Endometriosis: Diagnosis and Treatment

By Keith A Hansen M.D
Board Certified, Reproductive Endocrinology and Infertility
www.sanfordwomenshealth.org
Sanford Women’s Health
1500 W. 22nd Street, Suite 102
Sioux Falls, SD 57105
605-328-7700

Endometriosis remains an enigmatic, often debilitating disease affecting reproductive age women. Endometriosis is defined by the presence of endometrial glands and stroma outside of the normal intrauterine location associated with evidence of hemorrhage. This aberrantly located endometrial tissue is under the influence of ovarian steroids, and one sees a similar response as with normally located endometrium. Because of their responsiveness to ovarian steroids these ectopic glands and stroma undergo cycles of proliferation and bleeding on a monthly basis.

Endometriosis can present with pain, infertility, pelvic masses and some unusual symptoms such as catamenial epistaxis or hematothorax. The etiology of endometriosis remains a puzzle with a number of theories to explain it. These include theories of retrograde menstruation, coelomic metaplasia, venous or lymphatic dissemination or local implantation.

In the past endometriosis was thought to be a disease of the older reproductive years, but recently it has been discovered to occur at any time in the reproductive life of an individual. This knowledge has led to earlier diagnosis and treatment of this disease. Hopefully this earlier treatment will result in reduced long term morbidity and complications resulting from endometriosis.

The diagnosis of endometriosis still relies on surgical visualization and biopsy of lesions with pathologic confirmation of endometrial glands and stroma outside of the uterus. Typical endometriotic lesions include powder-burn spots and chocolate cysts (endometriomas) in the ovary. Recent discoveries have demonstrated glands and stroma in atypical lesions such as clear or pink vesicles. At the time of surgery it is important to classify the degree of endometriosis which is dependant on the number of endometriotic lesions and pelvic adhesions. The American Society of Reproductive Medicine (formerly the American Fertility Society) has developed a classification system for endometriosis based on the quantity of endometriosis as well as the quantity and severity of pelvic adhesions. According to this classification scheme endometriosis can be classified as minimal, mild, moderate and extensive.

The treatment of endometriosis can be divided into conservative techniques for those who wish to maintain their fertility and radical for those who have completed childbearing. Conservative techniques can be further divided into medical and surgical therapies. Medical therapies function by reducing the cyclic fluctuation of estrogen and progesterone which is normally seen in the menstrual cycle. The major medical therapies include oral contraceptive pills either used in the regular fashion or in a continuous fashion, progestational agents like depo-provera and gonadotropin releasing hormone agonists. Previously danocrine was popular in the treatment of endometriosis but has decreased in use due to its number of androgenic side-effects. New medications which are being tested in the treatment of endometriosis include progesterone antagonists and aromatase inhibitors. All of these medical agents have been effective in the treatment of endometriosis. One draw-back of these medications is that they disrupt normal ovarian steroidogenesis which disturbs fertility while on the agents. Hence medical therapy tends to delay fertility until after the patient completes the medical regimen. Current research will hopefully identify treatments for endometriosis that will enhance fertility while the patient is on the medication.

Surgical treatment of endometriosis is divided into conservative and radical methods. Conservative surgery requires removal or destruction of endometriosis and adhesions while maintaining the reproductive organs. In patients with endometriosis conservative surgery has been beneficial in improving pregnancy rates and reducing other symptoms. The disadvantage of conservative surgery is the real possibility that the endometriosis can return and cause a relapse of symptoms. Radical surgery involves removing the uterus, fallopian tubes and ovaries as well as any areas of endometriosis and adhesions which is the definitive treatment for endometriosis.

Current research is exploring less invasive methods of diagnosis of endometriosis such as blood tests. New research will also hopefully lead to more effective therapies in young women with this often debilitating disease.