Endometriosis: The Diagnosis Your Doctor Could Miss

“They” said that Black women rarely got the disease, Endometriosis. “They” are wrong! Endometriosis is a condition in which the cells that line the uterus, the endometrium, somehow get outside of the uterus and implant themselves in the ovaries, tubes, pelvic sidewalls, or the space between the vagina and rectum.  Normally, the endometrium is shed at each menses. With endometriosis, displaced endometrium continues to respond to the hormonal changes in your body, causing pain, scarring, and infertility.

by Dr. Yvette Gentry, Medical Director – East Bay Women’s Health

There are several different theories as to how endometrium cells get outside the uterus. Explanations range from the back flow of menstrual blood, to a genetic predisposition, to auto immune problems, to a combination of all three.

Who gets endometriosis?

A previous misconception was that African-American women rarely got this disease. This disease was thought to be more common among “goal oriented” women. It is now known that 3-10% of reproductive age women of all races and 25-35% of infertile women, have this problem. Unfortunately, there is no way to prevent this disease.

What are the symptoms?

Symptoms of endometriosis range from none to severe pelvic pain. Typically, women will have worsening painful periods, painful intercourse, and/or infertility. Specifically, endometriosis should be suspected if painful periods develop years after pain-free menses, or while on birth control pills.

Eventually, those with endometriosis may develop pelvic pain not related to their menses. Worsening painful intercourse with deep penetration is also a symptom. Infertility is also more common in women with endometriosis.

How is endometriosis diagnosed?

Endometriosis is diagnosed definitively by a surgical exam. A doctor may suspect endometriosis based on symptoms and or a pelvic exam. During this exam the ovaries or the area behind the uterus is painful to the touch or
nodularity is felt in the space between the uterus and the rectum. If mild disease is suspected the diagnosis may be presumed and treatment begun to avoid surgery initially. Laparoscopy (minimally invasive surgery) is the usual surgical approach to determine if endometriosis is present. This involves making a small incision at the belly button and inserting a scope with a camera to look for endometriosis lesions.

A pelvic sonogram or ultrasound can detect endometriosis cysts of the ovaries, but cannot detect implants of endometriosis in the pelvis. Unfortunately, endometriosis can look similar to other kinds of ovarian cysts on sonogram . Thus a surgical evaluation is required if the cyst persists through 2 menstrual cycles. Endometriosis does not always involve an ovarian cyst.

How does endometriosis affect fertility?

If your endometriosis involves your ovaries or tubes, scar tissue can blocks the tubes or interfere with their ability to pickup the egg. Forty percent of infertile women have endometriosis noted on Laparoscopy whereas only 5% of fertile women have this finding. However ,the long term fertility rates of women with minimal or mild endometriosis are high even in those not treated. Those patients with moderate to severe disease can expect a pregnancy success rate of 60 % to 35% respectively, after surgical treatment.

How is endometriosis treated?

Treatment for endometriosis depends on the severity of the disease, the symptoms and the fertility desires. Keep in mind that some cases of endometriosis are detected as an incidental finding. For example, it may be found at the time of a tubal ligation in a patient with no symptoms. In those scenarios it is not clear that treatment will definitely help the patient. But, given that the disease can progress, many doctors will treat it if it is seen.

Medical or hormonal treatment of endometriosis involves suppression of ovulation and or temporary shrinkage of the endometrial tissue. This can be accomplished by either birth control pills or medications which make the body think it is in menopause (Gnrh Agonist). Gnrh Agonist can only be used for 6 months consecutively due to the possibility of osteoporosis after more prolonged use. Progesterone has also been used to treat endometriosis. Daily use is thought to cause shrinkage of endometrial implants. These medications simply suppress the symptoms rather than cure. It is thought that these medications will essentially halt the process of endometriosis. The side effects of these medications range from water retention, irregular bleeding, and fluid retention to hot flashes, vaginal dryness and sleep disturbance. The choice of medical treatment depends on your medical history, severity of symptoms, contraceptive needs, and tolerance.

Surgical treatment of endometriosis involves the restoration of normal anatomical relationships and excising or burning as much of the endometriosis as possible. The recurrence rate is usually below 20%, but when it does come back second surgeries to aid in fertility have a limited chance for success.

How do I know if I have endometriosis?

This can be a difficult disease to detect especially as pelvic pain becomes an expected part of one’s life. Gradually worsening menses to the point of debilitating pain is abnormal. Debilitating pain can be defined as such when
it interferes with an individual’s ability to perform her usual daily activities.

If a few doses of over-the-counter medication are not sufficient to bring your discomfort to a tolerable level and your pelvic exams are always normal then endometriosis is a definite possibility. If the discomfort continues despite birth control pills then endometriosis could be the cause. A normal pelvic exam and a normal pelvic ultrasound does not mean endometriosis has been ruled out. Any of the above symptoms combined with infertility (no conception after one year of unprotected sex) is a possible indication of the disease.

The path to diagnosis may not be quick, but continued work with your doctor can eventually result in an improved quality of life.

SYMPTOMS OF ENDOMETRIOSIS symptoms-of-Endometriosis-family-digest-520
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