February 7, 2017

What you need to know about Endometriosis

Among the women’s health issues that are being discussed widely are menstrual issues, infertility, uterine fibroids, cervical cancer, uterine cancer, sexually transmitted infections, sexual dysfunction and endometriosis. It is important for general practitioners to be competent in recognizing these health issues in females and refer appropriately to the gynaecologists for specialized interventions.

What is Endometriosis?

Endometriosis, Medical Concept with Pills, Injections and Syringe. Endometriosis - Printed Diagnosis with Blurred Text. 3D Toned Image.

Endometriosis is a condition which occurs when uterine tissue migrates to areas outside of the uterus. Some of these sites which can have uterine tissue are the:

  • Ovaries
  • Cervix
  • Fallopian tubes
  • Bladder
  • Bowels (large intestines)
  • Lungs

The mere presence of uterine tissue on these organs is not the only problem. This tissue swells up and bleeds at the time the female is having her monthly menses. The same hormones which regulate the menstrual cycle also act on the endometrial tissues to cause same bleeding effect. It is still not clearly understood why endometrial tissue grows outside of the uterus. What is known is that high estrogen levels worsen the symptoms and this explains why this gynecological problem is seen in the adolescent years up to women in their forties.

When an adolescent or woman has been diagnosed with endometriosis, she need to know as much as she can about this gynecology condition and how to monitor and self-manage the symptoms.  It is still not clearly understood why endometrial tissue grows outside of the uterus. What is known is that high estrogen levels worsen the symptoms and this explains why this gynecological problem is seen in the adolescent years up to women in their 40s. Symptoms improve and may even abate in the menopausal period of a woman’s life. Endometriosis is a chronic, painful condition that has no cure. Alleviation of symptoms is offered by GPs and gynaecologists. Women who have been diagnosed with this disease are being instructed how to monitor and self-manage the symptoms.

Endometriosis Signs and Symptoms

The symptoms of endometriosis vary from one patient to the next. This is as a result of the important link between where the abnormal endometrial tissue is growing and the symptoms that are experienced by the patient. Take for example the patient who coughs up blood during her menses, this raises the index of suspicion that her lungs may have endometrial tissue. Another example is passing blood in the stool during the menstrual bleeding, this implicates endometriosis involving the bowels.

Frequently experienced symptoms include:

  • Pelvic pain which is lower abdominal pain occurs when the endometrial tissue is on the outside of the uterus or on the ovary. Any site in the pelvic cavity can host the endothelial tissue.
  • Lower backaches, rectal and vaginal pain, indicate the probable site of the abnormal tissue.
  • Painful periods also known as dysmenorrhea. Worsening of the symptom indicate there needs to be a clinical and diagnostic review
  • Menorrhagia is the medical term used to describe heavy periods which can lead to severe anemia.
  • Painful sex. This may be an indication that the endometriosis is in the wall of the vagina or on the cervix (neck of the womb).
  • Post-coital bleeding (when bleeding occurs after sexual intercourse).
  • During the monthly menses (period there can also be blood in stool, nose bleed and vomiting blood. These are important signs of the extra-uterus endometriosis
  • Infertility is the result of scar tissues on the uterus, ovaries or fallopian tubes. It is possible to get pregnant after laparoscopic surgery to remove scarred tissue.

It is useful to make notes on where and when the symptoms occur. Also, note improvement, worsening or no real change when given medication or when a procedure has been performed. There are also women who have no symptoms at all and the endometriosis is an incidental finding during infertility procedures.

Risk Factors

Adolescents with a strong family history of endometriosis are at risk of developing this condition. Another risk factor for developing endometriosis is taking high doses of estrogen and other menstrual cycle hormones.

Diagnosis

Young woman having stomach ache

History taking: The doctor takes a detailed history to ascertain how long you have been having the symptoms. It is also important to establish whether there is any association with the menstrual cycle. Pain and bleeding are most noted during the menses.

Family history illness: Establishing a family history of endometriosis is an important clue to be noted.

Drug history: It has been established that drugs containing estrogen can worsen the symptoms. The doctor should be advised if you are taking and oral, injectable or implanted contraceptives.

General Physical Examination: Some important physical signs not to be missed are pallor, weakness, painful distress and lower abdominal tenderness.

Pelvic Examination: specific pelvic organ tenderness found by passing a speculum and during the digital exploration.

Diagnostic Investigations: There are other gynecological illnesses that cause chronic pelvic pain and so it is important to give as much information to the gynecologist. The other conditions are: uterine fibroids, pelvic inflammatory disease, adhesions and pelvic congestion. A physical exam and diagnostic tests (transvaginal ultrasound, CAT scan and a MRI) help to narrow the diagnosis of the pelvic pain. A laparoscopic exam is the confirmatory exam.

Treatment Options

The option that may be recommended for you depends in part on how mild or severe your symptoms are, your age and whether you wish to get pregnant.

Conservative Treatments include:

  • Acupuncture and acupressure are helpful pain management treatment modalities.
  • Heat pads put on the site of the pain helps to relieve the pain.
  • Exercise done regularly helps to improve the pelvic symptoms.
  • Home remedies which include over the counter OTC pain relievers, vitamins and herbal supplements may help to relief pain.

Medical Treatment

  • Analgesics for the pain include NSAID (ibuprofen, Motrin, Advil, Aleve/naproxen).
  • Hormonal therapy which include birth control pills and other preparations of hormones. When estrogen and the other menstrual cycle hormones are kept in balance the symptoms often resolve. An oral contraceptive Ethinyl estradiol norethindrone acetate and other similar hormonal preparations prevent ovulation. This is effective for patients with mild endometriosis. Synthetic progesterone includes provera which is an oral preparation and Depo-Provera which is an injectable presentation.
  • Other drugs are testosterone derivatives and GnRH Agonists
  • Infertility Treatment

Surgical Procedures

Woman with abdominal pain. Pain in the human body isolated on white

Gynecologists offer what is called laparoscopic or keyhole surgery. The procedure allows the surgeon to remove the abnormal tissue some of which is sent for biopsy examination. A hysterectomy is done in the case of severe endometriosis which has damaged the uterus and ovaries. If you have a desire to get pregnant, you should definitely explore the option for laparoscopic surgery to minimize the scar tissues. After laparoscopic surgery, it is possible that the endometrial tissue can regrow in the same area.

Healthy Lifestyle tips for managing your symptoms

  • Avoid medication with estrogen since estrogen has been proven to worsen the symptoms of endometriosis.
  • Exercise 5 times weekly for at least 20 minutes
    • Walking
    • Jogging
    • Swimming
    • Dancing
    • Water exercise/aerobics
  • Eating a healthy diet rich in omega 3 fatty acids (fatty fish such as salmon, tuna and sardines. Many seed and nuts have a good source of Omega fatty acids. Daily portions of  fresh fruits and vegetables are essential for the vitamins and fiber. The Diet for fertility is the whole food diet (organic). This diet promotes the health of the womb, increases ovulation and decreases the incidence of miscarriages. Suggestions of healthy food s include:
  • Whole food
    • Whole grain: quinoa, brown rice
    • Sprouted grain
  • Vegetables: Kale, Turnip, Collard, Mustard green, Kelp
  • Chinese herbs:
    • Wakame seaweed
  • Lean protein (organic)
  • Omega fatty acid: Cod liver oil, Salmon, Tuna, Mackerel
  • Multi-vitamins, minerals and micronutrients especially;
    • Vitamin D
    • Folic acid
    • Calcium
  • Limit processed foods and foods with added sugar
  • Drink 6-8 glasses of water daily to keep yourself well hydrated.

Find a support group for emotional support. Consider therapy if you are feeling overwhelmed and anxious about your illness. Take control of your health and wellbeing as there are options to pursue to improve the quality of your life.

Complications

sitting - in the toilet

Among the complications of endometriosis are the following:

  • Menorrhagia
  • Chronic pain in the extra-uterine sites
  • Anemia
  • Severe pelvic pain
  • Infertility

Luckily there are treatments for these complications. Treatment is aimed at improving the quality of life of the patients.

Prognosis

The prognosis is ‘guarded’ as not every patient will resolve even with our best efforts to treat the endometriosis. Medical and surgical procedures have vastly improved to give hope to women with endometriosis. In older women, the symptoms lessen in severity as she approaches menopause. Patients who have had laparoscopic surgery to remove endometrial tissue should.be counselled that the endometrial tissue can regrow at the same spot. Lifestyle adjustments is useful for all patients who have been diagnosed or at risk of endometriosis.

An important note to patients: How to Monitor the Progression of the Symptoms

Endometriosis. Treatment and prevention of disease. Syringe and vaccine. Medical concept. Selective focus

The common symptoms are indicative of where the abnormal endometrial tissue is growing and may even be spreading:

  • Keep a journal to note any change in the symptoms. It is important to note improvement, worsening or no real change.
  • You should pay close attention to any new gynecology symptom which may appear.
  • Another importance of monitoring your symptom carefully is that your observations can allow the doctor to make a differential diagnosis
  • There are several Treatment Options and only you can determine what works and what has not given the desired results.

The option that may be recommended for you depends in part on how mild or severe your symptoms are, your age and whether you wish to get pregnant.

Conservative Treatment may be helpful

  • Acupuncture and acupressure are helpful pain management treatment modalities.
  • Heat pads put on the site of the pain helps to relieve the pain.
  • Exercise done regularly helps to improve the pelvic symptoms.
  • Home remedies which include over the counter OTC pain relievers, vitamins.
  • Herbal remedies include:
    • Valerian: popularly use to treat pain including menstrual cramps
    • Chamomile: a calming herb which has sedative properties.
    • Cramp Bark: used by Native Americans as a uterine sedative
    • Wild Yam: has anti-inflammatory action. Used in Chinese and Ayurvedic medicine
    • Motherwort; Chinese remedy used to stimulate uterine activity
    • Feverfew: used as a folkloric remedy for regulating menstrual cycle
    • Yarrow: use to relax cramps and curtail bleeding
    • Black Cohosh: a hormone balancer
    • Dang Gui: used in Chinese medicine to tone and regulate the female reproductive system.
    • Red Raspberry: This herb may help to relief heavy menses.
    • Dandelion: helps the liver to metabolize excessive hormones that may promote the growth of endometrial tissue.
    • Burdock: helps the liver to metabolize excessive hormones that may promote the growth of endometrial tissue.
    • Yellow Dock: there has been no conclusive research on this herb but traditionally it is used as a cleansing herb
    • Licorice, Maca, Vitex, Tribulus, White peony: These are herbs which may promote hormonal balance:

Important Note: most of these herbal remedies may relieve symptoms. These should never completely replace conventional medical therapy. Always advise your primary physician when you are taking herbal remedy or when you are considering trying natural remedies. Similarly let your alternative practitioner be aware of underlying medical conditions.

Endometriosis

Do not be bashful to give your physical feedback on his/her course of Medical Treatment. Have you gotten any relief with the following?

  • Analgesics for the pain include NSAID (ibuprofen, Motrin, Advil, Aleve/naproxen).
  • Hormonal therapy which include birth control pills and other preparations of hormones
  • Infertility Treatment

Note: After laparoscopic surgery continue to make notes on the post-op recovery and monitor for improvement of the symptoms

Gynecologists offer what is called laparoscopic also called keyhole surgery. This surgery is considered when there is no improvement with hormone therapy and analgesics. The procedure entails inserting a thin tube with a light through a tiny incision. The procedure allows the surgeon to remove the abnormal tissue some of which is sent for biopsy examination. The laparoscopic procedure has the benefits of being less stressful for the patient and the surgeon, shortens the post-op period and has less complication. The traditional open abdominal surgery is still an appropriate option. A hysterectomy is done in the case of severe endometriosis which has damaged the uterus and ovaries.

If you have a desire to get pregnant, you should definitely explore the option for laparoscopic surgery to minimize the scar tissues.

  • Join a support group for emotional support
  • Consult with a therapist if you are feeling overwhelmed and anxious about your illness

Monitoring your endometriosis symptoms is empowering as it allows you to be in control of your treatment. The self-help recommendations allow you to determine which dietary suggestion, exercise and adjunct therapies work best for you.

Research on Endometriosis

Study 1

Bottom of Form

Laparoscopic endometriosis treatment: is it better?

GD Adamson, SJ Hurd, DJ Pasta, BD Rodriguez – Fertility and sterility, 1993 – Elsevier

Objective To assess the hypothesis that pregnancy rates (PRs) after operative laparoscopy
(Laparoscopy Group) for endometriosis treatment would be equal to or greater than the diagnostic laparoscopy only (No Treatment Group), diagnostic laparoscopy with medical

Study 2Fewer

Endometriosis: treatment strategies

RF VALLE, JJ SCIARRA – Annals of the New York Academy of …, 2003 – Wiley Online Library

Abstract: Endometriosis is often a perplexing medical condition for both the physician and the patient. Accordingly, development of treatment strategies based on the needs of the individual patient is highly desirable.

Study 3

Use of GnRH antagonists in the treatment of endometriosis

W Küpker, RE Felberbaum, M Krapp, T Schill… – Reproductive …, 2002 – Elsevier

Endometriosis is an oestrogen-dependent disease that is treatable by oestrogen withdrawal, a therapy that has been effectively provided by the use of a gonadotrophin-releasing hormone (GnRH) agonist.

Saving…Study 4 Fewer

Conservative treatment of endometriosis: the effects of limited surgery and hormonal pseudopregnancy

CB Hammond, JA Rock, RT Parker – Fertility and sterility, 1976 – Elsevier

This study compares the effects of limited surgery or hormonal pseudopregnancy, or a combination of these two, upon fertility and the need for subsequent surgery with respect to the extent of the disease at the time of initial diagnosis in patients with endometriosis

Study 5Fewer

Endometriosis: treatment with hormonal pseudopregnancy and/or operation

WC Andrews, GD Larsen – American journal of obstetrics and gynecology, 1974 – Elsevier

In the years 1957 to 1971, 301 patients with endometriosis were treated at the Norfolk
General Hospital by operation alone. During the same period, 53 patients in our series were treated by hormonal pseudopregnancy with or without operation. Of these 53 patients, 47

Study  6

Endometriosis: treatment with gonadotropin-releasing hormone agonist buserelin

AMHW Franssen, FM Kauer, DR Chadha, JA Zijlstra… – Fertility and sterility, 1989 – Elsevier

Fifty-one women with pelvic endometriosis were treated with the gonadotropin-releasing hormone agonist (GnRHa) Buserelin (Hoechst Holland NV, Amsterdam, The Netherlands)
300 μg three times a day intranasally for 6 months. Forty-nine women completed treatment;

Antiprogestin and/or gonadotropin-releasing hormone agonist for endometriosis treatment and bone maintenance: a 1-year primate study.

The fact that RU 486 curtailed estrogen-induced endometrial proliferation in primates and relieved pelvic pain in women with endometriosis is the reason for continuing research on antiprogestins.

Study 7

Conservative treatment of endometriosis externa: the effects of methyltestosterone therapy

MG Hammond, CB Hammond, RT Parker – Fertility and sterility, 1978 – Elsevier

Twenty-four women with documented endometriosis externa were treated with methyltestosterone. Twenty-one of these patients desired fertility and three conceived (one
after methyltestosterone therapy alone, two after conservative operation)

Study 8Fewer

The cost of inpatient endometriosis treatment: an analysis based on the Healthcare Cost and Utilization Project Nationwide Inpatient Sample.

SZ Zhao, JM Wong, MB Davis, GE Gersh… – The American journal …, 1998 – europepmc.org

OBJECTIVE: To determine the prevalence and cost of endometriosis-related hospitalizations based on the Nationwide Inpatient Sample (NIS) from the Healthcare Cost and Utilization Project (HCUP-3).

Study 9

Pulmonary endometriosis: treatment with danazol.

WM Johnson 3rd, CM Tyndal – Obstetrics and gynecology, 1987 – europepmc.org

Abstract Pulmonary endometriosis is a rare clinical problem. There is limited information available regarding management of this disorder. Four cases of successful treatment with danazol have been reported. This is a report of a woman with catamenial hemoptysis.

Study 10

Recent advances in endometriosis with emphasis on pathogenesis, molecular pathology, and neoplastic transformation.

M Wells – International journal of gynecological pathology, 2004 – journals.lww.com

… Skip Navigation Links Home > October 2004 – Volume 23 – Issue 4 > Recent
Advances in Endometriosis With Emphasis on Pathogenes

Study 11

Gonadotropin-releasing hormone analogue (goserelin) plus hormone replacement therapy for the treatment of endometriosis: a randomized controlled trial

R Howell, DK Edmonds, M Dowsett, D Crook, B Lees… – Fertility and sterility, 1995 – Elsevier

This research looks at the effects of Zoladex depot and Zoladex depot plus Kliogest in the treatment of endometriosis. …
Ultrastructural comparison of endometriotic implants and eutopic endometrium. … Steroidal regulation of endometriosis tissue: lack of induction of 17β-hy-droxysteroid dehydrogenase.

Study 12

Interim report of a study of danazol for the treatment of endometriosis

Endometriosis and infertility: a review of sixty-six patients treated with danazol.
Postgrad Med J, 55 (Suppl 5) (1979), p. 21. 6. L. Ronnberg, P. Ylostalo, PA Jarvinen;
Effects of danazol in the treatment of severe endometriosis.

Study 13

The impact of treatment on the natural history of endometriosis

TA Mahmood, A Templeton – Human Reproduction, 1990 – ESHRE

… et al., 1989) have compared danazol with LHRH agonists reporting a comparable reduction in endometriotic deposits and … E., Lantto.T., Ronnberg.L. and Vihko.R. (1981) Estrogen and progestin
receptors in endometriosis lesions: comparison with endometrial tissue.

Study 14

A quantitative overview of controlled trials in endometriosis-associated infertility

EG Hughes, DM Fedorkow, JA Collins – Fertility and sterility, 1993 – Elsevier

To undertake quantitative overviews of the following commonly used treatments for endometriosis-associated infertility: ovulation suppression, laparoscopic … A comparison of ovulation suppression and ovulation stimulation in the treatment of endometriosis-associated infertility.

Study 15

[HTML]Advances in the medical management of endometriosis

N Panay – BJOG: An International Journal of Obstetrics & …, 2008 – Wiley Online Library

Direct action on endometrial deposits, anti-inflammatory agents, Suppression of ovulation/estrogen,
Direct action in endometriotic deposits, Immunomodulation. … whether analgesics, such as nonsteroidal anti-inflammatories (NSAIDs), work in treating endometriosis-associated pain.

Study 16

New advances in the understanding of endometriosis related infertility

NG Mahutte, A Arici – Journal of reproductive immunology, 2002 – Elsevier

… Other investigators have examined molecular markers of endometrial receptivity in women with
endometriosis … These studies clearly show that endometriosis does not affect implantation rates
in oocyte … GnRH-a and/or carefully controlled estrogen levels during the treatment cycle.

Study 17

Dysfunctional uterine bleeding: advances in diagnosis and treatment

MG Munro – Current Opinion in Obstetrics and Gynecology, 2001 – journals.lww.com

Dysfunctional uterine bleeding occurs during the reproductive years unrelated to structural uterine.

Study 18

Conventional medical therapies for endometriosis

VM Rice – Annals of the New York Academy of Sciences, 2002 – Wiley Online Library

The study of an inhibition of endometrial growth within and exterior to the endometrial cavity.
References

Cramps in a stomach. Female holding hand to spot of painful pregnant belly.

  • Endometriosis, WebMD available at http//www.webmd.com/women/endometriosis/medical-reference-index?page=2. Accessed June 11,2014
  • StÖppler Melissa, Endometriosis Symptoms and Surgical Treatment. Available at, htpp//www.medicinenet.com/script/main/mobileart.asp?articlekey=356. Accessed June 11 ,2014
  • Endometriosis, American College of Obstetricians and Gynecologists. Available at,www.acog.org/~/media/For%20Patients/faq013.pdf?dmc=1. Accessed June 11, 2014
  • The Doctor’s Guide to Natural Medicine, D. Paul Barney MD
  • Women’s Health, Women’s Herbs,  Christopher Hobbs L.Ac
  • Herbs for Health, Logan Chamberlain PhD

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