Washington Center for Reproductive Medicine

Endometriosis

Endometriosis is an enigmatic condition that affects up to 1 in 10 women of reproductive age and up to 40% of women with infertility. Additionally, over 50% of women with pelvic pain, or dyspareunia (painful intercourse), suffer from endometriosis. Endometriosis may be silent but its ramifications are serious and deleterious to a woman's reproductive health.

 Definition

Endometriosis is defined by the presence of endometrial tissue (cells from the lining of the uterus) outside of the uterine cavity. It occurs on the pelvic structures, or occasionally in other areas including abdominal scars, the umbilicus, the intestines, the diaphragm, and even the lung. These endometriosis lesions are dependent upon the hormone estrogen for growth and may induce severe inflammation and scarring around the affected area(s).

Endometriosis is a condition that initially affects the surface of pelvic organs as well as the lining of the pelvic cavity (the pelvic peritoneum). With time, the disease invades the organ upon which it is found causing significant alterations in both structure and function.

Common sites in the pelvis for the occurrence of endometriosis include:

  • Pelvic peritoneum
  • Ovaries and Fallopian tubes
  • Pouch of Douglas (the space between the rectum and vagina)
  • The intestines including the rectum, sigmoid colon, and appendix as well as the rectovaginal septum (the space between the rectum and vaginal)
  • The uterus
  • The bladder

Several theories exist regarding the genesis of endometriosis but there is no consensus as to the causation. Most likely, it is a combination of the following:

  • The back flow of menstrual blood via the fallopian tubes combined with a defect in the immune system precluding the absorption of this material.
  • Blood borne or lymphatic spread.
  • Spontaneous transformation of the peritoneum (pelvic lining) to endometrial cells.
  • Endometriosis induces a hostile inflammatory environment in the pelvis, which may lead to adhesion formation and tissue destruction.

Pathogenesis

Because the tissue of endometriosis comes from the uterus, it is dependent upon estrogen for growth, enlarging and bleeding internally during the menstrual cycle. The condition is rare before puberty and disappears after menopause unless estrogen therapy is utilized.

There is a known genetic basis for endometriosis with familial clustering, including twins, and increased prevalence in first-degree relatives. Research to genotype the condition (identify the genetic cause) is presently underway.

Environmental toxins may cause immune and endocrine (hormonal) disruption leading to endometriosis .There are known immune alterations in endometriosis patients including a hostile inflammatory environment in the pelvis. The changes include alterations in the immune system (prostaglandin's, T and B cells and immunoglobins leading to decreased fecundity (chance of becoming pregnant each month) and an increased incidence of infertility.

Endometriosis and Infertility

Patients with endometriosis exhibit decreased fecundity (monthly pregnancy rates). It is therefore helpful to optimize the pelvis with meticulous removal of endometriosis before infertility treatments. If treatments have been unsuccessful without a satisfactory explanation, endometriosis must be excluded.

Endometriosis affects fertility in many ways:

  • Altered pelvic anatomy due to scarring and inflammation
  • Ovulation dysfunction and luteal phase defects
  • Destruction of sperm by the inflammatory process within the pelvis
  • Impaired fertilization
  • Inhibition of early embryo development in an environment of chronic pelvic inflammation

Endometriosis and IVF

Patients with active endometriosis do not perform as well as others in an IVF setting. Oocyte quality may be poor with decreased implantation rates for embryos and a reduced pregnancy rate per cycle.

This reduction in fecundity may be due to:

  • Alterations in egg pick up and transport
  • Hormonal changes in the ovary
  • Interference with sperm function, fertilization, or embryo implantation

Patients with endometriosis have an increased incidence of the following conditions that may have an immune basis:

  • Lupus
  • Mononucleosis
  • Yeast Infection
  • Ovarian cancer
  • Breast cancer
  • Hematopoietic cancer

Endometriosis Symptoms

  • Pain
  • Infertility
  • Menstrual abnormalities

An astute physician considers this important diagnosis in the asymptotic infertility patient (especially if there is a family history or if child bearing has been delayed). Other factors include the woman who presents with pelvic pain during menstruation, intercourse, bowel movements or bladder emptying.

The diagnosis of endometriosis may be suspected after a thorough gynecological exam reveals the presence of tenderness, nodularity, and possibly scarring in the pelvis. Sometimes endometriosis is seen on the ovary as a chocolate cyst (a collection of altered blood) via an ultrasound examination. MRI has also recently shown much promise in the diagnosis of advanced endometriosis.

Laparoscopy forms the cornerstone for the evaluation and diagnosis of endometriosis. The procedure is performed under general anesthesia in a surgical center. A small needle is inserted into the abdominal cavity and CO2 gas is introduced. The laparoscope (a telescope with a strong light, a laser, and a camera) is introduced through the navel into the pelvis and through other small incisions; a variety of instruments can be inserted to perform diagnostic and corrective surgery.

This procedure allows Dr. Kustin to directly visualize the internal organs and identify endometriotic lesions. In every case, he undertakes a meticulous evaluation of the pelvis, documenting his findings by video (it is routine for Dr. Kustin to review this video with his postoperative patients so that they may gain a first hand understanding of their surgical problems). All cases of endometriosis are staged according to the criteria of the American Society for Reproductive Medicine (Stage one (mild) to Stage 4 (severe)).

Endometriotic lesions present in many forms. Some are classical and others are subtle requiring careful microscopic evaluation. Classical endometriotic lesions are dark blue, dark brown, or black and may be cystic.

Non classical endometriotic lesions may be non-pigmented minimal in nature and are seen in young patients who experience a great deal of pain. These lesions may present as red, white, or yellow spots, non-pigmented vesicles or circular folds.

Failure to diagnose and remove non-pigmented endometriotic lesions may lead to a sub optimal outcome with continued pain and infertility. It is important to realize that endometriosis is an inflammatory process that results in adhesion formation (scarring), which has a distorting effect on the tissue, that it affects i.e. ovary, bowel, and bladder. As the inflammatory process advances, it may be the adhesions that are responsible for the pain and alteration of function seen in the pelvic organs.

Dr. Kustin has completed advanced training (and is certified in the use of several lasers) and has over twelve years experience in treating advanced cases of endometriosis using minimally invasive laparoscopic surgery. He is truly an expert in the diagnosis and treatment of this crippling disease.

By incorporating a multidisciplinary surgical approach (with a bowel surgeon and urologist) he is able to perform even the most complex operations, including the resection of stage 4 endometriosis, via the laparoscope thus avoiding painful laparotomy (a large incision to enter the pelvis compared to three or four small incisions required for laparoscopy.) He was one of the few physicians in the Pacific Northwest who can perform these complex laparoscopic surgeries.

Laparoscopy provides an opportunity for the simultaneous diagnosis and treatment of endometriosis. Dr. Kustin routinely performs the following procedures:

  • Endometriotic lesions and scar tissue may be excised from the pelvis thus restoring the anatomy to normal and improving pain and fertility. The lesions are usually removed with laser or electric scissors. In advanced cases, the peritoneum (lining of the pelvis) is completely removed in the hope that the regenerated tissue will be free of endometriosis (peritoneal striping)
  • Endometriomas (ovarian cysts of endometriosis) can be conservatively treated with restoration of a functional ovary and tube. In more severe cases, the ovary may need to be removed
  • Lesions on the bowel and bladder are removed without damage to the underlying organs. In cases involving the urethra (tube between kidney and bladder) uteric stints are placed through the bladder by the urologist using a telescope. This facilitates the safe removal of overlying uteric endometriosis
  • Procedures performed to limit pain (LUNA procedure, pre-sacral neurectomy uterine supersion)

The endoscopic approach described above facilitates a speedy recovery after outpatient surgery or a short hospitalization with less pain and scarring compared to traditional open surgery by laparotomy and some studies show superior pregnancy rates.

In the most advanced cases (usually when child bearing is complete), when pain is unremitting and all other approaches have failed) total abdominal hysterectomy with removal of the ovaries, appendectomy, and possibly bowel and urologic surgery may be indicated. Dr. Kustin employs a multidisciplinary surgical approach involving an experienced bowel surgeon and a urologist in the patient's direct care.

Endometriosis- The Enigma

The sophisticated reader should be aware that there are many facets of this disease that remain unclear and require further study.

  • There is an imprecise correlation between the degree of pain and extent of the disease
  • Early lesions clear or red are possibly more metabolically active and more painful that older dark or fibrotic lesions.
  • There is no definite relationship between the severity of endometriosis and infertility.

Endometriosis tends to recur in some patients following laparoscopic treatments and it is impossible to predict who will be affected. In severe cases, the use of additional medical therapy may be indicated postoperatively, especially if the amount of residual disease is low (following extensive resection) and the efficacy of medical treatment is enhanced. Medical Treatment of Endometriosis Endometriosis is a chronic condition requiring a multidisciplinary approach with realistic goals.

Dr. Kustin and his entire staff are dedicated to treating people not patients. We are pleased to work with other health professionals such as pain specialists, Internists, and pain psychologists to insure the best outcome for our patients. The goals of treatment must be clearly outlined at the outset. These include:

  • Decreasing pain
  • Improving function
  • Limiting recurrence and improving the quality of life
  • The maintenance or enhancement of infertility

Given the hormonal dependence of the endometriotic lesions, drug therapy (sometimes combined with surgery) has a role in the treatment of this disease, and may take several approaches including:

  • Continuous oral contraceptives to suppress menstruation
  • GnRH analog (Lupron or Synarel) administration for 6 months to reversibly lower estrogen levels to the menopausal range facilitating the regression of endometriosis

Side effects of Lupron include:

  • Hot flashes
  • Cessation of menses
  • Slight osteopenia (bone loss) approximately 3-4% of bone mass loss without total recovery.
  • Vaginal dryness
  • Mood changes
  • Decreased libido.

If side effects become problematic, small amounts of estrogen (carefully monitored) may be administered to raise the estrogen level slightly while maintaining a therapeutic level. Progestins may also be used to help control side effects. Pain improvement is seen in over 80% of patients treated with this modality.

Danocrine, a male hormone, is rarely used these days because of its intolerable side effects. Sometimes estrogen and Progesterone are combined to stop menstruation.

Adenomyosis

Adenomyosis is a common condition where the uterine lining (endometrium) invades the uterine musculature causing an inflammatory process. It is therefore, a form of endometriosis involving the uterus.

Patients with this condition present with pelvic pain and painful menses. The uterus feels soft and boggy on examination. The only reliable way to treat this condition, and make the diagnosis, is by performing a hysterectomy

In summary, endometriosis is a common condition in infertility patients that may be silent, but must be considered.

As we approach the next millennium, there are many treatment options and as new information becomes available, new therapies will follow. These new therapies will hopefully improve pregnancy rates.

 


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