Endometriosis

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Original Editors - Rebecca Clark from Bellarmine University's Pathophysiology of Complex Patient Problems project.

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Definition/Description

Endometriosis is a female reproductive disorder which affects the lining of the uterus, otherwise known as the endometrium.  This estrogen-dependent disorder is defined by the presence of endometrial tissue outside of the uterus and becomes apparent after the start of menses.

In a typical monthly menstrual cycle, endometrial cells lining the uterine walls are stimulated through a release of horomones and multiply in order to provide an ideal environment for egg fertiliztion.  If fertilization of the egg does not occur, the uterus sloughs off the lining of blood (endometrial tissue) and menstrual flow occurs for 3 to 5 days.

When affected by endometriosis, endometrial tissue is misplaced outside the uterus in various places. Despite the location of the tissue, the same monthly menstrual cycle occurs.  The misplaced tissue engorges with blood, as it would in the uterine lining. Since this blood has no course to drain out of the vagina it remains where it is resulting in "chocolate cysts" wherever endometrial cells are located.  In addition to cysts, trapped blood may lead to scar tissue, adhesions and irritation of the surrounding tissue which causing pelvic pain and fertility problems. 

Blood deposits or ectopic implantation may occur anywhere in the body but most commonly affects the  ovaries, fallopian tubes, broad ligaments, bladder, pelvic musculature, perineum, vulva, vagina, or intestines.  It has been discovered that endometrial tissue has the ablility to migrate through the body, and in less common cases has been found in the abdominal cavity, kidneys, small bowel, appendix, diaphragm, pleura, bone and even the brain.

Prevalence

The incidence of Endometriosis has been on the rise in Western countries for the last 40 to 50 years.  Although there are statistics in the literature, the true prevelence of endometriosis is unknown because many women remain asymptomatic.  It has been reported that endometriosis occurs in a wide range of 7%- 60% of all women.  Further Reports in 2008 revealed that endometriosis occurs in 7%-10% of women in the general population, 2%-50% of women suffering from infertility, and 71%-87% of women with chronic menstrual pain.  Unlike many common disorders, there have been no correlations between endometriosis and specific populations.  Endometriosis has been shown to affect women of all race, cultures, ethinic origins, socioeconomic status, and geographic backgrounds. 

Characteristics/Clinical Presentation

Generally, endometriosis becomes apparent soon after menses begins in early teen years, and symptoms continue until menopause.  Although any woman of child bearing age is at risk of developing Endometriosis, it is more common in those who have postponed pregnancy.

Endometriosis has been shown to vary in its degree of severity. In order to gage level of severity, the American Society of Reproductive Medicine has developed five stages of classification: I (minimal), II (mild), III (moderate), IV (severe), V (extensive).  Despite these classifications, symptoms do not always correlate with disease severity.  Many women with severe endometriosis have little pain or remain asymptomatic, while some with minimal or mild classification may experience intense symptoms affecting quality of life.  It is likely that if gone untreated, sypmtoms will progress and worsen over time.

Common Sign and Symptoms

• Abdominal pain, fatigue and mood change beginning 1-2 days before menstration and continuing for duration
• Constant/intermittent, or cyclical pelvic and/or low back pain (unilateral or bilateral)
• Infertility - often first diagnosed in women who are seeking treatment for infertility
• History of ectopic pregnancy or miscarriage
• Dysmenorrhea (painful menstration) - commonly identified as the chief complaint if implants are located over the uterosacral ligaments
• Dyspareunia (painful intercourse) - local adhesions may be irritated by penile penetration
• Painful defication - adhesions may be present over the large bowel. As fecal matter moves through the intestines these adhesions can be stretched causing local irritation. 
• Low-grade fever
• diarrhea, constipation, rectal bleeding
• referred pain to the low back/sacral groin, posterior leg, upper abdomen, or lower abdominal.suprapubic areas
• menorrhagia/menometrorrhagia - excessive or occasional heavy periods may be experienced, along with bleeding between periods 

Less Common Signs and Symptoms

• Chest pain/hemoptysis - due to endometrial implants in the lungs
• Headache/seizures - due to endometrial implants in the brain

Associated Co-morbidities

• It is not yet clear exactly what factors, if any, increase the risk of endometriosis. 
• Several other health problems have been shown to exist in combination with endometriosis. 
• A large percentage of women experience co-morbidities such as:

            -fibromyalgia

           -hypothyroidism

           -chronic fatigue syndrome

           -allergies

           -asthma

           -rheumatioid arthritis

           -multiple sclerosis

           -systemic lupus erythematosus

           -auto-immune disorders

Medications

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Diagnostic Tests/Lab Tests/Lab Values

The following are common tests used to identify physical clues leading to the diagnosis of endometriosis: 

• Laparoscopy: Accurate diagnosis of endometriosis requires direct visualization of endometrial tissue through laproscopic proceedures.  This is accomplished by distending the abdomen through injection of carbon dioxide for adequate visualization of the reproductive organs.  A instrument with a camera (laproscope) is inserted through a tiny incision near the navel in order to determine if reproductive and abdominal organs possess endometrial implants.  Laproscopy is a valuable tool guiding the course of treatment for endometriosis by identifiying the severity, size and location of foreign implants.     
• Pelvic Exam: Manual palpation of the pelvic region to identify abnormalities such as cysts or scar tissue surrounding reproductive organs. Although this exam may reproduce pain in large areas of implantation, it is often not possible to feel small areas, making this test less reliable at identifying the presence of endometriosis.
• Ultrasound: Ultrasounds work by using sound waves from a transducer wand to create a video image of organs. Vaginal ultrasounds are performed by inserting a wand into the vagina to view images of the reproductive organs, while abdominal ultrasounds are done by moving a wand over the abdomino-pelvic region. Ultrasound is done in order to identify the presence of cysts associated with endometriosis, but it is important to note that this is not a definative test used to diagnose endometriosis.
• MRI: An MRI is used to view endometrial implants but proves to be more sensative in comparison to the use of ultrasound. 
• Blood Labs: Cancer antigen 125 (CA 125) is a blood test that has been used to detect common proteins found in those with endometriosis.  This is the same test that is used to tumor markers for various types of cancer.  Although this blood test may identify proteins in advanced cases of endometriosis, it is not sensitive to the detection of mild or moderates disease.  Due to the fact that this test is not senstive to early disease detection, it is not recommended as a screening test for endometriosis. 

Causes

The exact cause of endometriosis is unknown, yet several theories have been developed that explain the existance of displaced endometrial tissue. 

The most common theory suggests that mentrual blood containing endometrial cells flows into the pelvic cavity through the fallopian tubes through a process known as retrograde menstruation.  This form of endometrial migration has been shown to occur in 90% of women affected by endometriosis.

Systemic Involvement

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Medical Management (current best evidence)

Endometriosis is a non-curable disease. The objectives of medical treatment focus on resoring normal pelvic anatomy, removal of endometriotic implants, and prevention of reoccurance to decrease pain and increase fertility.  In order to achieve these goals, the course of medical management depends heavily on the severity of symptoms, severity of disease, age and future child bearing plans.  Generally, conservative treatment is recommended to control symptoms prior to surgical management.

Treatment options include:

• Medications to control pain - (refer to medication section)
• Horomone Therapy - (refer to medication section)
• Surgical management - less common approach due to unchanged etiology and rapid implant regrowth. 
• Non-traditional management - (refer to alternate/holistic management)

The main aspect of medical management is aimed at reducing or blocking ovarian function due to the fact that endometriosis is related to horomone funtion.  Common medical treatments and their functions are listed in the medication section.  In the instance that symptoms are severe and disabling, or conservative medical treatment fails, surgical proceedures can be useful in removing/destroying implants and decreasing or ceasing symptoms.  It is important to note that implant regrowth may occur following removal and may only be a temoporary source of symptom relief.

Surgical Management:

• Pelvic Laproscopy/Laparotomy - proceedure done to identify implants and diagnose endometriosis.
• Laproscopic Cauderization - implants are destroyed using a cauderization probe.  Indicated if endometriosis is mild with minimal adhesions. 
• Laparotomy - removal of endometrial implants or scar tissue. Removal has been correlated with success of conception and is indicated for those trying to become pregnant. 
• Laproscopic unterine nerve ablation (LUNA) - indicated for patients experiencing intractable pelvic pain.  This proceedure works by interrupting pain-conducting neural pathways by destroying the efferent uterine senstory fibers in the uterosacral ligament as well as their secondary ganglia exiting the uterus.  Uterine prolapse and ureter injury are seconday risk factors that may occur following this proceedure.
• Total hystorectormy - removal of the uterus, both ovaries and fallopian tubes.  Indicated for women 35 to 40 years of age who are diabled by pain, and do not wish to continue childbearing.  Symptoms return in 1 out of 3 women who undergo partial hystorectomy's.  Total hystorectomy has been shown to be the best surgical proceedure in the hopes of curing endometriosis.   

Physical Therapy Management (current best evidence)

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Alternative/Holistic Management (current best evidence)

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Differential Diagnosis

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Case Reports

Differential Diagnosis of Endometriosis

in a Young Adult Woman with Nonspecific

Low Back Pain.

Mark R Troyer

proquest.umi.com.libproxy.bellarmine.edu/pqdweb

Resources

• Endometriosis Zone : Sponsored by the Universe of Women's Health and directed by a board of obstetricians and gynecologists. This organization provides information for the use of professionals, the medical industry, and women. 

    endozone.org

    www.endometriosiszone.org

• The International Endometriosis Association (IEA) : Established by Mary Lou Ballweg, RN, PhD. The IEA functions as a online support and advocacy outlet for women diagnosed with endometriosis.

    www.endometriosisassn.org

• The National Library of Medicine : Interactive tutorial about endometriosis offered in spanish and english.

    www.nlm.nih.gov/medlineplus/tutorials/endometriosis

• Endometriosis Research Center : A lobbying organization working to support those with endometriosis through education.

    www.endocenter.org or call (800) 239-7280

Recent Related Research (from Pubmed)

see tutorial on Adding PubMed Feed

References

see adding references tutorial.