Endometriosis can cause pain and even infertility—but women have options for treating this common disorder
By Amy Lynn Smith
A young woman and her husband are trying to get pregnant, but it’s just not happening. Another woman in her late 30s is in so much pain every month during her menstrual period she doesn’t feel like going to work. And her young niece, who just started having her period, complains of terrible backaches every month.
Every one of these women could be suffering from endometriosis, a condition that affects 5.5 million women in North America, according to the National Institutes of Health (NIH).
Sometimes referred to as “endo,” endometriosis is caused when tissue that normally grows along the lining of the uterus is found outside the uterus, commonly on the ovaries or behind the uterus. When left untreated, endo can cause severe abdominal and lower back pain.
For some women, the first tip-off that something might be wrong is that they’re having trouble getting pregnant, says Cynthia Sites, M.D., director of UAB’s Division of Reproductive Endocrinology and Infertility. “In women with infertility, we see endometriosis roughly 15 percent to 20 percent of the time,” she explains. “Fortunately, there are a number of options available to help these women get pregnant.”
Going Against the Flow
Experts agree that the exact causes of endometriosis aren’t fully understood. Dr. Sites explains that the most common cause is menstrual blood flowing backward through the fallopian tubes into the abdomen. Normally, the blood flows out through the cervix.
This condition—called retrograde menstruation—also occurs in women without endometriosis, which means there may be other factors involved. One theory is that the immune response of some women may allow for implantation of blood and tissue outside the uterus.
Endometriosis has even been found in young girls who haven’t started menstruating, which supports another theory: that the condition could develop in some women while they’re still in their mother’s womb. It also is possible that cells in the abdomen or pelvis may transform into endometrial cells in some instances.
Interestingly, a few rare cases of a type of endometriosis have been seen in men, usually those who are taking a synthetic version of the hormone estrogen as a treatment for prostate cancer. This supports the idea that endometrial cells are fed by estrogen, which is a hormone produced during the menstrual cycle.
But, no question, endometriosis is ultimately a women’s issue, and certain risk factors can increase a woman’s chances of developing it.
The most significant risk factor is menstruation. Women who take birth control pills continuously are less susceptible to endometriosis, as are women who have had several pregnancies at an early age—and therefore have not had as many menstrual periods.
Other risk factors for the disease include a family history and uterine anomalies such as vaginal blockages that prevent blood from flowing out-ward. Although there’s been speculation for years that tampons may contribute to endometriosis, Dr. Sites says that has never been proven.
Not a Fact of Life
Although women can go for years without suspecting they have endometriosis, others experience severe menstrual pain that can’t be alleviated with over-the-counter pain relievers. Some women with the disorder miss work or school during their period because the pain is so severe.
Pain between menstrual periods is another symptom, as is painful intercourse. The pain is typically abdominal, but some women also experience severe backaches, bloating, shooting pain down their inner thighs or burning pain in the pelvis.
These symptoms seem like reason enough for a visit to the doctor, but many women think monthly pain is just part of being a woman. Not so, Dr. Sites says.
“Especially with women in their late teens or early 20s with very painful periods, people will tell them ‘Oh, you’ll outgrow it,’” she says. “I heard once that women had symptoms of endometriosis for 10 years on average before they were diagnosed. That’s just way too long to wait for a diagnosis.”
Many women first visit their doctor because they’re having trouble getting pregnant—another possible sign of endometriosis. Dr. Sites says women under 40 who have regular periods should see a doctor if they can’t conceive after 12 months. Women over 40 with regular periods should see a doctor after six months.
When it comes to the relationship between endometriosis and infertility, there are a number of possibilities, she adds. One is the fact that endometriosis can be associated with scarring in the pelvis, which can prevent the fallopian tubes from picking up eggs.
Chemicals created by the endometrial implants in the pelvis may be another factor, as well as pelvic inflammation caused by endometriosis.
Charting a New Course
According to Dr. Sites, the most definitive way to diagnose endometriosis is by laparoscopy, a minor surgical procedure that involves a small incision just below the belly button. The doctor inserts a lighted tube through the incision to view the reproductive organs and determine if endometriosis exists.
She says many cases of endometriosis are treated right then and there. The doctor removes as much of the endometriosis as possible, often using a laser beam or electric current. However, this form of treatment isn’t a permanent cure: the endometriosis can reappear down the road. But it’s a particularly good option for women who still want to conceive—and it is typically quite successful in reversing infertility caused by endometriosis, Dr. Sites says.
She also points out that women who have been diagnosed with endometriosis might want to consider having children sooner rather than later. Endometriosis tends to be progressive, and conception gets more complicated for women as they age—so the combination tends to make getting pregnant even more difficult, Dr. Sites says.
Even women who still can’t get pregnant on their own because of endometriosis have options, she adds. There’s in vitro fertilization, which involves removing the eggs from one of the mother’s ovaries and fertilizing them with the father’s sperm. The embryo is then placed inside the woman’s uterus to develop. Women also can consider an injection that causes several eggs to form on the woman’s ovary. This injection is used in tandem with intrauterine insemination, in which sperm is placed directly into a woman’s uterus using a catheter.
For women who aren’t interested in getting pregnant, other treatments for endometriosis are available. Some symptoms, particularly pain, may be alleviated by birth control pills or high-dose synthetic progesterone, a hormone also produced by women during their menstrual cycle. According to Dr. Sites, endometriosis is cured after menopause, when production of both estrogen and progesterone decline. A hysterectomy that includes removal of the ovaries also cures endometriosis.
As researchers continue to seek a better understanding of endometriosis, women should remember two important facts: Endometriosis is treatable and any severe menstrual pain or trouble conceiving should be discussed with a doctor.
“Especially if women find their pain is getting worse over time, they should seek treatment,” Dr. Sites says. “Women shouldn’t have to see their quality of life diminished when there’s something they can do about it.”
For UAB’s free “Reproductive Endocrinology and Infertility Services” brochure, please call (205) 996-6000.