By Amos Cutler, MD
Myrtle Street Obstetrics & Gynecology
Sarah is 25 years old and is recently married. She has never been pregnant. She scheduled this appointment to discuss birth control options. She is planning to get pregnant in one to two years. She had a history of very heavy and painful periods. When she was in high school, she started taking birth control pills to help with her menses. The birth control pills made her menses lighter and less painful; however, she decided to stop them a year ago because she gained weight and she was worried that she had been taking the birth control pills for too long. Her body needed a break. Since stopping the birth control pills, she noticed that her menses are getting heavy and painful again. She takes ibuprofen each month for the pain with her menses. She is not experiencing any pain with intercourse.
Sarah read about endometriosis and wants to know how she could find out if she has endometriosis. Her mother had a hysterectomy at age 45 because she had heavy and painful menses. If her mother did in fact have endometriosis, Sarah wonders how likely she is to also have endometriosis and is asking whether the condition could affect her chances for getting pregnant.
Let’s start with the basics.
What is endometriosis?
Endometriosis is when tissue that is found inside the lining of the uterus (the endometrium) grows outside of the uterus. This tissue can then bleed like the uterine lining does during the menstrual cycle. Surrounding tissue can become irritated, inflamed and swollen. The breakdown and bleeding of this tissue each month also can cause scar tissue, called adhesions, to form. Sometimes adhesions can cause organs to stick together. The bleeding, inflammation, and scarring can cause pain, especially before and during menses.
Some women with endometriosis have no symptoms, but most have lower abdominal pain before or during the menses, between menses, during or after sex and when urinating or having a bowel movement (often during the menses). The lesions of endometriosis can be anywhere outside the uterus. The most common sites where endometriosis occurs are the ovaries, the fallopian tubes, the bowel, and areas in front, in back and the sides of the uterus.
Women with endometriosis can develop ovarian cysts containing endometriosis. This is called an endometrioma. Endometriomas are usually filled with old blood that resembles chocolate syrup and, thus, sometimes called chocolate cysts. They are sometimes seen during a pelvic ultrasound or felt during a pelvic exam.
There is no cure for endometriosis, but there are several treatment options.
Endometriosis occurs in about 6% to 10% of reproductive-age women, with a prevalence of 38% in infertile women. Patients with an affected first-degree relative (mother or sister) have a 7- to 10-fold increased risk of developing endometriosis.
The cause for endometriosis is not known. A common theory is that menstrual blood and endometrial cells flow back from the uterus through the fallopian tubes into the pelvis during the menstrual period. The cells then grow where they land in the pelvis. This theory is called retrograde menstruation. There are other theories that try to explain endometriosis.
Endometriosis is suspected when women have pelvic pain or painful menstrual periods. However, the only way to know for sure if there is endometriosis is to have surgery to visualize the lesions. Endometriosis cannot be diagnosed by ultrasound, x-ray or other non-invasive methods. It is considered mild, moderate or severe depending on what is found during surgery. Women with mild disease can have severe symptoms, and women with severe disease can have mild symptoms. Medicines such as NSAIDs (ibuprofen) or hormonal birth control can treat the symptoms of endometriosis. Even though surgery would diagnose endometriosis, in many cases surgery is reserved for women for whom medical treatment does not improve the pain.
Endometriosis and fertility
Almost 40% of women with infertility have endometriosis. Inflammation from endometriosis may damage the sperm or egg or interfere with their movement through the fallopian tubes and uterus. In severe cases of endometriosis, the fallopian tubes may be blocked by adhesions or scar tissue. While endometriosis can cause infertility, many women who have this condition don’t have any difficulty getting pregnant. In addition, surgery itself can cause adhesions, which may impair fertility. Therefore, the decision to do surgery is complex and needs to be individualized.
So what did Sarah decide to do?
Sarah wanted to review the different methods of contraception. We discussed that any of the hormonal contraception options can help with the symptoms of endometriosis. Since she used birth control pills before, she wanted to start them again until she decides to get pregnant. She had a pelvic ultrasound that was normal. Even though, based on her symptoms and family history, she was more likely to have endometriosis, she wanted to avoid surgery at this time. If she has difficulty getting pregnant, then she would consider surgery to look for endometriosis.
Amos Cutler, MD, is an Obstetrician/Gynecologist at Myrtle Street Obstetrics & Gynecology, practicing in the main office at 59 Myrtle Street in Saratoga Springs, and the satellite office at 2105 Ellsworth Boulevard in Malta. For more information, contact the office at 587.2400, or visit www.myrtlestobgyn.com.