Endometriosis

Endometriosis is an often painful disorder in which tissue similar to the tissue that normally lines the inside of the uterus (the endometrium) grows outside of the uterus. The endometrial-like tissue acts like endometrial tissue — it grows, breaks down, and bleeds during the menstrual cycle. But because this tissue is not supposed to be there, it can cause pain and inflammation, and ultimately lead to development of scar tissue and adhesions. Adhesions are abnormal bands of fibrous tissue that can cause pelvic tissues and organs to stick to each other.

About 10% of women have endometriosis. Up to 87% of women with chronic pelvic pain may have endometriosis.

There are roughly three categories of endometriosis: superficial peritoneal endometriosis, deep infiltrating endometriosis (DIE), and endometrioma. Although usually found in the pelvis, endometriosis may spread beyond the pelvis, and can be found in places like the diaphragm. 

• Superficial peritoneal endometriosis: endometriosis grows on the peritoneum of the pelvis. The peritoneum is a thin cell layer of tissue (kind of like plastic wrap) that covers the inside of the pelvis, abdomen, and organs.
• Deep infiltrating endometriosis (DIE): endometriosis can also invade into the tissues it is growing on. This is commonly seen in the uterosacral ligaments (the supporting ligaments behind the uterus). DIE can be found in other areas too, such as the intestines.
• Endometrioma: when endometriosis involves the ovaries, cysts called endometriomas may form. Sometimes called “chocolate cysts” (because of how the old, trapped blood in the cysts look), these are very painful and can also impact fertility. 

The primary symptom of endometriosis is pelvic pain, often worse during a menstrual period. Some women with severe symptoms may be unable to work or go to school during a flare.

Common signs and symptoms of endometriosis include:

• Painful periods (dysmenorrhea). Pelvic pain and cramping may begin before a period and last for several days. Cramping pain may be accompanied by lower back and abdominal pain.
• Pain with intercourse. Pain during or after sex is common with endometriosis.
• Pain with bowel movements or urination. 
• Women may experience fatigue, diarrhea or constipation, bloating or nausea

One complication of endometriosis is possible issues with infertility. Approximately one-third to one-half of women with endometriosis may have difficulty getting pregnant.

One thing to keep in mind is that severity of symptoms does not necessarily reflect the extent of disease present inside the abdomen and pelvis. After having surgery, some women will be told what stage of endometriosis they have by their surgeon (Stage I – IV). Women with Stage I endometriosis may have severe symptoms and those with Stage IV may have minimal symptoms. The stages of endometriosis are used by surgeons to quickly communicate the location and characteristic of patient’s endometriosis burden, not how severe their symptoms are.

The only definitive way to diagnosis endometriosis is by having surgery, where a biopsy of suspicious tissue is taken for pathologic evaluation. Endometriosis is then confirmed by histology (under the microscope diagnosis).

Imaging can provide useful information, either to help plan upcoming surgery, or to support a clinical suspicion for endometriosis. Imaging options include MRI or ultrasound.

MRI of the pelvis can identify DIE, endometriomas, and if endometriosis is involving the rectum, bladder, or intestines. Ultrasound can also be helpful in looking at the ovaries and to see if the uterus, bladder, and rectum move normally. It is important to note that neither MRI nor ultrasound are perfect, as they are not very good at identifying superficial peritoneal endometriosis. Even if the results of the imaging are negative, superficial peritoneal endometriosis may still be present.

Endometriosis can be treated medically, surgically, or with a combination of both. 

Medical management is focused on ovarian suppression – using hormones to suppress ovarian function and cycling. For some women, ovarian suppression can significantly improve endometriosis symptoms. Unfortunately, for many women, hormonal management may not lead to significant pain relief.

There are two types of surgical approaches: ablation and excision. When a surgeon performs ablation of endometriosis, they use energy to burn the surface of lesions that appear suspicious. For many reasons, most expert surgeons specializing in endometriosis believe ablation is a substandard treatment approach.

I only perform excision of endometriosis. The goal of excisional surgery is to completely remove disease, to maximize the benefit of surgery. Specifically, I perform a procedure called complete pelvic peritonectomy.