Endometriosis is a chronic health condition that manifests when tissues akin to the endometrial lining start to grow outside the uterus. This exogenous growth of endometrial-like tissue can be found in various areas such as the ovaries, fallopian tubes, and bladder. However, endometriosis can also occur in less common areas like the diaphragm, organs in the upper abdomen, like the stomach, in the retroperitoneum like the lymph nodes and kidneys, and so on. Of these uncommon findings, finding some amount of endo on the diaphragm is perhaps most common.
Understanding the Diaphragm
The diaphragm is a large, dome-shaped muscle located beneath the lungs, responsible for the crucial function of respiration. Acting as a separation between the abdominal and thoracic (chest) cavities, its involuntary contraction and relaxation facilitate the breathing process. The diaphragm also has openings that allow important structures such as the esophagus and major blood vessels to pass through.
Endometriosis in the Diaphragm
In most cases, diaphragmatic endometriosis affects the right side of the diaphragm. The endometrium-like tissue that builds up on the peritoneal surface of the diaphragm reacts to the menstrual cycle’s hormones in the same way it does in the uterus, which can cause a range of symptoms in the affected individuals.
Read More: Understanding How Endometriosis Can Cause
Symptoms of Diaphragmatic Endometriosis
The most common symptoms of diaphragmatic endometriosis include pain in the chest, upper abdomen, right shoulder, and arm. This pain typically occurs around the time of your period and may get worse when you take deep breaths or cough. In rare cases, if it grows through the diaphragm and involves the lungs, it can lead to a collapsed lung. This is known as catamenial pneumothorax. However, diaphragmatic endometriosis can often be asymptomatic while only small superficial implants are present. Hence, surgery usually involves at least looking at the diaphragms to document if there are any endo implants even if there are no symptoms in that area.
Causes of Diaphragmatic Endometriosis
The exact causes of diaphragmatic or other types of endometriosis remain unknown. However, it is plausible that endo cells from the pelvis can travel throughout the abdomen and up into the diaphragm. What makes them implant and grow there is unknown. Alternatively, there are other possible etiologies, such as lymphatic or blood stream spread to this area or direct transformation of stem cells or growth of embryologic remnants into endometriosis implants. This is all likely facilitated or repressed by genetic and genomic molecular signalling that is only now coming to be appreciated and unraveled.
Diagnosis of Diaphragmatic Endometriosis
Diagnosing diaphragmatic endometriosis can be challenging. Diagnosis often involves a combination of medical history, physical examination, and imaging tests such as a CT (computed tomography) scan or MRI (magnetic resonance imaging).
The most reliable way to diagnose diaphragmatic endometriosis is via minimally invasive laparoscopic or robotic surgery. Ideally, the surgeon who is excising endo in the pelvis can also remove diaphragmatic implants or have a surgeon available as part of the team, who can do so. In the much rarer event that endo is suspected to be inside the chest and/or growing on or in the lungs, a thoracic surgeon should be consulted.
Treatment of Diaphragmatic Endometriosis
Surgery is the main treatment for diaphragmatic endometriosis and this can usually be accomplished using minimally invasive laparoscopic or robotic surgery. Again, the excision surgeon or surgical team should be capable of removing endo from the diaphragms.
In some cases, endo is not suspected to be growing on the diaphragm. In that case, if the surgery cannot be safely accomplished by the surgeon or surgeons on the team, it is best to back out and not cause more harm than good. The diaphragm is very thin and it is rather easy to enter the chest as part of the excision. In expert hands, that is not a problem. However, going one step beyond diaphragmatic endo, if it is unclear whether or not the endo may be crossing into the chest cavity it is best to back out, re-evaluate with proper imaging and consultation and perform the surgery with a thoracic surgeon at a later date.
Complications of Diaphragmatic Endometriosis
In relatively rare cases, endometriosis of the diaphragm can lead to defects or holes forming in the diaphragm. Endo can then grow into the chest cavity and possibly involve the lungs. This can lead to life-threatening complications such as a collapsed lung during your period (catamenial pneumothorax) or significant bleeding into the chest, also compressing the lung.
In conclusion, while it is relatively uncommon, endometriosis can indeed spread to your diaphragm. Under more rare circumstances it can even grow into the chest and lungs. Expert endometriosis consultation and care is always prudent. But if you are experiencing upper abdominal or chest symptoms as discussed this this article, it become crucial.