Women's Health - Endometriosis

By James Brann, M.D.

       
Learn about endometriosis treatment and stages.

Endometriosis

Endometriosis is a condition that affects 10-15 percent of women during their reproductive years. More than 90 million women globally will suffer from the condition during their lifetime. Endometriosis is a complicated disease to diagnosis, because it can only be confirmed via a surgical procedure referred to as laparoscopy.

Women with endometriosis may experience a wide range of symptoms including pain and menstrual discomfort, and even infertility. The symptoms of endometriosis often intensify with time becoming a problem for your health.



What is Endometriosis?
With endometriosis, tissue like that found in the uterus called the endometrium is found in other areas in the body. It looks and acts like the tissue in the uterus. Symptoms of endometriosis result when the endometrial tissue outside of the uterus bleeds. This is why most women who experience pain will feel it at or around the time of their normal menstrual cycle. For some women however endometriosis results in constant or severe pain.

The Stage or Severity of Endometriosis
Surgery via the laproscope is the only way to determine the severity or stage of endometriosis . Doctors commonly place the severity of endometriosis into different stages. Here are the common stages of endometriosis:

  • Stage 1: Endometriosis in stage one is classified as minimal. Most patients will get a score of 1 to 5 points, meaning there are isolated incidents of endometrial tissue growth outside the uterus.

  • Stage 2: Endometriosis in stage two is considered mild. A patient having a score of 6 to 15 points has mild endometriosis. A doctor makes this diagnosis when there are several small implants and a few small areas of scar tissue or adhesions.

  • Stage 3: Stage the endometriosis is moderate. Patients with 16 to 40 points have moderate endometriosis. The implants in stage three must be superficial and deep. There must also be several prominent areas of scar tissue or adhesions. Typically the symptoms of endometriosis are common in patients with moderate Stage III endometriosis.

  • Stage 4: This is the most severe stage of endometriosis, with over 40 points needed for diagnosis. Patients with stage IV endometriosis will have many superficial and deep implants as well as large adhesions. Endometriosis symptoms including infertility are common in patients with stage IV endometriosis.

Some women with endometriosis will have no symptoms at all. The symptoms of endometriosis experienced by women do not necessarily correlate with the severity of the disease or the stage of endometriosis. Some women with stage 1 endometriosis will experience severe symptoms, while women with stage 4 endometriosis may not have any symptoms at all. Pelvic pain however is most common in women with severe endometriosis.

If you suspect that you are experiencing any of the symptoms of endometriosis it is important that you consult with your healthcare provider. Your doctor can provide you with several different treatment alternatives for relieving the pain and discomfort of endometriosis.

Symptoms of Endometriosis
For many women with endometriosis severe pelvic pain is the main symptom experienced during their reproductive years. The pelvic pain typically starts to intensify before menses and increases in severity with menses. The pain characteristically decreases with completion of menstrual flow. Some women with endometriosis will experience little or no pain, whereas for others the pain is severe and constant.

Other symptoms of endometriosis include pain during bowel movements, premenstrual spotting, frequent or heavy periods and pain during intercourse. The pain associated with menstrual flow is characterized by mild to severe discomfort (often cramps) in the lower abdomen that becomes worse over time. Some women experience constant pelvic soreness or pain in the lower back that radiates down each leg that is aggravated during menses or intercourse.

Other symptoms of endometriosis include:

  • Spotting before your menstrual cycle.
  • Irregular cycles.
  • Heavy periods.
  • Pain that over-the-counter remedies do not relieve during the menstrual cycle.
  • Swelling and bloating in the lower abdomen.
  • Blood in the stool during ones period.
  • Infertility or difficulty becoming pregnant.
  • Pain with bowel movements.
  • Frequent and irregular menstrual cycles.

Treatment of Endometriosis

Treatment for endometriosis depends on the extent or stage of the disease, the amount of pain you have, and whether you want to have children. It can be treated with medication, surgery, or both. Although the treatments may relieve pain and infertility for a time, symptoms may return after treatment.

Treating endometriosis often entails a multifaceted approach. Doctors look at several health issues when treating women with endometriosis. There is no treatment method that is the most effective for treating this condition. Rather, treatment will depend on the severity of the condition and its effects on the women it has affected.

There are a variety of treatment options for endometriosis which include:

  • Expectant management

  • Pain relief with nonsteroidal antinflammatory drugs

  • Birth control pills

  • Medical therapy with progestin, danazol, or gonadotropin-releasing hormone analogs
  • Surgical therapy either conservative (retains uterus and ovarian tissue) or definitive (removal of the uterus and ovaries)

  • Combination therapy in which medical therapy is used before and/or after surgery

Below we will discuss some of the more common treatment choices available for women with endometriosis.

Expectant Management of Endometriosis
Expectant management Management is considered for two special groups of women with endometriosis. Some women with endometriosis will not have symptoms, thus no treatment is an alternative for them. These women may opt for birth control pills because they can prevent endometriosis from progressing and protect against unwanted pregnancy. Women approaching the menopause may also be managed expectantly, because the growth of endometriosis is suppressed after the menopause.



Medical Therapies
Medical Therapies for women with endometriosis that have minimal pelvic pain include nonsteroidal anti-inflammatory drugs (NSAIDS), analgesics, and oral contraceptives. Medical therapy alone is not appropriate for women with more advanced stages of endometriosis or for women desiring pregnancy. Medical therapy, unlike surgery, does not enhance your chances of conception.

The three medications most commonly used to treat endometriosis are progestins, danazol, and gonadotropin-releasing hormone (GnRH) agonist analogs . These drugs inhibit the secretion of estrogen from the ovaries which will inhibit the progression of endometriosis. Let's look at each of these more comprehensively:

GnRH analogs: GnRH analogs are effective as other medical therapies in relieving pain associated with endometriosis, but, similar to other drug treatments, they do not help fix or heighten fertility. Medical therapy is used only to relieve the pain associated with endometriosis after a definitive diagnosis of endometriosis is made at the time of surgery.

GnRH analogs are administered by nasal spray and monthly subcutaneous or intramuscular injections. The usual dose is 400 to 800 mcg daily for nasal nafarelin, 3.6 mg for monthly subcutaneous goserelin, and 3.75 mg for monthly intramuscular leuprolide.

How do these drugs work? They prevent the pituitary from secreting gonadotropin. This prevents the ovary from producing estrogen. Decreased estrogen production can lead to side effects similar to menopause, including vaginal dryness, hot flashes, reduced libido and insomnia. Some women may also experience a loss of bone density and body calcium, another symptom common in women with estrogen shortages.

Typically patients treated with GnRH analogs will experience a relief in symptoms for up to five years, after which between 37 to 74 percent of patients experience a resurgence of symptoms.

Fortunately there are methods for reducing the side effects of GnRH therapy, including adjusting the treatment protocols. Doctors can reduce bone mineral loss for example by lowering the dose of GnRH used and adding back other hormones such as estrogens and progestins. This is called add-back therapy.

Oral Contraceptive Hormones: Oral contraceptive hormones or birth control pills (OCH & BCPs) are often used either cyclically or continuously to reduce the growth of endometrial tissue in the body. Most patients with mild pain realize symptomatic relief when using birth control pills. Use of oral contraceptives may also inhibit endometriosis from growing.

GnRH agonists as well as danazol are often more effective than BCPs to treat moderate and severe forms of endometriosis, however oral contraceptives are helpful for women with mild symptoms. They produce few known side effects.

Progestins: Treatment of endometriosis with progestins typically helps significantly improve the symptoms of endometriosis. More than 80 percent of women with endometriosis symptoms feel better with progestin treatment. Progestin prevents endometrial tissue from growing and causes the endometriosis to waste away. Progestins may also reduce the pituitary's ability to secrete gonadotropin.

Treatment consisting of oral medroxyprogesterone acetate (10 mg three times a day) or norethindrone acetate (5 mg daily) is initiated and generally continued for six months. Depot medroxyprogesterone acetate can also be given as an injection (100 to 150 mg monthly).

The most common side effect associated with progestin treatment includes nausea, fluid retention, depression and irregular bleeding.

Danazol: this is a derivative of a substance called 19-nortestosterone. Danazol is progestin like in its effects. It inhibits the pituitary from secreting gonadotropin, inhibits the growth of endometrial implants and may inhibit enzymes in the ovary that result in estrogen production. Most patients continue treatment for 6 months, and may take up to 600 mg of danazol every day.

The side effects of danazol are mainly dose dependent. They may include cramps, weight gain, acne, oily skin, hot flashes, depression and hirsuitism.

Recommendations for Medical or Drug Therapy
At this time research has not clearly proved the benefits of certain medical therapies to treat endometriosis over others.

Up to 90 percent of patients will realize an improvement in symptoms when they use medication to treat their symptoms. Use of medication to treat endometriosis depends largely on the goal of patients. Many medications come with side effects, which are unwelcome by some women. However others find drug therapy side effects less troublesome than the pain of endometriosis.

Surgical Treatment
Patients with severe forms of endometriosis are candidates for surgery. Typically surgery becomes a choice after medical management and drug therapy has failed to reduce patient symptoms. When anatomic distortions because of endometrial growths are present, surgery is also the primary choice for treatment.

There are two types of surgery associated with endometriosis:

  • Conservative: this surgery saves as much ovarian tissue as possible and the uterus.
  • Definitive: this surgery results in a partial or complete hysterectomy.

Let's talk more about each of these choices.

Conservative Surgical Treatment of Endometriosis
Laparoscopy is the most common conservative surgical approach for treating endometriosis. Laparoscopy can usually remove endometrial implants and adhesions and prevent further progression of the disease sometimes.

Surgery comes with risks including accidental damage to surrounding organs and infection. Trauma to the pelvis may also result in more adhesions.

The goal of conservative surgery is restoration of the normal anatomy of the pelvis. There are advantages of laparoscopy over laparotomy. The primary advantages include shorter recovery times and hospitalization. However, some patients may need more involved laparotomy when severe and invasive endometrial tissue is found near structures including uterine arteries, the bladder and bowel.

Most patients who undergo conservative surgery realize a relief of pain symptoms associated with endometriosis. The recurrence rate however is high, as much as 40 percent 10 years post surgery.

Definitive Surgery
Patients may need more invasive surgery when they experience severe forms of endometriosis and when patients do not want to get pregnant. Women over the age of 30 who undergo definitive surgery are less likely to report residual or recurring symptoms.

Sometimes doctors don't remove the ovaries so estrogen replacement therapy is not necessary. However a doctor must remove the ovaries when both ovaries are severely affected by endometriosis. Following surgery women are treated with estrogen or a combination of estrogen and progestins, which help prevent menopausal symptoms.

Recurrence in patients with definitive surgery is much smaller than in patients with conservative therapy.

Combination Drug and Surgical Treatment for Endometriosis
Some patients may opt for combination therapy. Sometimes hormones are given before surgery to help reduce the size of implants and thus allow more conservative surgery to progress.

In other cases use of drug therapy is indicated after surgery to help prevent endometrial recurrences or residual disease. The most common drugs used to prevent endometrial recurrences in patients with surgery include GnRH agonists, progestins and danazol.

Infertility Treatment
Endometriosis commonly causes reduced fertility, however many women with endometriosis can still conceive with adequate treatment of endometriosis.

Fertility may decrease because of pelvic adhesions or production of substances that negatively impact ovarian function, fertilization or the process of implantation.

Most women realize a relief of symptoms if they become pregnant. Treating infertility in patients with endometriosis usually entails combination of therapies including surgery, expectant management and assisted reproductive technologies.

Drug treatment is not helpful for women who are trying to conceive usually.

The most common treatment choices for infertility in patients with endometriosis include:

  • Surgical Therapy
  • Hormonal Suprression
  • Assisted Reproduction

Typically a combination of these therapies results in successful pregnancy. IVF is a good option for women with severe forms of endometriosis.

Pelvic Mass Treatment
Large pelvic masses or endometriomas often do not respond well to drug therapy. Thus excision or ablation of endometriomas or pelvic masses is the preferred treatment choice.

Deep Endometriosis
This term describes severe and invasive forms of endometriosis that involves areas outside the reproductive system including the uterosacral ligaments, bowel and bladder.

If a patient presents with no symptoms, deep endometriosis is treated with expectant management. Drug therapy typically results in little relief of symptoms. Most patients will undergo surgical treatment to relive pain and dyspareunia associated with deep endometriosis.

Finally
Endometriosis is a long-term problem for some women. Many women can have symptoms off and on until they have gone through the menopause. Keep in mind with your doctor's help there are many treatment options available. Endometriosis can often be treated with success. If you think you have symptoms of endometriosis, see you doctor for diagnosis and treatment.
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