Understanding and managing endometriosis 
by W. Paul Dmowski, MD, PhD

Endometriosis is a disease affecting 5.5 million women in the U.S. and Canada, and is characterized by the growth of the uterine lining (endometrium) outside of the uterus. Uterine endometrium during the first half of the menstrual cycle increases in thickness, and during the second half acquires a spongy-like consistency to facilitate embryo implantation. 

If there is no pregnancy, uterine endometrium sheds along with the menstrual blood during the menstrual period. The same cyclic changes occur also in the endometrium of endometriosis, causing bleeding into the abdomen or into other organs, inflammatory reaction, development of adhesions (scar tissue), or appearance of cysts filled with blood, which over time, acquires a consistency of liquid chocolate (chocolate cysts). These cyclic changes in endometriosis are responsible for symptoms of the disease such as:

• Painful menstrual periods
• Pain during or after urination
• Pelvic pain unrelated to menstruation
• Heavy, prolonged menstrual periods
• Pain during and after sexual intercourse
• Pain during or after bowel movements, and
• Infertility.

The frequency and intensity of these symptoms varies, and there is no direct relationship between symptoms and severity of endometriosis. Some women have advanced endometriosis and few, if any, symptoms. Others have severe symptoms with minimal disease. The intensity of symptoms is most likely related to the local inflammatory reaction and production of substances such as prostaglandins and cytokines by the endometriotic cells and cells of the immune system.

Endometriotic lesions, although benign, may spread like cancer from the reproductive system to other organs and sometimes even to distant locations away from the pelvis. We have seen women with endometriosis of the bladder, bowel, liver, lungs, arms, thighs, and even brain. If endometriosis spreads outside of the pelvis, it can cause generalized symptoms and/or symptoms of pain or bleeding referred to other organs. In general, any symptom or change in the body that undergoes cyclic changes coincidental with the menstrual cycle, should be suspect of being endometriotic in origin.

Misplaced endometrial cells are common 
For more than 30 years, Institute for the Study and Treatment of Endometriosis, which is affiliated with the Oak Brook Fertility Center, has been in the forefront of endometriosis research. Our studies indicate that during the menstrual period, blood and fragments of shed endometrial tissues are transported through fallopian tubes into the abdomen in all women.

In healthy women, these misplaced cells are programmed to die (undergo apoptosis) and are removed by the cells of the immune system (macrophages). In about 10 percent of women, apoptosis and the ability of macrophages to remove misplaced endometrial cells is impaired. The misplaced cells are allowed to survive and implant. Typically they implant on the peritoneal surfaces (lining of the abdomen), in the anterior and posterior cul-de-sacs (anterior is between uterus and urinary bladder, posterior is between uterus and rectum), on the ovaries, and on other abdominal organs. Following implantation, endometrial cells divide, multiply, and form typical endometriotic lesions. Changes in endometrial apoptosis and in the immune system that lead to the development of endometriosis may be transmitted genetically from mother-to-daughter or may be acquired as a result of the environmental effect on the immune system.

Diagnosing Endometriosis 
Endometriosis can be suspected based on characteristic symptoms, physical examination findings, changes on pelvic ultrasound, CT scans, or x-rays. However, other diseases may give similar findings and the only way to diagnose endometriosis is through a surgical procedure — laparoscopy or laparotomy. The diagnosis must be confirmed by microscopic examination of the tissue. Not every lesion having a visual appearance of endometriosis is actually endometriotic and sometimes atypical lesions may be endometriotic in nature. Your laparoscopic surgeon should take a biopsy to confirm his visual diagnosis. He should also be able to assign a score for the size, depth, and location of endometriotic lesions which is the basis for classifying endometriosis as Stage I, II, III, or IV, with Stage I being the minimal and Stage IV the most advanced. Endometriosis is a progressive disease which impairs fertility, tends to come back after treatments, and lasts as long as the ovarian function, that is, until menopause. Therefore, prompt definitive diagnosis and staging are extremely important for the lifelong treatment, recurrence prevention, and family planning.

Laparoscopy is a minor surgical procedure performed under anesthesia on an outpatient basis. An experienced laparoscopic surgeon should be able to resect or destroy endometriotic lesions with electrical current or laser at the time of laparoscopy. Alternative treatments include various types of hormonal medications, the purpose of which is to suppress ovarian function and stop menstrual cycles. Without menstrual bleeding, endometriotic lesions heal and gradually disappear. Large chocolate cysts and adhesions may have to be removed surgically.

Treatment 
The choice of treatment in endometriosis depends on several factors such as:

• Woman’s age
• Severity of symptoms
• Fertility status
• Stage of the disease
• Prior treatments, if any,
• Treatment response and side effects, if any.

These factors, as well as patient-specific indications and contraindications, advantages and disadvantages, and risks and benefits of different treatment options need to be thoroughly discussed and considered prior to treatment selection.

At the Endometriosis Institute, our objective is to help patients select the treatment option that is most appropriate for her case. Our overall goal is to remove or suppress endometriosis, to delay its recurrence, control its progression, and to take care of its symptoms without adversely affecting a woman’s fertility and without exposing her to undesirable side effects of treatments. Different women may respond differently to the same treatment, both in terms of the effectiveness and side effects, and there is no one treatment that would be effective in all women.

W. Paul Dmowski, M.D., is the Director of the Oak Brook Fertility Center and the Director of the Institute for the Study and Treatment of Endometriosis in Oak Brook, Illinois.

Editor’s Note: The Institute for the Study and Treatment of Endometriosis always has several ongoing clinical research projects. Frequently, the Institute has new medications for clinical trials before they become generally available. Such clinical studies, including medications, are often at no charge to the patient. For more information about participating in a study, please call 630-954-0054.