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 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.
The most common cause of unexplained female infertility is endometriosis.
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 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.
- Birth Control Pills: Birth control pills, or oral contraceptives, are the combination of estrogen and progestin pills to regulate a patient’s hormonal levels and suppress endometrial growth. While a patient is on birth control pills, ovulation usually ceases and endometrial lesions shrink. The common side effects of taking birth control pills are weight gain, nausea, headache, mood changes, depression, irregular vaginal bleeding, and loss of sexual desire.
- GnRH Agonists: This agent works by suppressing the pituitary hormones (FSH and LH) to stop the ovary from producing estrogen, putting the patient into a menopausal state, and thus shrinking the endometrial lesions. The names of GnRH agonists include Lupron Depot, Synarel, and Zoladex. The drug can be given by injection or nasal spray. The main side effects of menopausal syndromes are hot flashes, cold sweat, insomnia, vaginal dryness, loss of sexual interest, and depression. The FDA has approved GnRH agonists for no longer than six months in a lifetime due to the risk of osteoporosis.
- Progestins: Progestins work by keeping the ovarian hormone (estrogen and progesterone) levels low to prevent ovulation and suppress endometrial growth. Common names of progestins are Provera, Cycrine, Megace, Micronor, Amen, Nor-Q.D., and Depo-Provera. The main side effects include irregular vaginal bleeding, depression, breast tenderness, moodiness, weight gain, headache, and fluid retention.
- Danazol: Danazol exhibit some androgen (male hormone) effect and reduces ovarian hormonal production. Most women will stop ovulation and menstruation when they are on Danazol, and their endometrial lesions will shrink and become inactive. The main side effects of Danazol are weight gain, decrease in breast size, acne, oily skin, male-pattern hair growth, and deepening of the voice.
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.