A Case of Endometriosis
A Typical Case Example of Endometriosis:
Stephanie is 33 years old, working as a waitress, with a 7-year-old daughter, and happily married to Brett (a carpenter) with whom she shares a monogamous relationship. Stephanie has regular menstrual cycle intervals every 28-30 days, a several year history of moderate to severe intensity lower pelvic cramps with heavy flow for about a day (effectively treated with non-steroidal anti-inflammatory agents like Motrin), recent progressively increasing pelvic and lower back pain (now described as “killer cramps”) that now last for 1-3 days with each cycle (keeping Stephanie out of work for 1-2 days a month), and recent diarrhea along with a sharp stabbing pain during urination at the time of her menstrual flow. Her gynecologist told Stephanie that she might have endometriosis.
“What is endometriosis?”
Endometriosis is an abnormal condition in which tissue that closely resembles the normal lining tissue of the uterine cavity (endometrium) grows outside the body of the uterus.
The way in which this endometrium-like tissue finds its way outside the uterus is not always clear, but certainly may include retrograde (backwards) flow of endometrium (that is normally shed) during menses through the fallopian tubes into the pelvis, migration of endometrium (that is shed during menses) into opened blood vessels or lymphatic vessels potentially to distant sites, or direct transplantation (via mechanical translocation) of endometrium during uterine surgery involving the uterine cavity (such as Cesarean Section or myomectomy) into the pelvis or the surgical scar.
Normally the body’s immune system detects and destroys tissue that is out of place. It is not clear why endometrium-like tissue is allowed to grow outside the body of the uterus (as endometriosis), but possibilities include the deposition of very large quantities of endometrium-like tissue (that exceeds the normal ability of the immune system to clear the entire amount of tissue) and abnormalities of the immune system that either reduce its ability to detect (recognize) endometrium-like tissue or reduce its ability to destroy this abnormally located tissue once it is recognized.
Endometriosis is not a rare condition, affecting up to 10% of all women in the USA. Endometriosis is identified in about 33% (one third) of women having a laparoscopy to identify and treat the cause of pelvic pain and up to 50% (one half) of women having a laparoscopy to identify and treat the cause of infertility. Risk factors that increase the likelihood of endometriosis include short menstrual cycle intervals, heavy or prolonged menstrual flows, never having been pregnant, a first degree relative (mother or sister) with endometriosis, and possibly coexisting autoimmune disorders, fibromyalgia and chronic fatigue syndrome.
The most common sites for endometriosis are near the ends of the fallopian tubes, and include (in decreasing order of frequency) the ovaries, the anterior (upper) and posterior (lower) surfaces adjacent to the uterus, the broad ligaments, the outside (peritoneal) surface covering the uterus, the fallopian tubes, the colon and the bladder.
Stephanie was referred by her gynecologist to my office for further assessment and treatment of probable extensive endometriosis since her symptoms included the gastrointestinal system (bowel) and the urinary system (bladder) in addition to the reproductive system (uterus, tubes and ovaries).
“What are the symptoms of endometriosis?”
The symptoms of endometriosis can include a wide range of problems, however, a woman with endometriosis often presents with her own unique pattern of symptoms. Also, some women with endometriosis, found incidentally during surgery (for other reasons), have no symptoms.
Symptoms that are associated with endometriosis, from more common to less common, include progressive (increasing) pelvic pain (may be mostly on one side) during periods, progressive pelvic pain (deep not superficial) with intercourse, persistent pelvic pain throughout the month, lower back pain, painful bowel movements (including diarrhea, constipation, bloating) especially during menses, painful urination (or bloody urination) during menses, infertility, and chronic fatigue.
Many of these symptoms of endometriosis are also seen in other gynecological or medical conditions, such as pelvic inflammatory disease and irritable bowel syndrome. Unfortunately, there is no symptom, or cluster of symptoms, that is so characteristic of endometriosis that it alone can make the diagnosis. Diagnosis relies on visual identification, which in turn, requires surgery (generally a same day surgery called laparoscopy). Therefore, endometriosis is tremendously under-diagnosed and consequently also under-treated.
The physical findings associated with endometriosis also vary, depending partially on the size and location of the endometriosis implants. Most often, there are no abnormal findings on physical examination or radiological (mostly ultrasound) evaluation. Sometimes, an implant of endometriosis will be inflamed and superficial enough to palpate, in which case palpation could result in localized (point) tenderness. Point tenderness may occur along the back (posterior) wall of the vagina, where tender nodules of endometriosis are sometimes palpable along the ligaments behind the uterus (uterosacral ligaments), the (peritoneal) lining along the outside of the back wall of the uterus, or along the ovaries and fallopian tubes. Pelvic adhesions, or scar tissue, caused by the chronic irritation of endometriosis can also limit the mobility (range of motion) of the uterus, ovaries and fallopian tubes and this can sometimes be appreciated on the gynecological examination.
In my own clinical practice, most women with endometriosis present to the office with a complaint of progressive pelvic and/or lower back pain that is most severe during their menstrual flow, but over time this pain often continues throughout most of the month. This pain is often stabbing and sharp in nature, but can also be an aching dull squeezing sense of fullness. The pain is often relieved, at least partially, with non-steroidal anti-inflammatory drugs (such as Ibuprofen). More extensive endometriosis often also results in painful intercourse (with sharp pain deep in the pelvis), irregular (often painful) bowel movements (either diarrhea or constipation) especially around the time of menses, and sharp pain during and after urination. Many patients with otherwise unexplained infertility and no other symptoms of endometriosis are also found to have endometriosis on laparoscopic evaluation.
Stephanie consulted with me at the office, at which time we reviewed her medical and gynecological histories, discussed several gynecological conditions that could at least partially account for her progressive symptoms, and then focused our discussion on endometriosis (its definition, the common associated symptoms, diagnostic tests, and the available treatment alternatives). On examination, the posterior wall of the uterus was tender without nodularity and there was reduced mobility of the ovaries possibly due to adhesions (scar tissue). On ultrasound examination, the uterus and ovaries were normal appearing without endometriomas (ovarian cysts characteristic of endometriosis).
“How is endometriosis diagnosed and treated?”
The only way to diagnose endometriosis with certainty is to directly visualize endometriosis implants, which is most commonly done by laparoscopy (a low risk minimally invasive day stay surgery). The experience of the surgeon and the appearance of the implants (location, type, depth) can affect the accuracy of diagnosis. When there is any uncertainty about a particular lesion, it is usually possible to biopsy the lesion for confirmation (pathologists view the tissue that is removed using a microscope and they will be able to see endometrial glands or stroma if it contains endometriosis).
A very experienced endometriosis surgeon may be able to identify (and then remove) several atypical lesions that are causing significant symptoms to improve overall therapeutic success. It is also possible that there are microscopic implants of endometriosis, invisible on direct visualization (without a microscope), within normal appearing peritoneum that might cause significant symptoms. From a detailed history of any pain characteristic of endometriosis and an understanding of where endometriosis usually occurs, a surgeon can often suspect where microscopic implants exist if there are no visible lesions in the region.
In certain clinical situations, surgical diagnosis and treatment may be undesirable. The operating room equipment or the surgical staff may not be ideal, the patient may have medical conditions that make surgery dangerous, the patient may not have medical insurance to cover surgery (which is generally costly), or the patient may simply not want surgery for personal reasons. In these situations, it is possible to initiate medical management for endometriosis if the symptoms are highly suggestive and if this treatment is effective then this further suggests (but still does not definitely diagnose) endometriosis. It is important to note that medical management of endometriosis is for the treatment of pain due to endometriosis and these medications are not thought to improve fertility. The most common medical treatments for presumed endometriosis are oral contraceptive pills or GnRH agonist therapy (such as Lupron), and either of these should be continued for at least 3 months to allow the medication to have a significant effect on symptoms.
Treatment options for endometriosis include pain medication (especially medication that reduces inflammation such as non-steroidal anti-inflammatory drugs, including ibuprofen and naproxen), hormonal contraceptive treatment (including oral birth control pills, the contraceptive patch or the contraceptive vaginal ring), progestins (synthetic progesterone), GnRH agonists (medication that causes a temporary menopause-like condition, including Lupron or Synarel), and surgery (ideally with the ultrapulse CO2 laser since it allows very aggressive removal of abnormal tissue while causing very little postoperative scar tissue).
When a woman with endometriosis is actively trying to get pregnant, treatment with contraceptives or medications that cause a temporary menopause-like condition are contraindicated. Additionally, pre-treatment with these medications to reduce the overall amount of endometriosis that might interfere with fertility does not seem to be effective. Therefore, I generally suggest laparoscopy for women with symptoms suggestive of endometriosis, to aggressively reduce the amount of endometriosis within the pelvis if they are trying, but having difficulty, becoming pregnant.
Treatment with medication is often effective at reducing pain associated with endometriosis. This medical management often takes at least 3 months to start working effectively and usually is effective only when the endometriosis lesions are superficial and small. If pain management is the primary concern, fertility is not immediately desired, and medical management is effective then this treatment can often be continued for a long period of time. An exception is with GnRH agonists, which should generally only be used for up to 6 months, to avoid loss of bone mineral content (osteoporosis), unless replacement of estrogen is added to the treatment regimen.
Over the 6-9 months prior to our initial consultation, Stephanie developed incapacitating pelvic pain that lasted for a few days each month, that was only partially treated with non-steroidal anti-inflammatory drugs, and that began to involve her bowel and urinary systems. Therefore, Stephanie chose a pelvic evaluation with laparoscopy and hysteroscopy to diagnose and treat any pelvic abnormalities (including endometriosis) that would cause pain or reduce future fertility. Several superficial and deep implants of endometriosis were identified, including many atypical lesions, on the ovaries and the peritoneum behind the uterus, covering the bladder and along the bowel. Over the pasts 15-20 years I have used the ultrapulse CO2 laser almost exclusively for the treatment of these lesions since the ultrapulse waveforms allow for vaporization of undesired tissue while causing very little lateral thermal damage. This in turn helps to reduce postoperative adhesion formation or scar tissue. Following surgery, Stephanie recovered normally and fortunately her pelvic pain as well as her bowel and bladder problems were essentially eliminated.
A video testimonial that expert treatment of endometriosis can truly accomplish remarkable results!
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