of
endometriosis have no pain at all. There are two main routes of infertility
at the hands of endometriosis. One, as mentioned above, is the inflammatory
and humoral disruption of a conception-friendly environment. The
other is adhesion formation that may kink a fallopian tube or put up a
mechanical barrier between the ovulating ovary and the tube which would
normally carry the egg toward conception at mid-tube.
Endometriosis is a terrible disease for many
reasons. The pain and suffering, and the depriving a couple of children
is one thing. The other thing is that it is a surgical diagnosis.
In other words, a doctor cannot examine a patient and say, "You have
endometriosis." He or she can say a patient may have it, but
the actual determination has to be based on seeing it in the abdomen or
pelvis. Since this can only be done by laparoscopy or other surgery,
the judgement of a woman's doctor is very important:
If a doctor is too aggressive in ruling out
or ruling in endometriosis, then too many needles laparoscopies will be
done. If the doctor is too conservative, not enough laparoscopy will
be done and too many undiagnosed cases of endometriosis will be allowed
to continue on damaging a woman's reproductive chances. It's a difficult
fine line to negotiate, and most doctors over the years narrow that line
to a point that is comfortable for them.
My own fine line involves time limits.
If a woman wants me to investigate her pelvic pain, I do a careful exam,
including a thorough history. An ultrasound is also part of my work-up
to rule out other diseases or cysts. If all of my findings are normal,
including negative cultures for sexually transmitted diseases, and if the
only abnormality remaining is the history of pain, I usually give her discomfort
a time limit. We together determine at which point it will be appropriate
to get more invasive with the diagnostics--meaning a laparoscope exam.
(The laparoscope is the insertion of a lighted tube into the belly button
to actually look into the pelvis.)
During the course of the laparoscopy, if
endometriosis is identified, it can be burned away and the tubes checked
for patency. Post-operative therapy for endometriosis involves a
wide assortment of medical treatments. The newest one is called a
GnRH-agonist, a drug that stimulates the production of female hormones
until her ability to make them "burns out," which then starves
any remaining endometriosis.
GnRH-agonists are fairly effective, but the
down side is that they put the patient into a temporary menopausal state.
After a few months of the treatment, assuming the patient hasn't discontinued
therapy herself because of the menopausal side effects, the drug must be
withdrawn anyway because of the dangers of osteoporosis. What all
of this means is that the disease is terrible, the diagnosis method is
very inconvenient, and the treatment is terrible, too. But we strive
to do better. Newer drugs are on the pipeline already in hopes of
treating the disease without the side effects.
Endometriosis tends to run in families.
What causes it is still mysterious, but the most commonly held theory is
that it's from "retrograde" menstruation--that is, menstrual
tissue is squeezed backwards through the tubes during a period, and it
drips onto the pelvic surfaces. But this theory doesn't explain how
some women can have endometriosis in their lungs, brain, or elsewhere.
There are reports of nosebleeds with periods!
Although our treatment of this very frustrating
disease still goes unperfected, we nevertheless are pursuing it aggressively
in the research areas of pharmaceuticals, surgical techniques, and early
detection. The most important thing a woman can do is report pelvic
pain to her gynecologist. Her very fertility may depend on it.
