Endometriosis is a condition resulting from the appearance of endometrial tissue outside of the uterus, which causes pelvic pain.
This type of tissue, known as endometrium, is normally found only inside the uterus and makes up the lining of the uterus. This inner lining of the uterus is normally shed with each menstrual cycle.
Debate continues over the root causes of endometriosis.
Older theories of spread of cells from the uterus via the lymph nodes and blood vessels do not seem to be supported by any real evidence. Further, we know well that almost all women have endometrial cells from the uterus go into the pelvis during menstruation - this is called retrograde menstruation. Because it happens so frequently and relatively few women have endometriosis, there must be factors at work other than retrograde menstruation.
Those other factors include: immunologic dysfunction, alterations in inflammatory processes, and various genetic factors.
This all leads to the typical characteristics seen in endometriosis. Those characteristics include: scarring, inflammation, and invasion across tissue planes where other benign diseases would not go.
Most commonly, endometriosis is associated with painful menses, painful intercourse and infertility.
However, other problems are often seen in women with endometriosis-associated pain. Those other problems include: migraine headaches, chronic fatigue syndrome, irritable bowel syndrome, fibromyalgia, pelvic floor muscle spasm, interstitial cystitis, and depression.
These problems may not necessarily exist in a patient because she has endometriosis. Instead they are problems called “co-morbidities”, or in medical terms, a problem that exists with another problem.
It is interesting that a woman can have severe endometriosis or mild endometriosis and not have any pelvic pain. So, there must be other factors at work in regulating how much pain a woman experiences from endometriosis.
In general, pain is caused by multiple factors that make up an individual's pain threshold (i.e. the amount of pain it takes before one actually feels pain). These factors are genetic, experiential, and psychologic.
Endometriosis acts as a pain generator through multiple mechanisms. Endometriosis causes a significant amount of inflammation. This inflammation can result in scarring and nerve damage. It is this scarring and nerve damage that leads to stimulation of the spinal cord and ultimately the brain to detect continuous pain signals. When this becomes long term and severe, phenomena such as spinal wind-up and neuroplasticity occur, leading to difficult-to-treat chronic pain.
A lot of women have endometriosis but no associated pain (although they may have infertility or subfertility), thus they do not require treatment for pain associated with endometriosis.
Endometriosis can cause pain via multiple mechanisms. Thus, a gynecologist who truly understands both endometriosis and pain is likely to offer you a multipronged approach that pays respect to other pain issues as well as the central nervous system pain problem.
In general, just like many other diseases, there can be both medical and surgical treatments.
Medical therapies that actually treat endometriosis really only exist in one class of drugs - the aromatase inhibitors.
Other medical therapies such as birth control pills, gonadotropin releasing hormone agonists (lupron, synarel, and zoladex), progesterones, and danazol simply suppress pain associated with endometriosis by reducing inflammation, decreasing local estrogen responsiveness, and acting on the estrogen receptors in the spinal cord (which partially explains why some of these therapies suppress pain not associated with endometriosis).
So, in the long run, when using these treatments, which often produce significant side effects, there is a suppression of pain symptoms without actually treating and eliminating the root cause - endometriosis.
However, the aromatase inhibitors (letrozole and anastrazole) are medications that have been shown in animal models to actually decrease the anatomic volume of endometriosis. This is important because it is often that distortion of anatomy that leads to pain.
The optimal surgical management for pain associated with endometriosis is radical resection of endometriosis. This means during surgery, the maximum amount of visible endometriosis will be removed regardless of its location. This means removing endometrial tissue from the root and cutting deeply underneath the disease, until only normal tissue is left behind.
Some gynecologists believe that is equally acceptable to surgically burn or "fulgurate" endometriosis. However, this technique often leaves behind most of the disease and adds to the damage caused by burning tissue.
After seeing many patients who have had multiple (up to 17) surgeries to burn endometriosis with no long lasting effect, it became clear that this technique is not only dangerous and foolish, but also ineffective, as it provides no long-term relief from endometriosis pain.
Absolutely! The goal is to work within your reproductive needs. This procedure has been shown to be a safe and effective method for minimizing or eliminating pain while maintaining fertility.
Radical resection of endometriosis has been performed numerous times on many young women.
In order to both treat the pain and maximize future health outcomes, it is best to optimize the production of natural hormones. In order to do this, the ovaries must be left intact. Contrary to popular belief, this does not decrease the efficacy of the procedure. Remember, the key to the procedure is maximally removing endometriosis, not whether or not the ovaries are still present.
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