Chronic pelvic pain is responsible for approximately 10-15% of all gynecologic visits in the United States. Pelvic pain is a significant disease process affecting millions of American women not only in terms of monetary costs, but the emotional strain it places on a woman and her family is even a heavier burden to bear. Many times a woman who complains of painful periods is told to take an aspirin and wait till her period ends. She is often told that was the way her body is built, and there is not much she can do about it. This advice is commonplace but rarely is it helpful. A more holistic approach must be taken. A good portion of chronic pelvic pain cannot be attributable to a diseased uterus, ovary, or fallopian tube. Chronic pelvic pain is a complex problem which frustrates both physician and patient. However for 5 million American women a chronic disease called endometriosis is responsible. This disease is definitely treatable. Endometriosis occurs most commonly during the reproductive years. But rarely do girls develop it before their first period and menopausal women are seldom afflicted by it. Endometriosis has even been found in men.

What is Endometriosis?

Endometrial tissue is normally found in the lining of the uterus which is shed off every month during a woman's period. Endometriosis is a condition where the bits of tissue from the lining of the uterus are present and grow outside the uterine cavity. There is a condition called adenomyosis where endometrial tissue is found in the wall of the uterus. These bits of tissue can be found in the pelvic cavity, the bladder, behind the uterus, on the peritoneum (lining covering the abdominal cavity), and on the intestines-in other words, they are found in the wrong place. Endometriosis has even been found in the lungs and growing in old surgical scars. The ectopic (out of place) endometrial responds to the hormonal fluctuations of a woman's menstrual cycle and acts similarly to the endometrial tissue in the lining of the uterus.

What is it Caused by?

Basically we don't have a good explanation. There are three accepted theories. The first theory is that of retrograde menstruation or the backward flow of menses. Instead of blood flowing down the vagina, the endometrial cells move into the tubes and out into the pelvic cavity. These endometrial cells can seed the cavity. Another theory states that the tissue was there at birth transported by lymph flow or in blood vessels. Once estrogen is produced in high amounts starting at puberty, these cells begin to grow. The last credible theory states that a weak immune system will allow endometrial cells to proliferate outside their normal place. While all these theories are conceptually correct, they cannot completely support the facts nor can they prove the origins of endometriosis.

What are the symptoms?

The symptoms of endometriosis usually go beyond the occasional cramps a woman suffers during her period. The diagnosis is strongly supported by a patient's initial history. Pelvic pain is a hallmark symptom. The timing of the pelvic pain is important. Typically, endometriosis patients have pain just before the onset of menses, and the pain subsides a bit just after the menstrual flow starts. In addition, patients suffer from dyspareunia-painful intercourse especially with deep penetration. If endometrial tissue is growing in the bladder or intestines, the patient may have bloody urine or bowel movements respectively. Implants (tissue) on the surface of the bowel may cause bloating during the time of menstruation. Worse of all for many is the infertility connection. Between 20% and 68% of those who see doctors for infertility have endometriosis. Endometrial tissue can interfere with the transport of the egg and sperm in the fallopian tubes by causing adhesions or scar tissue to form.

How is Endometriosis Diagnosed?

A typical scenario is a woman will present with a complaint of pelvic pain, and she will be labeled with a diagnosis of endometriosis and placed on birth control pills, Depoprovera (an injectable progesterone), or another medication will be used to treat the disease. Granted most cases of endometriosis can be diagnosed with a good patient history and physical; a definitive diagnosis is made by biopsy and histologic identification. This can be done laproscopically which is a procedure that involves a small camera being placed into the pelvic cavity. The doctor can then look inside the abdomen and biopsy any suspicious lesions. A published dialogue between a panel of four experts seems to agree that medical treatment for endometriosis prior to surgical intervention is a valid one.

Laparoscopy has long been considered the best tool for diagnosing and treating endometriosis; however, by one estimate, the lesions are not identified in 25% of women. This can be extremely frustrating to a woman who may have endometriosis, but the implant may have not been visible during the operation. Therefore, a trial of medications prior to a surgical diagnosis is an acceptable option.

What are the Treatments for Endometriosis?

Treatment for endometriosis can be divided up into two general categories; surgical and medical. There are a number of medications a doctor may prescribe to treat endometriosis. In the past, a weak male hormone called Danazol used to be given. This has been associated with undesirable side effects. More commonly birth control pills are prescribed because the progesterone in the combination pills (contain estrogen and progesterone) shrinks endometrial tissue. Progesterone by itself can be administered to shrink the endometriosis tissue. A newer line of medications called GnRH agonists are gaining popularity. These medications act like a natural hormone to shut off a woman's supply of estrogen. GnRH agonists create a chemical menopause in which a woman may experience similar symptoms as a woman going through natural menopause. Women taking this medication will not menstruate. Nearly 90% of women have experienced pain relief with GnRH agonists which justify their use prior to actually obtaining a tissue diagnosis.

Surgery alone has been shown to improve the symptoms of 65-80% of women. During the surgery, the doctor will identify and destroy all possible endometriosis lesions. Sometimes lesions will be deep seated and hidden from the surgeon's view. Therefore, most authorities will recommend the use of GnRH agonists after surgery. In general, medications and conservative surgical treatment (not removing the uterus and ovaries) controls the symptoms and cures infertility problems for a window of time to either eliminate symptoms or to allow a woman to have a family. It's used as a stop gap until a woman has completed her family. If symptoms persist after conservative treatment a total hysterectomy (removal of both uterus and ovaries) can be done for definitive treatment.

What is the Chance of Conceiving with Endometriosis?

With treatment the chances are excellent. Women with minimal to mild endometriosis have a 60% to 70% chance of conceiving in 1 year without any fertility treatments. Even women with severe disease involving at least one ovary have a 30% chance. New innovations in infertility such as in vitro fertilization have greatly increased a couple's chance of success.

Ryan K. Lee is a physician specializing in Obstetrics and Gynecology. He is currently in private practice in Glendale and Los Angeles, California.