Endometriosis is a condition in which the lining of the uterine cavity (endometrium) grows outside of the uterus. Endometriosis can be found anywhere in the pelvic cavity, including all the reproductive organs as well as on the bladder, small bowel, colon, rectum, appendix, and vagina. However, endometriosis cannot be considered simply as misplaced endometrium, because it differs in hormonal responses and visual appearance.

The most common sites of endometriosis in the pelvis are the uterosacral ligaments, cul-de-sac, pelvic side walls, and ovaries. In rare occasions, endometriosis has been found on surgical scars such as from C-section or laparotomy, as well as inside the bladder, lung, spine, and brain. Although endometriosis differs somewhat from the normal lining of the uterine cavity, it does respond to a woman's hormones each month. As a result, the endometrial lesions can be inflamed and can bleed into the surrounding tissues, causing irritation of the affected area. They may produce a variety of other symptoms as well. This cycle of inflammation and bleeding often causes scar tissue to form. Such scar tissue can be extensive and may become bands of adhesions that are capable of distorting anatomy and affecting the normal function of internal organs.

What causes Endometriosis?

The real cause of endometriosis remains unknown. There are many theories that try to explain the etiology of endometriosis, but none of them can explain all cases of endometriosis. We do know, however, that endometriosis is not caused by anything that the patient has done. One theory is Sampson’s Theory.

Sampson's Theory

This theory was proposed by Dr. John Sampson of Boston in the 1920’s. His theory that menstrual blood refluxed through the fallopian tubes and was deposited and grew on the pelvic peritoneum and pelvic organs remains popular, but the initial attachment of single or multiple endometrial cells on the peritoneal surface has not been demonstrated. Additionally, the time-related geographic spread of endometriosis throughout the pelvis that would be predicted to occur with repeated seeding of the peritoneum by refluxed endometrium has not been demonstrated.

The fact that 90% of women have retrograde flow but only 15 % of women develop endometriosis further repudiate the validity of the theory. This theory of origin also implies that older age groups of patients with endometriosis have more disease than younger age group and a high and progressively increasing rate of recurrence after complete surgical resection. The literature, however, as well as our own experience has shown that the actual rate of persistent or recurrent disease is surprisingly low after aggressive conservative surgical excision at laparoscopy or laparotomy, and the rate of recurrent or persistent disease does not appear to increase with the passage of time following excision.

Symptoms of Endometriosis

Patients with endometriosis can have symptoms varying from constant excruciating pelvic pain to no symptoms whatsoever. Paradoxically, the extent of endometriosis has no correlation to the amount of pain a woman will experience. Some women with severe endometriosis do not have any symptoms and may not know they have endometriosis until a pelvic mass is detected on a routine pelvic examination or a problem with infertility is discovered. The following are the common symptoms of endometriosis, but remember that women with endometriosis may have all, some, or none of these symptoms.

Pain and Discomfort in the Pelvic Area

Women with endometriosis most commonly experience increasing pain and discomfort right before and during their monthly cycles. Painful sexual intercourse, pressure and bloating in the lower abdomen and severe, sometimes incapacitating, cramps during this period are not uncommon. Some women with endometriosis, however, have constant pelvic pain, cramps, and painful intercourse which may not be associated with monthly cycles.

Abnormal Uterine Bleeding

A woman with endometriosis may have some vaginal spotting a few days before and/or after her period, or she may have abnormally heavy and long periods.

Gastrointestinal Symptoms
Gastrointestinal dysfunction ranges from abdominal bloating or nausea to intestinal cramps, cycles of diarrhea and/or constipation. Rectal bleeding and painful bowel movements may occur when the rectum and sigmoid colon are invaded by the endometriosis.

Infertility

The most common cause of unexplained female infertility is endometriosis.

Urinary symptoms

Frequency, urgency, bladder pain, and occasionally bloody urine may occur when endometriosis has involved the bladder. Endometriosis can invade the ureter (tube between the kidney and the bladder), may cause obstruction of the ureter, and damage the kidney.

Lower back pain which may radiate down the legs

Diagnosis of Endometriosis

Laboratory and imaging tests (ultrasound and x-rays) are not as helpful as the history and physical examination in diagnosing endometriosis. Indeed, in our own experience, the high suspicion and persistence in seeking the diagnosis of the patient are the two most important factors in leading to the majority of the diagnoses of endometriosis. Visualization of endometriosis on the lower genital tract (vagina and cervix) and tender nodules palpable above the vagina during routine pelvic examination is considered by many physicians to be diagnostic of endometriosis. However, laparoscopy (laparo = abdomen, scopy = inspection, thus, laparoscopy = inspection of abdominal cavity) to directly inspect the abdominal and pelvic cavity is the only definitive diagnosis of endometriosis.

Treatment of Endometriosis

Currently there are two ways to treat endometriosis – hormonal therapy and surgery.

Depending on the patient’s expectations and the extent of the disease, we may prescribe hormonal therapy, surgery, a combination of surgery and hormonal therapy, or occasionally a just “wait and see” approach.

Hormonal Therapy

Hormonal therapy is based on the knowledge of the response of existing estrogen and progesterone receptors on ectopic endometrial tissue to certain hormonal agents. Since endometrial lesions are not all the same with regard to the number and response of receptors to the hormonal agents, the result of the hormonal treatment may vary from patient to patient. Hormonal therapy is considered as suppressive, thus temporary. Endometriosis will recur after the treatment is discontinued. Following are some of the currently available hormonal agents for treatment of endometriosis.

Surgical Treatment

Laparoscopic surgery is the main and definite way to diagnose and treat endometriosis. Ideally, all the endometrial lesions should be excised through the laparoscope at the initial diagnosis of endometriosis. Unfortunately, most gynecologists are not well trained in treating extensive endometriosis through laparoscopy. Thus many women with extensive endometriosis often require more than one surgery and suffer from many undesirable sequelae of poorly performed surgery. It can not be emphasized more the importance of finding a well trained gynecologist at initial diagnosis and treatment of endometriosis.

The definite treatment of endometriosis is NOT hysterectomy and bilateral salpingo-oophorectomy (remove both uterus and ovaries) – Many gynecologists nowadays still mistakenly believe that remove both uterus and ovaries are the cure for endometriosis. In our center we believe strongly that the correct way of treating endometriosis is the complete excision of the endometrial lesions, whether it appears on the pelvic organs or on the bowel, ureter (draining tube between the kidney and the bladder), and bladder.

The decision of whether to perform hysterectomy or oophorectomy at time of endometriosis surgery will purely based on whether there are any coexisting uterine or ovarian pathology in addition to the presence of endometriosis and patient’s desire for future childbearing. For example, if patient is known to have severe endometriosis and no longer desires to bear a child, and meanwhile fibroids (benign tumor of womb which may cause heavy menstrual bleeding and cramps) are found on her uterus, then hysterectomy along with excision of all endometriosis should be recommended for patient. Throughout the years, we have performed numerous laparoscopic surgeries for extensive endometriosis with excellent results without removing either normal uterus or ovaries.

The Role of Presacral Neurectomy in Conservative Surgical Treatment for Endometriosis

We sometimes perform Presacral Neurectomy (resection of part of presacral nerve which is in charge of pain sensation in the midline pelvic area. The procedure will reduce the pain and cramps in the midpelvic area and it does not affect the sexual feeling or sensation of the patient) along with the excision of endometrial implants for those patients desire to have future childbearing but suffer from severe midline pelvic pain and cramps.