Endometriosis Overview

Endometriosis is an inflammatory disorder defined by the presence of glandular endometrial and stromal cells outside the uterine cavity (Becker, 2015). An estimated 11% of women have endometriosis with varying degrees of severity of symptoms and infertility; the severity of symptoms does not necessarily correlate with extent of lesions (McCance & Huether, 2014).  Despite the high incidence of endometriosis, diagnosis is often delayed by 10 years due to symptoms being misdiagnosed or dismissed as normal menstrual cramps, by the lack of satisfactory biomarkers to diagnose, and by the definitive diagnostic standard being surgical visualization with histological confirmation (Ahn, Singh, & Tayade, 2017; Schliep, 2015). While endometriosis is a benign condition, it is related to higher incidence of ovarian carcinomas, autoimmune disorders, and cardiovascular disease (Kvaskoff, Mu, Terry, Harris, Poole, Farland, & Missmer, 2015).  

Precipitating Factors 

The cause of endometriosis is unknown, but it is likely to be multi-factorial, including environmental and genetic factors (Ashrafi, Sadatmahalleh, Akhoond, & Talebi, 2016). Being female is a significant risk factor as endometriosis is mainly seen in females; however, it has been in seen in men, usually those undergoing chemotherapy for prostate cancer (Jabr & Mani, 2014; Martin & Hauck, 1985). Several risk factors have been associated to be relational to endometriosis but not causative. Patient gravidity has been negatively associated with endometriosis with the thought that pregnancy provided suppression due to anovulation and amenorrhea as well as metabolic, hormonal, immune and angiogenesis changes (Maggiore et al., 2015). However, this lack of pregnancy can also be considered as a symptom as endometriosis is highly related to infertility with up to 50% of infertility cases being related to endometriosis (Dunselman et al., 2014).  

A family history of endometriosis is also a risk factor, with one study reporting a rate of 56% of patients studied with endometriosis having a family history (Dun, Kho, Morozov, Kearney, Zurawin, & Nezhat, 2014).  Some studies have reported the proportion of endometriosis cases due to genetic factors to be in the range of 52% (Rahmioglu, Nyholt, Morris, Missmer, Montgomery, & Zondervan, 2014; Chettier, Albertsen, & Ward, 2014).  However, while multiple genetic aberrations have been identified, none have been proven conclusive enough to be a biomarker for endometriosis (Rahmioglu, Nyholt, Morris, Missmer, Montgomery, & Zondervan, 2014). One theory of the origin of endometriosis is Mullerian rests that allows for endometriosis to be laid down during fetal development and is associated with other Mullerian disorders (Acién & Velasco, 2013).  

There is an increased risk of endometrial polyps with endometriosis (Wang, Zhang, & Liu, 2016; Zheng, Mao, Zhao, Zhao, Wei, & Liu, 2015). Evidence of similar pathologies, such as estrogen driven proliferation of tissue, between endometriosis and endometrial polyps are noted (Zheng, Mao, Zhao, Zhao, Wei, & Liu, 2015). This association with endometriosis and endometrial polyps is important in infertility (Galal, 2016). Other risk factors include early age of menarche, short menstrual cycles, long duration of menstrual flow, and defects in the uterus or fallopian tubes (Ashrafi, Sadatmahalleh, Akhoond, & Talebi, 2016).  

Cellular Analysis 

Endometriotic lesions on a cellular level are not the same as the endometrium as endometriotic lesions are capable of high estrogen production, high prostaglandin production, and have a resistance to progesterone (Cristescu, Velişcu, Marinescu, Pătraşcu, Traşcă, & Pop, 2013). This is important in the symptoms seen. The endometriotic lesions respond to estrogen which signals to increase lesion size, fluid volume, increased epithelial cell height, and epithelial cell proliferation (Burns, Rodriguez, Hewitt, Janardhan, Young, & Korach, 2012). However, the endometriosis lesions are capable of estrogen production, have decreased responsiveness to progesterone, can produce cytokines and prostaglandins, and are capable of angiogenesis and neurogenesis (Hey-Cunningham, Peters, Zevallos, Berbic, Markham, & Fraser, 2013; Reis, Petraglia, & Taylor, 2013; Bulun et al., 2012; Chaban, 2012). These capabilities of the endometriotic lesions are thought to be responsible for the symptoms noted with endometriosis. 

The location of the lesions and the presence of adhesions can also affect the symptomology seen (Lu, Zhang, Jiang, Zou, & Li, 2014). Most symptoms arise from a chronic inflammatory state, noxious chemical release such as prostaglandins, musculoskeletal sequelae, and/or adhesions. An estimated 30-50% of patients with endometriosis are infertile due to the inflammatory environment and physical abnormalities such as adhesions (Koga, Yoshino, Hirota, Hirata, Harada, & Osuga, 2014). 

 Pain:  

• Chronic pelvic pain:  

          Chronic pelvic pain is strongly associated with endometriosis (Donnelly & Yeung, 2015). Pain with endometriosis is related to increased inflammation, nociceptors, and noxious stimuli (Alvarez, Bogen, & Levine, 2014; McKinnon, Bertschi, Bersinger, & Mueller, 2015). Morotti, Vincent, Brawn, Zondervan, and Becker (2014) note higher nerve fiber production and density, increased neurotrophins, and the location of lesions in proximity to areas such as the bowel to be contributory to pain in endometriosis. These nerve fibers are found within and near the endometriotic lesions as well as in the peritoneum and endometrium of those with endometriosis (Fraser & Berkley, 2013). In patients with endometriosis, increased pro-inflammatory estrogen unchecked by antiinflammatory progesterone (due to progesterone resistance) has also been hypothesized to be problematic in endometriosis pain (Bruner-Tran, Herington, Duleba, Taylor, & Osteen, 2013; Cristescu, Velişcu, Marinescu, Pătraşcu, Traşcă, & Pop, 2013). The peritoneal fluid of endometriosis patients has been noted to have higher amounts of tumor necrosis factor-α, several interleukins, RANTES, monocytes, and prostaglandins (Aredo, Heyrana, Karp, Shah, & Stratton, 2017). Cristescu, Velişcu, Marinescu, Pătraşcu, Traşcă, and Pop (2013) describe an “overproduction of estrogen in endometriotic stromal cells with high local production of prostaglandins” (p. 95) as well as overproduction of prostaglandins PGE2 and PGF2-alpha not only in the endometriotic lesions but also in the uterus. Pain can be either cyclical or acyclical.  Pelvic floor muscle dysfunction has been shown to be pathologic in pain with endometriosis patients (Raimondo et al., 2016). Most often hypertonicity of the pelvic floor is implicated in the musculoskeletal pain experienced (Aredo, Heyrana, Karp, Shah, & Stratton, 2017).  

• Dysmenorrhea: 

         Dysmenorrhea is a classic signal for endometriosis. Erasmo and Ferrero (2015) state that “in patients suffering from dysmenorrhea, the incidence of endometriosis ranges from 40% to 60% and the 70% of adolescents who experience dysmenorrhea are diagnosed with endometriosis” (p. 63). Erasmo and Ferrero (2015) note the pain to be visceral and somatic. They also indicate that inflammation, prostaglandins, nerve growth factors, deep infiltrating lesions, and increased uterine contractility to be causes of dysmenorrhea in endometriosis (Erasmo & Ferrero, 2015).  

• Intermenstrual pain 

           Pain between menstruations can be caused by the factors already mentioned of inflammation, nociceptors, noxious stimuli, and musculoskeletal dysfunctions. 

• Pain during exercise 

         The location of the lesions, the presence of adhesions, and other factors such as pelvic floor dysfunction, trigger points, and muscles spasms can all factor into pain with exercise (Hartmann & Sarton, 2014; Aredo, Heyrana, Karp, Shah, & Stratton, 2017).  High impact exercises can affect the tonicity of the pelvic floor. Adhesions can cause pulling sensations as well as musculoskeletal imbalances.  

• Fatigue: 

            Pain is one factor leading to fatigue (Morotti, Vincent, Brawn, Zondervan, & Becker, 2014).  Luisi et al. (2015) also noted hormonal alterations, chronic inflammation and impaired immune function as causes of fatigue in endometriosis. 

• Menstrual:
  • Premenstrual spotting: 

Spotting for greater than two days prior to menstruation has been associated as a strong indicator for endometriosis (Heitmann, Langan, Huang, Chow, & Burney, 2014). Although hormonal and inflammatory alterations could play a part in spotting, in this case, the presence of an endometrial polyp is the most likely cause of spotting in this patient (Thubert, Demoulin, Lamazou, Rivain, Trichot, Faivre, & Deffieux, 2014). 

• Menorrhagia 

While dysmenorrhea is defined as a classic sign of endometriosis, menorrhagia is more often associated with conditions that frequently coexist with endometriosis. Adenomyosis, leiomyomas, and endometrial polyps are often comorbidities of endometriosis and have the primary symptom of menorrhagia (Habiba & Benagiano, 2016; Nezhat et al, 2016; Thubert, Demoulin, Lamazou, Rivain, Trichot, Faivre, & Deffieux, 2014).  It may also be noted that polycystic ovarian syndrome is also frequently seen in endometriosis patients which can contradict this symptom (Likes & Lessey, 2014).  

• Gastrointestinal:
  • Dyschezia 

Elevated prostaglandin levels within the peritoneal fluid are seen in patients with endometriosis, and these prostaglandins affect gastrointestinal motility (McAllister, Giourgas, Faircloth, Leishman, Bradshaw, & Gross, 2016). The irritation of the gastrointestinal tract from the cytokines released can also contribute to dyschezia, particularly seen if lesions are located within the posterior cul de sac (Avila, Filogônio, Costa, & Carneiro, 2016). Hypertonic pelvic floor muscles can contribute to the pain and spasms felt upon defecation (Preil, Belkin, & Goldstein, 2016).  

• Bloating 

The exact cause of the bloating experienced with endometriosis is unknown. Some contribute it to the inflammatory process while others cite the coexistence of irritable bowel syndrome; however, many patients experience gastrointestinal symptoms cyclically which might indicate the inflammatory and/or hormonal impact (Ek, Roth, Ekström, Valentin, Bengtsson, & Ohlsson, 2015). Ek, Roth, Ekström, Valentin, Bengtsson, and Ohlsson (2015) identify mast cells as possible contributors from the inflammatory spectrum, but they also point out that hormonal receptors in the gastrointestinal tract could also explain the symptoms.  

• Alternating constipation/diarrhea 

Again, prostaglandins and inflammatory markers are contributory to altered bowel function as is pelvic floor muscular dysfunction. Endometriosis on or near the bowel has been seen as contributory to bowel symptoms, even to the extent of bowel obstruction due to lesion growth (Ruffo et al., 2014).  

• Urinary:
  • Pain on micturition  

While endometriosis of the urinary tract is rare, the most common site is the bladder (Knabben, Imboden, Fellmann, Nirgianakis, Kuhn, & Mueller, 2015). Estay et al. (2015) describes bladder symptoms as cyclical dysuria, dyspareunia, or resembling recurrent cystitis, and more rarely hematuria. Estay et al. (2015) described ureteral obstruction from endometriosis lesions presenting more as the loss of kidney function including anuria and hydronephrosis. Knabben, Imboden, Fellmann, Nirgianakis, Kuhn, and Mueller (2015) point out that bladder symptoms are usually symptomatic whereas ureteral are often not symptomatic. Again, irritation of the urinary tissue from the inflammatory markers described above can cause symptoms, particularly of the bladder. Endometriosis of the ureters would present more from obstruction due to lesion growth versus inflammation. In this case, endometriosis of the bladder would be suspected, however interstitial cystitis would need to be ruled out as it is frequently seen in endometriosis patients as well (Chen, Lee, & Wu, 2016).  

• Examination:
  • Tenderness with palpation 

Tenderness can be due to pelvic floor muscular dysfunction and/or to lesion location (Yamamoto, Carillo, & Howard, 2014). Particularly tenderness is noted in the rectovaginal area, bladder, and close to the uterosacral ligaments in many patients with endometriosis (Nourmoussavi, Bodmer‐Roy, Mui, Mawji, Williams, Allaire, & Yong, 2014; Yamamoto, Carillo, & Howard, 2014; Williams et al., 2016). If a patient had been sexually active, the symptom of dyspareunia might also have been described.  In addition to the contributory causes of inflammation, muscular dysfunction, and adhesions, Williams et al. (2016) also describe increased nerve bundle density noted in endometriosis patients with dyspareunia. This could also cause pain upon pelvic examination.  

• Diagnostic laparoscopic findings:
  • Glands and stroma in the pelvic cavity 

Endometriosis is diagnosed by the visualization and preferably the histological confirmation of endometrial glands and/or stroma outside of the uterus (Cristescu, Velişcu, Marinescu, Pătraşcu, Traşcă, & Pop, 2013). Visually, endometriosis can vary from the clear, white, red, tan, and black colorations that may be very small to blister like formations to polypoid masses (Kondi-Pafitis, 2012). Kondi-Pafitis (2012) describes the histological presentation as “one or more endometrioid glands surrounded by stromal cells, resembling the endometrial stromal cells of the proliferative phase…. consistent with inactive or irregular proliferative endometrium, although typical proliferative or secretory changes may be observed” (p. 106). Kondi-Pafitis (2012) also notes that inflammatory cells and fibrosis may be present. An older study, but worth noting, performed by Demco (2000) utilized patients under conscious sedation to perform pain mapping of the lesions. The study found that the different colored lesions produced different amounts of pain, that the pain extended beyond the visible border of the lesion, and that palpation of the endometriotic lesions produced “cramps” (Demco, 2000). This information is important in understanding the symptomology and in treating the disease.  

o Endometrial polyp 

As noted previously, endometrial polyps are frequently seen with endometriosis (Wang, Zhang, & Liu, 2016; Zheng, Mao, Zhao, Zhao, Wei, & Liu, 2015). Estrogen driven proliferation of tissue is seen in endometrial polyps as well as endometriosis (Zheng, Mao, Zhao, Zhao, Wei, & Liu, 2015). 

Medical Management 

Pharmalogical 

 Hormonal: Balancing hormones is reasoned to be beneficial in alleviating symptoms; however, it does not rid the patient of the disease. Most efforts are concentrated on lowering estrogen in order to alleviate symptoms, particularly pain. Birth control pills, progestins, gonadotropin-releasing hormone antagonists, aromatase inhibitors, selective estrogen receptor modulators, and oral and intravaginal danazol are different hormonal therapies trialed to decrease symptoms and slow progression of the disease. However, some of these therapies have limited evidence and many have untoward side effects, so much so that some are only recommended if all other medical and surgical options fail (Tosti, Biscione, Morgante, Bifulco, Luisi, & Petraglia, 2016; Dunselman, et al., 2014; Brown & Farquhar, 2015).  Also note that the resistance to progesterone seen in endometriosis lesions can cause some patients to be refractive to the effect of progestins (Cristescu, Velişcu, Marinescu, Pătraşcu, Traşcă, & Pop, 2013). In the following order, depending on patient tolerance, hormonal therapy could be trialed:  

• Oral contraceptives: Oral contraceptives are useful for dysmenorrhea, reduction of pelvic pain, and reduction in the recurrence rate for endometriomas (ovarian cyst endometriosis) (Zorbas, Economopoulos, & Vlahos, 2015).  
• Progestins (oral, intrauterine, injections): These can be useful for pain reduction (Gezer & Oral, 2015).

• Gonadotropin-releasing hormone analogs: These are as effective as other hormonal methods for endometriosis pain, but associated with a significant reduction in bone mineral density (Jeng, Chuang, & Shen, 2014). The most commonly prescribed is sold under the brand name Lupron, who recommends a lifetime maximum of 12 months of treatment (Lupron, n.d.).  
• Danazol: Danazol is useful for decreasing pain and lowering inflammation (shown via a lowered CA-125) (Szubert, Suzin, Duechler, Szuławska, Czyż, & KowalczykAmico, 2014). However, danazol can have strong androgenic side effects (deepening of voice, facial hair growth) (Godin & Marcoux, 2015). Vaginally administered danazol might help decrease the pain and the nodule size in rectovaginal endometriosis (Godin & Marcoux, 2015). 
• Aromatase inhibitors: These are only used if other hormonal methods and surgical therapies have failed but can be useful for pain (Hashim, 2014). 
• Selective estrogen receptor modulators: Their effectiveness and safety are not established and have shown an increased risk for thromboembolism, vaginal dryness, rash and abdominal cramps (Chen, Zheng, & Wan, 2014). 

Surgical 

As discussed, surgical visualization is the definitive method for diagnosing endometriosis. Surgical intervention within the diagnostic surgery is preferable and is aimed at removing the endometriotic lesions. Surgical treatment can help prevent the reoccurrence of endometriosis without the use of hormones afterwards (Jovanovic, Dikic, Janković-Raznatovic, Savija, & Radaković, 2015). While ablation of endometriosis has been utilized extensively, newer data suggests excising the lesions may lead to a better long term outcome for patients. Ablation may or may not destroy the full thickness of the lesion while excision allows for better margins and provides samples for histological study.  

A randomized, double-blind, five year follow up study concluded that surgical intervention was effective for at least up to five years and demonstrated that in some areas excision was more effective than ablation (Healey, Cheng, & Kaur, 2014). Excision is preferred in order for all tissue to be sent for histological review and confirmation (Dunselman et al., 2014; Donnelly & Yeung, 2015). Complete excision of deep infiltrating endometriosis has shown better outcomes versus incomplete surgical removal coupled with postoperative hormonal therapy (Angioni, Pontis, Dessole, Surico, Nardone, & Melis, 2015). Mackenzie (2015) suggests that excision be the standard of care for bowel endometriosis. Several other studies also suggest that excision is the preferable treatment method (Laganà, 2016; Alvarez, Giudice, & Levine, 2015; Koninckx, Donnez, & Brosens, 2016; Gingold & Falcone, 2016).  

Other 

• Dietary: Several dietary changes are suggested to alleviate symptoms. A diet rich in vegetables, fruit, and omega-3 fatty acids is recommended due to the oxidative stress created by the chronic inflammatory state (Gupta, Harlev, Agarwal, Al Safaar, Gupta, & Hack, 2015; Halpern, Schor, & Kopelman, 2015). Celiac disease has been connected with endometriosis through inflammatory markers and genetics and a gluten free diet has been shown to decrease painful symptoms (Santoro et al., 2014; Mormile & Vittori, 2013; Marziali, 2012). A study cites the role of inflammation and oxidative stress from endometriosis as factors leading to an increase in the risk of coronary heart disease in endometriosis patients, therefore a heart healthy diet would be beneficial as well (Mu, Rich-Edwards, Rimm, Spiegelman, & Missmer, 2016). A low fat diet is suggested as high fat consumption has been associated with increased inflammatory markers (Heard, Melnyk, Simmen, Yang, Pabona, & Simmen, 2016).  Due to the frequent diagnosis of irritable bowel syndrome in endometriosis patients, a low FODMAPs diet is suggested (Moore, Gibson, & Burgell, 2014).
• Physical Activity: As noted, endometriosis patients can be susceptible to pelvic musculoskeletal disorders, so physical therapy with a women’s health qualified physical therapist would be beneficial (DeBevoise, Dobinsky, McCurdy-Robinson, McGee, McNeely, Sauder, & Sullivan, 2015). This might include retraining of the pelvic floor muscles to prevent spasms, reestablishing musculoskeletal balance, trigger point therapy, and other pain relieving modalities (dos Bispo et al., 2016). Yoga therapy has been shown to decrease menstrual pain and increase quality of life (Yonglitthipagon et al., 2017; Gonçalves, Barros, & Bahamondes, 2016). 

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4 years ago Endometriosis Fertility , Endometriosis Specialist , What is Endometriosis No comment

Does Endometriosis Cause Infertility? Covering the Basics

Table of contents

• Learn More About the Connections Between Endometriosis and Infertilit y
• What is Endometriosis
• Endometriosis and Fertility: Exploring the Connection
• What Happens When Endometriosis Does Cause Infertility?
• Other Data on Endometriosis and Reproduction
• Diagnosing Endometriosis: A Multifaceted Approach
• Managing Endometriosis: A Multidisciplinary Approach
• Dietary and Lifestyle Considerations
• Endometriosis and Pregnancy: Potential Complications
• Mental Well-Being and Psychological Impact of Fertility Treatment for Endo Patients
• Endometriosis and Fertility: Navigating the Journey

Learn More About the Connections Between Endometriosis and Infertility

An endometriosis (endo) diagnosis can be a frightening thing. Very frightening. While this inflammatory condition can be binary or non-binary, women of childbearing age are prone to issues with reproduction due to endo. So does endometriosis cause infertility? Keep reading as I break down the basics of this topic. In this comprehensive guide, I will delve into the complex interplay between endometriosis and fertility, exploring the condition’s impact, treatment options, and strategies to overcome potential obstacles on the journey to parenthood.  I will also discuss the emotional impact of this condition on patients.

What is Endometriosis

Endometriosis is a chronic inflammatory condition. In this disease, endometrial-like lesions implant on tissues and organs throughout the abdomen and pelvis, even elsewhere in the body! These lesions contain glands and stroma, similar to the endometrium (the tissue that lines the uterine walls), causing chronic inflammatory reactions. 

Endometriosis lesions produce many substances and even make their own estrogen, which, as a result, causes a variety of issues locally and systemically. Pain is one of the most common symptoms, though silent endo exists as well. Please continue reading this article to learn more about endometriosis.

Endometriosis and Fertility: Exploring the Connection

While endometriosis does not automatically equate to infertility, there is a well-documented association between the two. Approximately 30% to 50% of individuals with endometriosis experience fertility challenges, though the reasons behind this link are not fully understood. Several potential mechanisms have been proposed:

1. Anatomical Distortions: Endometriosis can cause physical distortions in the reproductive anatomy, leading to scarring, adhesions, and obstructions in the fallopian tubes or ovaries, hindering the fertilization process.
2. Inflammatory Response: The lesions can trigger an inflammatory response, creating an inhospitable environment for fertilization and implantation.
3. Hormonal Imbalances: Endometriosis may disrupt the delicate hormonal balance required for ovulation and implantation, potentially impacting fertility.
4. Egg Quality: Some research suggests that endometriosis may adversely affect egg quality, further complicating the conception process.

Despite these potential challenges, it’s important to note that more than 70% of individuals with mild to moderate endometriosis can conceive naturally, offering hope for those seeking to start a family.

What Happens When Endometriosis Does Cause Infertility?

It can. 25 to 50% of women with infertility have endometriosis, and 30 to 50% of women with endometriosis have infertility. However, it is very encouraging to know that most women with endometriosis can become pregnant. 

This statistic is significant. Many younger women with this disorder feel psychological effects due to the possibility of not being able to have kids. Not all patients carry this sentiment. Growing numbers of people do not want to have children. However, for those who do, these thoughts and emotions about fertility can be devastating. Then, endometriosis patients who do conceive often worry about the pregnancy and subsequent delivery of the baby.

Other Data on Endometriosis and Reproduction

Studies have also demonstrated that the enzyme aromatase may also play a role in endometriosis and infertility. There is an abnormally high level of this enzyme in the endometrium and endometriosis lesions in patients with endometriosis. In the uterus, this enzyme may affect both natural endometrial development and its receptivity for the implantation of the fetus.

Progesterone is another hormone that may play a role in implantation failure. Resistance to this enzyme can affect reproduction, as it is necessary for a normal pregnancy. In some studies, progesterone receptors displayed abnormalities and caused dysregulation in the endometrial layer of the uterus in patients with endometriosis. Levels of progesterone should increase with pregnancy, but with endometriosis, this process is delayed and can cause an unopposed estrogen state that cannot sustain fertility.

Diagnosing Endometriosis: A Multifaceted Approach

Diagnosing endometriosis can be a complex process, as the symptoms can mimic those of other conditions. The diagnostic journey often begins with a physical examination and an evaluation of the individual’s medical history. If endometriosis is suspected, additional tests may be recommended, such as:

1. Ultrasound: An abdominal or transvaginal ultrasound can help identify cysts (endometriomas), possibly endometriosis lesions (this is not common but an up-and-coming area of research), as well as the potential impact on the organs themselves or other abnormalities in the reproductive organs.
2. Laparoscopy: Considered the gold standard for diagnosing endometriosis, a laparoscopy involves a minimally invasive surgical procedure where a small camera is inserted into the abdomen, allowing the surgeon to visually inspect the pelvic organs and take tissue samples if necessary.

While the severity of endometriosis is often classified into stages (minimal, mild, moderate, or severe) based on the extent and location of the endometrial growths, it’s important to note that the stage does not necessarily correlate with the intensity of symptoms or the degree of fertility challenges.

Managing Endometriosis: A Multidisciplinary Approach

The management of endometriosis typically involves a multidisciplinary approach, combining medical and surgical interventions tailored to the individual’s unique circumstances and fertility goals. Treatment options may include:

1. Pain Management: Over-the-counter or prescription pain medications, such as non-steroidal anti-inflammatory drugs (NSAIDs) or hormonal contraceptives, can help alleviate the discomfort associated with endometriosis.
2. Hormone Therapy: Hormonal treatments, such as birth control pills, progestin-only therapy, or gonadotropin-releasing hormone (GnRH) agonists, may have some impact on suppressing the growth of endometriosis and managing symptoms, though these options are only short-term while on the medications and can have some serious side effects.
3. Surgery: Laparoscopic or robotic surgery is recommended to remove endometriosis, scar tissue, or cysts, potentially improving fertility outcomes.
4. Assisted Reproductive Technologies (ART): In cases where natural conception remains challenging, assisted reproductive technologies like in vitro fertilization (IVF) or intrauterine insemination (IUI) may be recommended.

It’s crucial to work closely with a multidisciplinary team, including reproductive endocrinologists, gynecologists, and fertility specialists, to develop a personalized treatment plan that addresses both the management of endometriosis symptoms and the individual’s fertility goals.

Dietary and Lifestyle Considerations

While there is no definitive evidence that specific dietary or lifestyle changes can cure endometriosis or improve fertility outcomes, maintaining a healthy lifestyle can contribute to overall well-being and potentially alleviate some symptoms. Recommendations may include:

1. Balanced Diet: Consuming a diet rich in fresh fruits, and vegetables, minimizing grains, especially gluten, and lean proteins can provide essential nutrients and support overall health.
2. Exercise: Regular physical activity, such as low-impact exercises like walking or swimming, can help manage stress and promote overall well-being.
3. Stress Management: Engaging in stress-reducing activities like meditation, yoga, or deep breathing exercises can help promote relaxation and reduce the impact of stress on fertility.
4. Supplements: While the evidence is limited, some individuals report benefits from taking supplements for pain relief, reducing inflammation, and improving their quality of life.

It’s essential to consult with a healthcare professional before making significant dietary or lifestyle changes, especially if you are undergoing fertility treatments or considering assisted reproductive technologies.

Endometriosis and Pregnancy: Potential Complications

While endometriosis does not necessarily preclude a successful pregnancy, it’s important to be aware of potential complications that may arise. Some of the risks associated with endometriosis during pregnancy include:

1. Placenta Previa: Endometriosis may increase the risk of placenta previa, a condition where the placenta partially or completely covers the cervix, potentially leading to bleeding and complications during pregnancy or delivery.
2. Miscarriage: Research findings on the link between endometriosis and miscarriage have been mixed, with some studies suggesting an increased risk while others found no significant association.
3. Ectopic Pregnancy: Endometriosis may increase the risk of ectopic pregnancy, where the fertilized egg implants outside the uterus, typically in the fallopian tube.

It’s essential to work closely with your healthcare provider to monitor and manage any potential complications that may arise during pregnancy if you have endometriosis.

Mental Well-Being and Psychological Impact of Fertility Treatment for Endo Patients

Living with endometriosis can be a challenging and emotionally taxing experience, particularly for those struggling with fertility issues. The physical pain, emotional distress, and potential financial burdens associated with treatment can take a toll on an individual’s mental well-being. It’s crucial to prioritize self-care and seek support from mental health professionals, support groups, or counseling services if needed.

Furthermore, you and your partner can do these things to help prepare for these possible feelings:

• Prepare and be ready for the emotional journey ahead.
• Cope with grief and loss associated with unsuccessful prior attempts or miscarriages.
• Develop strategies for coping with the news of other people’s births and pregnancies.
• Keep the communication lines between you and your partner open and discuss feelings throughout the entire process.

Endometriosis and Fertility: Navigating the Journey

The path to parenthood for individuals with endometriosis can be challenging, but it’s important to remember that fertility challenges are not insurmountable. By working closely with a multidisciplinary team of healthcare professionals, exploring various treatment options, and maintaining a positive outlook, many individuals with endometriosis can achieve their dream of starting a family.

It’s crucial to be proactive in seeking support and guidance from healthcare providers, as well as accessing resources and support networks specifically designed for those navigating endometriosis and fertility challenges. Organizations like the American Society for Reproductive Medicine (ASRM) and Endometriosis UK offer valuable information, resources, and advocacy support for individuals on this journey.

While endometriosis may present obstacles, embracing a comprehensive approach that addresses both the condition and fertility goals can increase the chances of a successful outcome. With perseverance, the right medical support, and a commitment to self-care, the dream of parenthood can become a reality for many individuals with endometriosis.

REFERENCES

https://www.reproductivefacts.org/news-and-publications/fact-sheets-and-infographics/endometriosis-does-it-cause-infertility

https://www.pennmedicine.org/updates/blogs/fertility-blog/2016/august/endometriosis-and-fertility

https://www.brighamandwomens.org/obgyn/infertility-reproductive-surgery/endometriosis/endometriosis-and-fertility

https://www.tommys.org/pregnancy-information/planning-a-pregnancy/fertility-and-causes-of-infertility/how-does-endometriosis-affect-fertility

https://www.endometriosis-uk.org/endometriosis-fertility-and-pregnanc

Updated: August 9, 2024

4 years ago What is Endometriosis 4 comments

Endometrioma 101: Understanding Deep Ovarian Endometriosis

Table of contents

• Your Guide to Ovarian Endometrioma: Treatment, Symptoms, Doctors, Etc.
• What is Endometriomas (Deep Ovarian Endometriosis)? 
• Recurrence of The Lesions Following Surgery
  • Dr. Jon Einarsson :
  • Dr. Abhishek Mangeshikar
  • Dr. Ram Cabrera
  • Dr. Gabriel Mitroi
• Clinical Impact of Endometriomas (in Women of Reproductive Age)
• Major Concerns:
• Treatment and Surgery Options
  • Treatment for Females of Reproductive Ages
• Final Thoughts and Question for Readers

Your Guide to Ovarian Endometrioma: Treatment, Symptoms, Doctors, Etc.

Endometrioma (deep ovarian endometriosis) can be difficult to treat due to controversies and challenges surrounding the best approaches, treatment, and diagnosis. Many of these hurdles result from misunderstandings about the condition and underlying disease process – deep ovarian endometriosis.

If you suffer from these ovarian endometriosis lesions, our sincere thoughts go out to you. Often known as “chocolate cysts,” some consider endometriomas as the most severe threat to a woman’s reproductive system (aside from cancerous tumors found in the reproductive tract). Furthermore, these lesions don’t always respond well to medical treatment and can potentially ruin the health of ovarian tissue. This article will help you understand endometrioma, symptoms, and deep ovarian endometriosis treatment.

What is Endometriomas (Deep Ovarian Endometriosis)? 

Endometriomas happen when endometrial-like tissue grows inside the ovary or sometimes outside. Endometrioma is very common and affects between 17-44% of endo patients. Endometriomas are typically an advanced form of endometriosis, meaning stage three or four.

Surgery is often necessary to remove the endometriomas. However, eliminating endometrioma cysts and capsules is an advanced procedure and needs excellent skills. This surgery can potentially lead to partial or complete loss of ovarian function, especially if done by less experienced surgeons. These cystic masses can cause extreme challenges for women undergoing fertility treatments, i.e., assisted reproductive technologies (ART).

Endometriomas are dark-fluid-filled cavities, and they can present in a variety of shapes and sizes. An ultrasound can show suspected cases of endometrioma, but confirmation needs surgery and histology. Therefore, getting a diagnosis of endometrioma can be riddled with challenges.

Recurrence of The Lesions Following Surgery

On our social media accounts, we receive many questions about the topic of endometrioma recurrence. We took to Instagram to get the responses from endometriosis specialists about this recurrence. Here are some of their responses:

Dr. Jon Einarsson:

“It depends on several factors including the age of the patient, method of surgery, the experience of the surgeon, etc. In the literature, recurrence rates of over 30% have been reported, although I have personally not seen that high of recurrence risk.”

Dr. Abhishek Mangeshikar

“We’ve had ovarian recurrence rates of less than 10 percent in our two years of follow-ups of about 85 patients with ovarian endometriomas.”

“What’s important is to completely free the ovary and excise the peritoneum or uterosacral ligament it was adherent to, apart from excising the cyst. This will truly help reduce recurrence rates compared to just doing a cyst excision and leaving peritoneal disease behind.”

Dr. Ram Cabrera

“I share the same opinion, in my center, our recurrence rate is less than 8% a good technique and excision of all zone of endometrioma even peritoneal improve outcomes, also as previously said it depends on many factors like endometrioma size, multiple endometriomas, and post-op treatment.”

Dr. Gabriel Mitroi

“We have a very low recurrence rate. This is because often, during surgery, only the visible endometrioma cysts are removed. Anything under 2 cm is out of our visual field.”

Clinical Impact of Endometriomas (in Women of Reproductive Age)

Endometriomas does not cause infertility in all women it affects. However, studies show that between 25% to 50% of women with infertility have endometriosis, and 30% to 50% of women with endometriosis have infertility. However, that does not mean that endometrioma will necessarily cause infertility in women of reproductive age, especially when diagnosed and treated early with the best-practice treatments that have evolved over the years. 

One of the leading fertility challenges is that ovarian lesions affect the number of eggs in ovarian tissue. Endometrioma can also impair the maturation of the egg and cause the woman to have a lower antral follicle count (AFC) and Anti-Müllerian hormone (AMH). Also, women with endometriomas often have high follicle-stimulating hormone (FSH) levels.

Major Concerns:

• Intense pelvic pain
• Possible infertility
• Decrease ovarian function
• It can place women of child-bearing age at a higher risk of cancer

Treatment and Surgery Options

Treatment for endometriomas will vary from person to person. The number of lesions and the staging of the disease progress are just a couple of the factors that will influence the right treatment plan for you. 

Treatment for Females of Reproductive Ages

Many OB-GYNS and other healthcare providers still practice old treatments for endometriosis that don’t effectively manage the disorder. It’s a complicated condition. Thus, there are many myths and misconceptions about endometriosis. 

Women of reproductive ages who wish to maintain fertility should have a fertility specialist in their multidisciplinary endometriosis team. Women with endometriomas may respond to some of the following treatments: 

Non-surgical treatments: These treatment options are temporary choices to manage pain and complications in the short term.

• Medication therapy 
• Observation

Surgical treatment: this may include:

• Drainage
• Laser ablation
• Capsule excision (the procedure of choice for most top experts)

Final Thoughts and Question for Readers

Have you had to deal with endometrioma? If so, please share how it has impacted your endo journey.

4 years ago What is Endometriosis No comment

Endometriosis Myths & Facts: Dispelling the Misconceptions

Table of contents

• Debunking the Myths About Endometriosis & Exploring the Facts
• Overview of Endometriosis 
• Why is it Difficult to Diagnose Endometriosis?
  • Myth #1: Severe Period Pain is Normal
  • Myth #2: A Hysterectomy Cures Endometriosis
  • Myth #3: Endometriosis Only Affects the Pelvic Area
  • Myth #4: Endometriosis Symptoms are Simply a “Heavy Period”
  • Myth #5: Douching Causes Endometriosis
  • Myth #6: Having an Abortion Can Cause Endometriosis
  • Myth #7: You’re Too Young to Have Endometriosis
  • Myth #8: Endometriosis Can Be Prevented
  • Myth #9: Endometriosis is Always Painful
  • Myth #10: Pregnancy is a Cure for Endometriosis
  • Myth #11: Menopause Cures Endometriosis
  • Myth #12: Hormonal Therapy Cures Endometriosis
  • Myth #13: Endometriosis is Cancer
  • Myth #14: Tubal Endometriosis Always Causes Infertility
  • Myth #15: Endometriosis Symptoms Are the Results of Emotional Distress (It Is All in Your Head)
• We Want Your Input

Debunking the Myths About Endometriosis & Exploring the Facts

One in ten women worldwide is affected by endometriosis, also known as “endo,” for short. While this number is an estimate, the actual figures may be higher. Not only is the person with this inflammatory disorder affected, so are the family members and people around her due to the often debilitating effects of this disease. Endometriosis facts are important because it is complex and often misunderstood even though it’s a common disorder. Because of this, there are many myths and misconceptions regarding endometriosis prognosis, treatment, causes, symptoms, diagnosis, complications, etc. 

Focusing on the disease itself often ignores the vicious cycles of stress, fatigue, pain, doctor visits, flare-ups, and loss of productivity experienced by the patient. These factors can lead to a decreased quality of life. Worse is that endometriosis facts come behind outdated treatment options, myths, and misconceptions about this disorder. It takes an average of eight to ten years for a patient to be diagnosed with endometriosis. One of the biggest problems with the misconceptions about endo is that they can prevent women from seeking treatment. Keep reading as we review endometriosis facts and debunk the myths. 

Overview of Endometriosis 

Endometriosis is a pelvic disorder characterized by endometriosis tissue similar but not the same as the tissue inside the uterus, growing elsewhere. Typically, the growth occurs outside the uterus, ovaries, fallopian tubes, cervix, the surface of the bladder, bowel, and distant organs.

Endometriosis growths can cause pain, scarring, and sometimes infertility. Pain from endometriosis is usually the result of menstrual bleeding from the tissues. Unlike the endometrium inside your uterus, blood that comes from endo tissue outside this organ has no means of escaping the body. This blood causes increased pressure and inflammation, which can result in pain that’s often debilitating. If you would like to learn more information about endometriosis, please read our introduction article, “Endometriosis 101: Covering the Basics.”

Why is it Difficult to Diagnose Endometriosis?

Studies show that it can take an average of seven years or more for a woman to get an endometriosis diagnosis. Why is this? Endometriosis signs and symptoms are often similar to other conditions, such as irritable bowel syndrome or pelvic inflammatory disease (PID). Therefore, it’s often mistaken for another illness. Furthermore, the myths and misconceptions we discuss below also prevent a lot of women from seeking help. For this reason, it’s crucial to get the endometriosis facts clear. Keep reading as we debunk the myths and state the facts.

Myth #1: Severe Period Pain is Normal

Nineteenth-century doctors were often perplexed by “women’s problems.” As a result, women were often discounted as being unstable mentally. While the attitudes and thoughts have improved since, some of those old beliefs persist, including those regarding period pain.

Many patients with endometriosis hear that their severe period pain is “normal.” Pain and cramping are normal during menstruation. However, the pain should not be so intense that it interferes with functioning or impacts the quality of life. If your period pain is so severe that you cannot carry out daily activities, you should seek an endometriosis expert.

Myth #2: A Hysterectomy Cures Endometriosis

Endometriosis growths are tissues “similar” to those inside of the uterus. It is not the same tissue. Simply removing the uterus and/or ovaries without excising any endometriotic implants growing outside the uterus will not cure it. 

Myth #3: Endometriosis Only Affects the Pelvic Area

Locations within the pelvis, such as the surface of the uterus, bladder, or fallopian tubes, are the most common locations where endometriosis growths occur. However, endo can occur elsewhere in the body. In some cases, endometriosis growths have been present in distant organs, such as the lungs. 

Myth #4: Endometriosis Symptoms are Simply a “Heavy Period”

Bleeding during menstruation can be heavy at times. However, it should not exceed the saturation of a pad or tampon in one hour. If you experience that degree of bleeding, you should bring this up with your healthcare provider. The fact is that many women with endometriosis experience abnormally heavy flow due to the excess tissue.

Myth #5: Douching Causes Endometriosis

No scientific evidence links douching with the development of endometriosis.

Myth #6: Having an Abortion Can Cause Endometriosis

No scientific evidence demonstrates that having an abortion causes endometriosis. Those who claim otherwise might be confusing endometritis and endometriosis.

Myth #7: You’re Too Young to Have Endometriosis

A common misconception is that endometriosis is rare or doesn’t occur in young women and teenagers. As a result, many doctors do not consider an endometriosis diagnosis in young women with typical symptoms. Endometriosis facts demonstrate that teenagers and women in their early 20s can have the disorder. Most people with endometriosis state they experienced endo symptoms during adolescence. 

Myth #8: Endometriosis Can Be Prevented

It’s not clearly understood what causes endometriosis. Therefore, there are no proven ways to prevent this inflammatory condition. Anything else is purely speculation at this point.

Myth #9: Endometriosis is Always Painful

Not all women with endometriosis experience pain. Studies show that some women with advanced stages of endometriosis do not experience pain as a symptom.

Myth #10: Pregnancy is a Cure for Endometriosis

This misconception about endometriosis is slowly beginning to fade. However, not quickly enough! Pregnancy fluctuates hormones in the female body, which can temporarily suppress some symptoms of endometriosis. However, these symptoms usually recur for most patients following the pregnancy. Therefore, it’s not a cure.

Myth #11: Menopause Cures Endometriosis

Endometriosis symptoms often occur during menstruation, but many women experience them long after periods stop. Following menopause, the body still produces small amounts of hormones, and the endometriosis tissue still responds to them, thus causing pain. For many women, the symptoms of endometriosis may improve after menopause, but that does not mean it’s a cure. Depending on the case, it might be necessary to remove endometriosis implants or adhesions even after menopause. 

Myth #12: Hormonal Therapy Cures Endometriosis

Doctors have been treating endometriosis for years using hormonal therapy drugs. However, these medications do not have long-term effects on the disease itself. Hormones can help relieve the symptoms temporarily and even shrink the growths, but they do not cure endometriosis.

Myth #13: Endometriosis is Cancer

Endometriosis growths are not cancerous. To date, there is little evidence that shows endometriosis directly causes cancer. However, some types of cancers are more common in women who have endometriosis. Endometrial cancer is also known as uterine cancer. Many studies have examined the relationship between the two, and one showed that merely 0.7 percent of patients with endometriosis had endometrial cancer at the 10-year follow-up. Therefore, endometriosis does not equal cancer, but it may increase the risk of cancer.

Myth #14: Tubal Endometriosis Always Causes Infertility

Tubal endometriosis is not very common, and it does not always cause infertility. Does endometriosis cause infertility? It can be in many cases, but the mechanisms of infertility in endometriosis remain multifactorial. Can you get pregnant with endometriosis? It is possible, and many women do – especially with proper treatment early on.

Myth #15: Endometriosis Symptoms Are the Results of Emotional Distress (It Is All in Your Head)

Yes. People have heard many times that emotional distress could be the cause of their endometriosis and pain. This statement is false. The fact is, endometriosis is a highly complex disorder with many underpinnings. Those with endometriosis often experience emotional distress as an impact of the symptoms such as pain and infertility. But emotional distress it’s not the cause of endometriosis symptoms.

Endometriosis quick facts:

1- There is no blood test available for the diagnosis of endometriosis.

Mehedintu C, J Med Life, 2014

2- The diagnosis of endometriosis starts by taking a good history from patients, and performing a detailed physical exam including pelvic exam. In some cases, a doctor might ask for MRI and Ultrasound to have a more thorough picture. But the ultimate diagnosis is only possible with laparoscopic /robotic surgery and taking a biopsy for histopathology. There is no blood test that can tell if you have endometriosis.

3- Studies show that those with endometriosis have an increased risk of developing depression and anxiety disorders.

Chen LC, et al, J Affect Disord, 2016

4- Pelvic pain due to endo occurs a day part of an inflammatory cycle which can affect the pelvic organs and functions such as sitting, sex, bowel movements and even urination. Pelvic floor physical therapy can help with restoring balance to the pelvic floor muscles.

Dr. Juan Michelle Martin,  Endometriosis Physical Therapist.

5- “The most common clinical signs of endometriosis are menstrual irregularities, chronic pelvic pain, dysmenorrhea (painful periods), dyspareunia (painful sex), and infertility.”

Lagana AS, et al, Int J Womens Health. 2017

We Want Your Input

Are there any endometriosis myths or misconceptions we did not list here? Let us know in the comments below!

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