Endometriosis is the presence of endometrial type of tissue (that which normally lines the uterine cavity) outside of the uterus. When abnormally located, this tissue can lead to inflammation, scaring, distortion of normal anatomy as well as tissue and nerve invasion. The most common symptoms are pelvic pain, pain with menstruation (dysmenorrhea), pain with intercourse (dyspareunea), pain with bowel movements (dyschezia), low back pain and decreased fertility. The degree of symptomatology generally correlates with the degree of disease but this is not always the case. The most common location is in the pelvis on the lining tissue of the pelvic cavity (peritoneum). The pelvic cul-de-sac and ovary are the most common sites, although endometriosis can involve non-gynecologic organs (colon, appendix, and bladder) and occur at distant sites.
The disease affects 2-7% of American women. The cause is not definitively known, however the best fit with the natural history of endometriosis would be cellular transformation of primitive embryologic cells in predisposed individuals (known as the coelomic metaplasia theory). The commonly proposed theory of retrograde menstruation and implantation (Sampson’s theory) although widely accepted appears to lack rigorous scientific foundation and does not fit with the natural history of the disease. Endometriosis appears to be static in location over time and advances by tissue invasion, however spontaneous resolution has also been observed. Environmental factors (particularly dioxin) have been implicated as possible causative agents, but to date epidemiological and toxicology evidence is lacking to definitively link environmental agents as causative. A genetic component appears to exist but the exact basis of inheritance is unknown. To date no differences in the immune systems of patients with endometriosis have been identified or proven, although many believe some alterations in the immune system are a factor in developing endometriosis. Endometriosis in of itself is not a malignant disease but those with the disease epidemiologically appear to have a greater risk of developing gynecologic cancers latter in life.
The only definitive method of diagnosis is by laparoscopy in the individual with symptoms and findings suspicious for endometriosis. It has become increasingly evident that the best treatment for endometriosis is excision (removal) of the disease at the time of the initial laparoscopy. Excision of disease has a proven record of success documented in the literature with upwards of an 80% long term success rate in pain relief. Fertility can also best be improved by removal of the disease and assessment of anatomy in order to determine the best future course of treatment. Surgical excision of endometriosis is the only technique documented to be efficacious in very long term follow up of patients. Excised tissue is sent to pathology for definitive diagnosis. Nothing is left for chance, guesses or subjective observation. Excision allows one to determine the complete depth of endometriosis and removes disease in its entirety. The best results are obtained when the surgeon is highly experienced with the disease and utilizes excisional techniques. Many other methods have been utilized at laparoscopy (i.e. vaporization with laser or electrosurgery, heating of tissue-endocoagulation, ultrasound energy, etc.), unfortunately unless the disease is superficial, these leave most of the endometrioisis and symptoms recur. This can result in repeat procedures, often also ineffective, resulting in a laparoscopy treadmill of repeated procedures, ineffective results and ongoing symptoms.
Medications for endometriosis can be used to treat the symptoms of the disease (i.e. pain), but no medication can eliminate endometriosis. There is no medical literature demonstrating the superiority of one medication over another in treating the symptoms of endometriosis. Commonly used medications include oral contraceptive pills, various progestins, danazol and lupron. Combinations of medicines and surgery are also sometimes used.
Endometriosis is a variable complex disease with many remaining unanswered questions. However, treatment has become increasingly successful and should be undertaken by those with experience in managing the disease and possessing the surgical skills needed for excisional surgery.
Dr. Charles Dubin graduated from UCLA medical school and is a specialist in gynecology, menopause and gynecologic minimally invasive surgery. He is in private practice in Santa Monica, Calif. He was among the first 100 physicians in the United States certified in advanced laparoscopy and hysteroscopy by the Accreditation Council for Gynecologic Endoscopy. He was cofounder of the Westside Menopause Center and a member of the North American Menopause Society. He was founder of the Endometriosis Center of Southern California. Dr. Dubin’s practice caters to the needs of perimemopausal and menopausal women employing a customized, holistic approach using hormonal, herbal, dietary and lifestyle approaches.
