Endometriosis 101

Endometriosis 101: Covering the Basics

Sharp. Stabbing. Burning. Throbbing. Aching. All these adjectives have been used to describe endometriosis pain. Endometriosis is a condition that, for some women, can cause excruciating uterus pain. Some describe it as feeling like their insides are being pulled out of their bodies. Even worse – pain medication doesn’t cut through or provide relief for many patients with this condition. Therefore, an endometriosis diagnosis can be very serious and life-changing news.

Our commitment to our patients runs deep, and our mission is to help patients with endometriosis pain and other complications find the skilled doctors they need.

As our first introduction to the disorder, we will give you a brief overview of the signs and symptoms of endometriosis, its causes, complications, and treatment options (or, as we like to call it – hope). First, we will give you general information on the disease and cover what endometriosis is.

Table of contents

What is the Endometrium?

What is Endometriosis?

Signs and Symptoms of Endometriosis

Causes of Endometriosis

Complications of Endometriosis

Diagnosis of Endometriosis

Treatment for Endometriosis

Surgical Treatment Options for Endometriosis:

Multidisciplinary care

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What is the Endometrium?

The endometrium, also known as the endometrial lining, is the tissue that comprises the “wallpaper”, or lining of the uterus. The uterus is the pear-shaped organ that houses a growing baby. During pregnancy and menstruation, the endometrium plays vital functions.

What is Endometriosis?

Endometriosis is pronounced (en-doe-me-tree-O-sis). Endometriosis is a medical condition in which tissue similar to what normally lines the inner walls of the uterus, also known as the endometrium, grows outside the uterus. It is often a very painful, even debilitating disorder. It may involve the ovaries, fallopian tubes, bowels, vagina, cervix, and the tissues that line the pelvis. In rare cases, it can also affect other organs, such as the bladder, kidneys, or lungs.

Signs and Symptoms of Endometriosis

Signs and Symptoms of Endometriosis
signs of endometriosis
endometriosis symptoms

Not all women will experience the same symptoms of endometriosis or degree of intensity/severity. Some women may not experience any symptoms at all. 

It is also important to keep in mind that the severity of symptoms is not a solid indicator of the progress of the disease. There are women with advanced stages of endometriosis who experience no symptoms at all and others with mild cases who endure many. Common endometriosis symptoms include: 

  • Painful periods, or dysmenorrhea
  • Infertility
  • Diarrhea during period
  • Pain during intercourse
  • Heavy or abnormal menstrual flow
  • Abdominal or pelvic pain after vaginal sex
  • Painful urination during or between menstrual periods
  • Painful bowel movements during or between menstrual periods
  • Gastrointestinal problems, including bloating, diarrhea, constipation, and/or nausea

Mechanisms of signs and symptoms of endometriosis:

Painful periods (dysmenorrhea)

Cyclic release of multiple inflammatory factors activates nerve fiber growth, leads to cell damage and fibrosis, and exacerbates pain during periods

Infertility

The overall mechanisms can include tubal blockage, local inflammation, uterine muscle dysfunction, local hormonal alterations, and much more.

Diarrhea during menstrual periods

Diarrhea may result from endometriosis growing directly on the rectal muscle or endometriosis inflammatory substances. Local production of inflammatory molecules can lead to hyper-motility of the sigmoid and rectum muscles, which can manifest as cramping and diarrhea.

Pain during intercourse (dyspareunia)

Endometriosis implants have more nerve endings than usual (hyperinnervated) and can produce pain with pressure. The act of intercourse can apply this pressure on the upper vaginal area and uterosacral ligaments, which are common locations of endo implants. Once this pain occurs and local inflammation further causes tension in the pelvic floor, the muscles surrounding the vagina can contract, which worsens the problem.

Heavy or abnormal menstrual flow

Endometriosis can impact your bleeding by increasing stress from pain or damage to the ovaries, which can change local hormonal function.

Abdominal or pelvic pain after vaginal sex

Uterine and pelvic floor spasms are part of regular orgasms. When these areas are hypersensitive due to endometriosis, spasms lead to continued contractions and pain that lasts for a while. In addition, rectal fusion to the posterior vaginal wall will also cause more direct pain and inflammation by the vaginal area pulling on the rectal wall. Also, as you probably recognize, any event that stirs up the pelvis and causes some trauma leads to increased molecular signaling, further amplifying the problem. 

Painful urination during or between menstrual periods (dysuria)

Painful and frequent urination is a prevalent symptom of endometriosis. Endo cells and responding inflammatory cells produce inflammatory molecular signals that aggregate in the area of injury. These molecular signals affect all pelvic organs, including the bladder, leading to bladder wall spasms. Moreover, interstitial cystitis is common in endometriosis patients and can also be a factor. In the worst-case scenario, endo lesions implant inside the bladder, which can also cause cyclic bleeding from the bladder (hematuria). 

Painful bowel movements during or between menstrual periods (dyschezia)

Endometriosis causes inflammation and fibrosis or scarring as your body attempts to heal. This inflammation and fibrosis can severely alter the anatomy in the pelvis and distort the rectal course, gluing it to the uterus, cervix, and posterior vaginal wall. This angulation can cause constipation and trouble evacuating stool, while the inflammatory signals cause the rectal muscles to hyper-contract. These mechanisms lead to painful bowel movements, which worsen during the cyclic increases in inflammatory molecules. In the worst-case scenario, the endo will grow through the rectum wall over time, causing cyclic rectal bleeding.

Gastrointestinal problems, including bloating, diarrhea, constipation, and nausea

Generally, intestinal symptoms of endometriosis can be direct or indirect or related to conditions like small intestinal bacterial overgrowth (SIBO). Even if there are no direct implants on the bowel, the endo inside the abdomen and pelvis can cause enough inflammation to irritate the intestine and cause symptoms. In addition, endometriosis implants directly on the bowel can worsen the symptoms.

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Causes of Endometriosis

One cause of endometriosis is the direct transplantation of endometrial cells into the abdominal wall during a medical procedure, such as a cesarean section. Besides this known cause of endometriosis, other theories exist as to how it develops:

1. One theory is that during the menstrual cycle, a reverse process takes place where the tissue backs up through the fallopian tubes and into the abdominal cavity, where it attaches and grows.

2. Another theory is a genetic link. This is based on studies that show if someone has a family member with endometriosis, they are more likely to have it as well.

3. Some also suggest that the endometrial tissues travel and implant in other body parts via blood or lymphatic channels, like cancer cells spread.

4. A fourth theory suggests that all cells throughout the body have the ability to transform into endometrial cells. 

Complications of Endometriosis

The following are complications of endometriosis if left untreated or in advanced stages of the disorder:

  • Infertility/subfertility
  • Chronic pelvic pain that can result in disability
  • Anatomic disruption of involved organ systems (i.e., adhesions, ruptured cysts, renal failure)

Diagnosis of Endometriosis

The diagnosis starts with assessing signs and symptoms and then performing imaging studies such as MRI and ultrasonography. But the confirmation or exclusion of the endometriosis diagnosis is only possible with surgical biopsy and histopathology. Laparoscopy is the gold-standard surgical modality for diagnosis in all cases.

Treatment for Endometriosis

Endometriosis needs a multidisciplinary team approach for effective and holistic treatment. This team should include the following medical professionals:

  • Nutritionist
  • Physical therapist
  • Endometriosis surgeon
  • Mental health therapist
  • Pain management specialist

Pain is often the biggest complaint from patients with endometriosis. Therefore, many treatment options are aimed at pain control. So first, here are some options for women to help temporarily ease the pain of endometriosis:

  • Exercise
  • Meditation
  • Breath work
  • Heating pads
  • Rest and relaxation
  • Prevention of constipation

These therapies may be used in combination with medical and/or surgical options to lessen the pelvic pain associated with this disorder. Furthermore, alternative therapies exist that may be used in conjunction with other interventions, and those include but are not limited to:

  • Homeopathy
  • Immune therapy
  • Allergy management
  • Nutritional approached
  • Traditional Chinese medicine

*Be sure to discuss any of these treatment options with a physician before implementing them.

The Right Medical Treatment For You:

Options for medical and/or surgical treatments for endometriosis are going to depend on several factors, including: 

  • Desire for pregnancy
  • The extent of the disease
  • Type and severity of symptoms
  • Patient opinions and preferences
  • Overall health and medical history
  • Expectations of the course of the disease
  • Patients’ tolerance level for medications, therapies, and/or procedures

In some cases, management of pain might be the only treatment. In others, medical options may be considered. The following are typical non-surgical, medical treatments for endometriosis:

  • “Watch and Wait” approach, where the course of the disease is monitored and treated accordingly
  • Pain medication (anything from non-steroidal anti-inflammatory drugs [NSAIDs] to other over-the-counter and/or prescription analgesics)
  • Hormonal therapy, such as:
    • Progestins
    • Oral contraceptives with both estrogen and progestin to reduce menstrual flow and block ovulation
    • Danazol (a synthetic derivative of the male hormone testosterone)
  • Gonadotropin-releasing hormone antagonist, which stops ovarian hormone production

Surgical Treatment Options for Endometriosis:

Despite their effectiveness in symptom control, pain medications can have significant side effects. Moreover, these medications do not stop the progression of the disease, and symptoms might return once stopped. But on the other side, surgery can lead to long-term relief and can prevent further damage to tissues. Your treatment plan should be a shared decision based on your desires, goals, and abilities. 

Almost all endometriosis surgical procedures are laparoscopic or robotic. These are minimally invasive surgeries in which small tubes with lights and cameras are inserted into the abdominal wall. It allows the doctor to see the internal organs and remove endometriosis.

Common procedures include: 

Excision of endometriosis:

In this technique, a surgeon cuts out much or all of the endometriosis lesions from the body. Therefore, surgeons avoid leaving any endometriosis lesions behind while preserving normal tissues. This technique is widely adopted by highly skilled endometriosis surgeons who are world leaders.

Ablation of endometriosis:

In this technique, a surgeon burns the surface of the endometriosis lesions and leaves them in the body. Most top experts highly criticize this ablation method. Ablation is most popular with surgeons who have not received enough training to do excision. As a result, these surgeons are not comfortable performing excision, and they do the ablation.

Hysterectomy:

this is a surgery in which surgeons remove the uterus and sometimes ovaries. But, many surgeons consider hysterectomy an outdated and ineffective treatment for endometriosis. Almost all top endometriosis surgeons reject doing it unless there is a clear indication for hysterectomy such as adenomyosis.

Laparotomy:

this surgical procedure cuts and opens the abdomen and does not use thin tubes. Therefore it is more extensive than a laparoscopy. Very few surgeons still do laparotomy because of its complications. Almost none of the top endometriosis surgeons do laparotomy for endometriosis.

Multidisciplinary care

Along with effective surgical treatment, the patient should start working with endometriosis experts in physical therapy, mental health, nutrition, and pain management to achieve the best possible outcome.

The author of this article, Dr. Steven Vasilev MD is a fellowship-trained, triple board-certified integrative gynecologic oncologist specializing in complex pelvic robotic surgery. He focuses on advanced & reoparative endometriosis excision and molecular integrative healing, especially as it applies to women of older reproductive age and in menopause.

 
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