Endometriosis: A Case Study

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Endometriosis is a painful condition caused by the growth of the endometrium — tissue that normally lines the inside of the uterus — in other parts of the body. 

Endometrium can grow in the 

• ovaries 

• outer surface of the uterus 

• fallopian tubes 

• ligaments that support the uterus 

• bladder

 Abnormal endometrial tissue acts just like normal endometrial tissue. With each menstrual cycle, it thickens, breaks down, and bleeds. Unlike the menstrual fluid, which escapes through the vagina, endometrial blood and tissue remain trapped in the abdominal cavity, triggering pain, inflammation, and sometimes adhesions, a type of scarring (which can also result from surgery) The surrounding tissue can become irritated and may even develop scar tissue. 

There are many theories about the causes of Endometriosis. 

A leading one is called retrograde menstrual flow: Endometriosis occurs when the endometrial tissue sheds from the uterus during a menstrual period. But instead of exiting the body through the vagina as the menses, the tissue flows backward through the Fallopian tubes to the pelvic cavity. It’s also possible that the immune system or hormonal problems play a role. Because endometriosis tends to run in families, there may be a genetic component as well. 

Researchers have linked endometriosis, to a higher risk of two types of ovarian cancer – endometrioid and clear-cell subtypes. 

That said, even though the risk of these cancers may be higher than that of the average woman who doesn’t have endometriosis, the chances of developing one of these cancers is still very small – less than 1%. 

Symptoms of endometriosis:

 Most women with endometriosis have no symptoms. The condition is discovered during an operation for an unrelated reason. Most women with endometriosis have no symptoms. The condition is discovered during an operation for an unrelated reason. Pain is the most common symptom of endometriosis. It can appear as: 

• painful periods that may become 

increasingly uncomfortable over 


• persistent (chronic) pain in the 

lower back or pelvis 

• pelvic pain during or after sex 

painful bowel movements or urination during menstrual periods. 

Other symptoms include bleeding between periods and unexplained digestive problems such as diarrhea, constipation, bloating, or upset stomach, especially during menstrual periods. 

Some women with endometriosis get pregnant with no trouble. Yet nearly half of all women who have trouble getting pregnant have endometriosis. 

Endometriosis often gets better after menopause when there is a drop-off in the body’s production of reproductive hormones. But because the body still produces small amounts of estrogen, some women continue to have symptoms even after menopause. 

One way to determine whether your pelvic pain is cyclical and therefore hormonal is to chart it. Keep track of your symptoms on a calendar, and see if there’s a pattern. 

Does the pain begin about the same time every month? Does increased breast tenderness appear at the same time every month in relation to the beginning of the pain? 

Pain associated with the menstrual cycle typically starts 12 to 14 days after ovulation, so another approach would be to find out when you’re ovulating. You can do this by monitoring your basal body temperature (temperature upon waking), which rises about one-half degree right after you ovulate, remains elevated for the next 10 to 14 days, and then drops slightly. 

That’s when you’d normally start to menstruate, and if you have endometriosis, when you’d expect to feel pain. It may take two or three months to “prove” that cycle-related hormone changes are the culprit. Once you have an answer, take your findings to your clinician. (If your pain isn’t cyclical, she or he will want to look into other causes of pelvic pain, such as an ovarian cyst or a bowel problem.) 

Diagnosing endometriosis

 A woman’s symptoms, including the location of her pain and when it occurs, is a key piece of information in diagnosing endometriosis.

 Several tests may be done to check for endometriosis. These include a pelvic exam, an ultrasound exam, laparoscopy. 

Laparoscopy is the best way to diagnose endometriosis. During this procedure, a doctor uses a laparoscope, a slim instrument with a light and a camera, to view the organs in the pelvis. 

Sometimes endometriosis can be recognized simply by how the tissue looks. Other times the doctor must take a sample of tissue and send it to a lab for evaluation. 

Treating endometriosis all treatment options have risks and side effects. The right choice for you will depend on several things, including your age, how bad your symptoms are, and whether you’re planning to become pregnant in the near future. 

There are two basic goals in treating endometriosis: relieving and preventing pain and treating endometriosis-related infertility for women who wish to become pregnant.

 For women with mild symptoms, taking an over-the-counter pain reliever may be all that’s needed. 

Choices include nonsteroidal anti-inflammatory drugs such as ibuprofen and naproxen. Prescription pain medication may also be an option. Another way to stop the pain of endometriosis is by controlling estrogen and other hormones that fuel the growth or activity of endometrial tissue. losing weight, drinking less caffeine and alcohol to choosing a lower-estrogen birth control pill. as well as other hormone delivery methods such as patches, rings, injections, and implants. Gonadotropin-releasing hormone agonists and antagonists, which can help lower estrogen levels and thereby reduce symptoms. 

In addition, aromatase inhibitors, a new category of medicines designed to reduce estrogen levels by targeting the protein that makes estrogen.

Suggestions for coping with the pain of endometriosis include complementary and alternative approaches such as yoga, tai chi, and acupuncture; pelvic floor therapy; cognitive behavioral therapy; and stress management. Surgery to remove areas of endometriosis can provide significant pain relief, but the results may be temporary because each menstrual cycle gives endometriosis an opportunity to come back. 

GnRH agonists (Lupron, Synarel, and others), which stop the production of estrogens, are often used in the form of injections or a nasal spray to treat severe endometriosis pain. Long-term use of these drugs can result in bone loss and menopausal symptoms such as hot flashes; to help counter these effects, clinicians sometimes prescribe small amounts of estrogen or progestin. A final alternative is to have your ovaries removed.

 Ovarian hormones, even in small amounts, could be beneficial through the life span in ways that are currently unknown. There is already evidence that removing the ovaries before age 65 increases the risk of heart disease and hip fractures. Some women get relief with over-the-counter pain medication, such as ibuprofen (Motrin, Advil), aspirin, or acetaminophen (Tylenol). 

If that doesn’t help, your clinician can prescribe a stronger pain reliever, such as an opioid (narcotic) medication. Another option is to suppress your cycles by taking low dose birth control pills continuously — that is, without a placebo week. 

Progesterone-only pills are another possibility, although they can have some bothersome side effects, including bloating, weight gain, and mood changes. Endometriosis requires support from the ovarian hormones, so it is essentially only seen in women of reproductive age. The most common approach to treatment is to alter the hormones. This disrupts the growth of endometriosis. Oral contraceptive pills and other hormone treatments including Lupron, danazol, and progesterone may be used. 

For women with endometriosis-related infertility, surgery to remove areas of endometriosis may improve the chances of becoming pregnant. If this is not successful, assisted reproduction with in vitro fertilization is often the next step. 

Endometriosis may be treated surgically if the above treatment fails. The stray endometrial tissue can be removed or destroyed with a laser or cautery device. If the endometriosis forms a cyst on the ovary (an “endometrioma”) the cyst can be surgically excised. In rare cases when there is no response to conservative measures, a hysterectomy may be performed. Definitive diagnosis requires a surgical procedure (laparoscopy) and there is a wide range of available treatments. Each patient should consider the options and her goals carefully, review them with her doctor, and together they can choose the best approach to the diagnosis and decide on treatment. 

Non-birth control hormone option called GnRH (gonadotropin-releasing hormone), which is designed to lower estrogen levels (higher estrogen is associated with endometriosis). In addition, there’s information on a new category of medication for endometriosis 

aromatase inhibitors. 

For many women, the symptoms related to endometriosis will improve after menopause, when menstruation stops. However, because the ovaries will still produce small amounts of estrogen, this endometrial-like tissue may still respond to the hormone, and you may still experience symptoms. 

Your doctor may recommend treatments such as hormone therapy or surgery to remove the endometriosis implants or scar tissue in hopes of relieving symptoms. In some cases, surgery might also include removing the uterus or ovaries. Unfortunately, these procedures are not always successful in controlling pain. 

Each patient should consider the options and her goals carefully, review them with her doctor, and together they can choose the best approach to the diagnosis and deciding on treatment. 

Source – Harvard Health

Written by Manseerat Bacchal

Article Edited by Ria Bhatia

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