Endometriosis

Definition

Endometriosis is a condition in which bits of tissue similar to the lining of the uterus (endometrium) grow in other parts of the body (and within the uterus). Like the uterine lining, this tissue builds up and sheds in response to monthly hormonal cycles. The blood discarded from these implants falls onto surrounding organs, causing swelling and inflammation. This repeated irritation leads to the development of scar tissue and adhesions.

Description

Endometriosis is estimated to affect 7% of women of childbearing age in the United States. It most commonly strikes between the ages 25-40. Endometriosis can also appear in the teen years, but never before the start of menstruation. It is seldom seen in postmenopausal women.

Endometriosis was once called the "career woman's disease" because it was thought to be a product of delayed childbearing. The statistics defy such a narrow generalization; however, pregnancy may slow the progress of the condition. Women whose periods last longer than a week with an interval of less than 27 days between them seem to be more prone to the condition.

Endometrial implants are most often found on the pelvic organs, including the ovaries, uterus, fallopian tubes, and in the cavity behind the uterus. Occasionally, this tissue grows in such distant parts of the body as the lungs, arms, and kidneys. Ovarian cysts may form around endometrial tissue (endometriomas) and may range from pea to grapefruit size. Endometriosis is a progressive condition that usually advances slowly, over the course of many years. Doctors rank cases from minimal to severe based on factors such as the number and size of the endometrial implants, their appearance and location, and the extent of the scar tissue and adhesions in the vicinity of the growths.

Causes & symptoms

Although the exact cause of endometriosis is unknown, a number of theories have been put forward. Some of the more popular ones are:

• Implantation theory. This theory states that a reversal in the direction of menstrual flow sends discarded endometrial cells into the body cavity where they attach to internal organs and seed endometrial implants. There is considerable evidence to support this explanation. Reversed menstrual flow occurs in 70-90% of women and is thought to be more common in women with endometriosis.
• Vascular-lymphatic theory. This theory suggests that the lymph system or blood vessels (vascular system) are the vehicles for distribution of endometrial cells out of the uterus.
• Coelomic metaplasia theory. According to this hypothesis, remnants of tissue left over from prenatal development of the woman's reproductive tract transform into endometrial cells throughout the body.
• Induction theory. This explanation postulates that an unidentified substance found in the body forces cells from the lining of the body cavity to change into endometrial cells.

In addition to these theories, the following factors are thought to influence the development of endometriosis:

• Heredity. A woman's chance of developing endometriosis is seven times greater if her mother or sisters have the disease.
• Immune system function. Women with endometriosis may have lower functioning immune systems that have trouble eliminating stray endometrial cells. This would explain why a high percentage of women experience reversed menstrual flow while relatively few develop endometriosis.
• Dioxin exposure. Some research suggests a link between the exposure to dioxin (TCCD), a toxic chemical found in weed killers, and the development of endometriosis.

While many women with endometriosis suffer debilitating symptoms, others have the disease without knowing it. Strangely, there does not seem to be any relation between the severity of the symptoms and the extent of the disease. The most common symptoms are:

• Menstrual pain. Pain in the lower abdomen that begins a day or two before the menstrual period starts and continues until the end is typical of endometriosis. Some women also report lower back aches, and pain during urination and bowel movement, especially during their periods.
• Painful sexual intercourse. Pressure on the vagina and cervix causes severe pain for some women.
• Abnormal bleeding. Heavy menstrual periods, irregular bleeding, and spotting are common features of endometriosis.
• Infertility. There is a strong association between endometriosis and infertility, although the reasons for this have not been fully explained. It is thought that the build-up of scar tissue and adhesions blocks the fallopian tubes and prevents the ovaries from releasing eggs. Endometriosis may also affect fertility by causing hormonal irregularities and a higher rate of early miscarriage.

Diagnosis

The first step will be to perform a pelvic exam to try to feel if implants are present. Very often there is no strong evidence of endometriosis from a physical exam. The only way to make a definitive diagnosis is through minor surgery called a laparoscopy. A laparoscope, a slender scope with a light on the end, is inserted into the woman's abdomen through a small incision near her belly button. This allows the doctor to examine the internal organs. Often, a sample of tissue is taken for later examination in the laboratory. Endometriosis is sometimes discovered when a woman has abdominal surgery for another reason such as tubal ligation or hysterectomy.

Various imaging techniques such as ultrasound, computed tomography scan (CT scan), or magnetic resonance imaging (MRI) can offer additional information but aren't useful in making the initial diagnosis. A blood test may also be ordered because women with endometriosis have higher levels of the blood protein CA125. Testing for this substance before and after treatment can predict a recurrence of the disease, but is not reliable as a diagnostic tool.

Treatment

Although severe endometriosis should not be self-treated, many women find they can help relieve symptoms through alternative therapies. In a survey conducted by the Endometriosis Association, 40%-60% of the women who used alternative medicines reported relief of pain and other symptoms.

Diet

A high-fiber diet, particularly from grains and beans, may decrease cramping and inflammation. The oils in seeds, nuts, and certain fish (cod, salmon, mackerel, and sardines) may help to relieve cramping. Carrots, beets, lemons, cauliflower, brussels sprouts, cabbage, onions, garlic, citrus fruits, vegetables, chicory, radicchio, and yogurt may help to reduce symptoms. Some women have found relief when they turned to a macrobiotic diet (one that is very restrictive and intended to prolong life). Occasionally, an allergy elimination diet may be recommended.

Sugar and animal fats can increase inflammation and aggravate pain. Milk and meat may contain hormones so should be avoided. Vegetarian or vegan diets may be recommended for those with endometriosis.

Supplements

The following can be used to treat endometriosis:

• vitamin B complex to help the liver break down excess estrogen
• vitamin C to reduce heavy menstrual bleeding
• calcium
• bioflavonoids to help reduce heavy menstrual bleeding
• magnesium to relieve pain and flush out toxins
• vitamin E to heal inflamed tissues
• iron for anemia resulting from heavy bleeding
• lipotropic factors (Choline, methionine, and inositol enhance liver function.)
• fish oil capsules, flax oil, or any essential fatty acid to reduce cramping

Several herbal remedies for endometriosis exist. The first four in this list are the most commonly used remedies:

• Genistein (soy/isoflavone) helps the body excrete excess estrogen and possibly blocks estrogen effect.
• Cramp bark (Viburnum opulus) helps ease cramping.
• Dong quai (Angelica sinensis) balances hormone levels and reduces inflammation.
• Black cohosh (Cimicifuga racemosa) helps the body excrete excess estrogen and improves the health of pelvic organs.
• Red clover (Trifolium pratense) balances hormone levels.
• Milk thistle (Silybum marianum) helps the liver.
• Life (Senecio aureus) root may improve the health of pelvic organs.
• Feverfew (Chrysanthemum parthenium) eases pain and cramping.
• Dandelion eases pain and cramping and supports the liver.
• Yarrow (Archillea millefolium) eases cramping and restores hormonal balance.
• Evening primrose (Oenothera biennis) oil relieved endometriosis symptoms in 90% of patients in a study.
• Shepherd's purse (Capsella bursa-pastoris) reduces heavy menstrual bleeding and tones the uterus.
• Meadowsweet (Filipendula ulmaria) reduces pain.

Other treatments

Other remedies for endometriosis include acupuncture or acupressure to relieve pain, visualization, guided imagery , naturopathy, homeopathy (Lilium tigrum, sepia, and belladonna), hydrotherapy, exercise, and meditation.

Allopathic treatment

How endometriosis is treated depends on the woman's symptoms, her age, the extent of the disease, and her personal preferences. The condition cannot be fully eradicated without surgery. Treatment focuses on managing pain, preserving fertility, and delaying the progress of the condition.

Medication

Over-the-counter pain relievers such as aspirin, acetaminophen (Tylenol), ibuprofen (Motrin, Advil), and naproxen (Aleve, Naprosyn) are useful for mild cramping and menstrual pain. If pain is severe, a doctor may prescribe narcotic medications, although these can be addicting and are rarely used.

Hormonal therapies effectively tame endometriosis but also act as contraceptives. They include oral contraceptives, synthetic male hormones (danazol, gestrinone), progestins, and gonadotropin-releasing hormone antagonists.

Surgery

Endometrial implants and ovarian cysts can be removed with laser surgery performed through a laparoscope. For women with minimal endometriosis, this technique is usually successful in reducing pain and slowing disease progress. It may also help infertile women increase their chances of becoming pregnant.

Removing the uterus, ovaries, and fallopian tubes (a hysterectomy) is the only permanent method of eliminating endometriosis. This is an extreme measure that deprives a woman of her ability to bear children and forces her body into menopause.

Expected results

Most women who have endometriosis have minimal symptoms and do well. Overall, endometriosis symptoms come back in an average of 40% of women over the five years following treatment. With hormonal therapy, pain returned after five years in 37% of patients with minimal symptoms and 74% of those with severe cases. The highest success rate from conservative treatment followed complete removal of implants using laser surgery. Of these women, 80% were still pain-free five years later. Hysterectomy may be necessary should other treatments fail.

Prevention

There is no proven way to prevent endometriosis. One study, however, indicated that girls who begin participating in aerobic exercise at a young age are less likely to develop the condition.

Key Terms

Adhesions

Web-like scar tissue that may develop as a result of endometriosis and bind organs to one another.

Endometrial implants

Growths of endometrial tissue that attach to organs, primarily in the pelvic cavity.

Endometrium

The tissue lining the uterus that grows and sheds each month during a woman's menstrual cycle.

Estrogen

A female hormone that promotes the growth of endometrial tissue.

Laparoscopy

Procedure used to diagnose and treat endometriosis. It is performed by inserting a slender, wand-like instrument through a small incision in the woman's abdomen.

Menopause

The end of a woman's menstrual periods when the body stops making estrogen.

Retrograde menstruation

Menstrual flow that travels into the body cavity rather than out through the vagina.

Further Reading

For Your Information

Books

• Ballweg, Mary Lou. The Endometriosis Sourcebook. Chicago: Congdon & Weed, 1995.
• D'Hooghe, Thomas M. and Joseph A. Hill. "Endometriosis" in Novak's Gynecology, edited by Jonathan S. Berek, et al., 12th ed. Baltimore, MD: Williams & Wilkins, 1996
• Malesky, Gail. "Endometriosis." Nature's Medicines: from Asthma to Weight Gain, from Colds to High Cholesterol--the Most Powerful All-Natural Cures. Emmaus, PA: Rodale Press, 1999.
• Trickey, Ruth. Women, Hormones & The Menstrual Cycle: Herbal & Medical Solutions From Adolescence to Menopause. St. Leonards, Australia: Allen & Unwin, 1998.

Periodicals

• Aesoph, Lauri M. "Nature's Rx for Endometriosis." Let's Live. 67 (June 1999): 70+.
• Drexler, Madeline. "What Can You Do About Endometriosis?" Self 17 (January 1995):122+.

Organizations

• Endometriosis Association International Headquarters. 8585 North 76th Place, Milwaukee, WI 53223. (800) 992-3636. http://EndometriosisAssn.org.

Gale Encyclopedia of Alternative Medicine. Gale Group, 2001.