Endometriosis is a common disease in women, in which the inner lining of the uterus (endometrium in Latin) implants outside the womb, causing cysts and/or scarring. There are different theories why the lining migrates, causing damage; the most popular theory being «retrograde menstruation» - during menstruation, one part of the blood does not flow out of the vagina, but is transported backwards into the abdominal cavity through the Fallopian tubes. This in itself is a normal phenomenon, and it is also normal to find living cells of the lining in this blood.
Now comes the abnormal part: the cells of the uterine lining implant, multiply and participate in the menstrual cycle. This in turn produces waste products and inner bleeding during subsequent menstruations, waste that cannot escape. The body reacts with a kind of inflammatory reaction with increased blood flow, pain and scarring.
Picture on the right: Red and brown spots of endometriosis in a typical location on the posterior ligaments of the womb. During menstruation, inner bleeding and pain occur.
It is estimated that 10 to 15 percent of women suffer from endometriosis. The extent of disease does not always go in parallel with the perceived symptoms - some women do not feel any pain at all, while others have intense pain early in the process or cannot conceive.
increased pain before and during menstruation
pain during sexual intercourse, especially sore spots deep in the woman's pelvis (not to be confounded with pain at first peneration, which is usually related to cramping and lack of lubrication)
fertility problems (subfertility). Endometriosis can block the Fallopian tubes, form cysts in the ovaries (which, in turn, interfere with ovulation) and alter the biochemical situation in the woman's pelvis, affecting egg quality and egg transport. Some women do not conceive merely by avoiding intercourse because of anticipated pain. You will find more informations in the Fertility section.
Picture on the right: Close-up view of a typical deep focus of endometriosis behind the left ovary, showing sprouts of new blood vessels coming from all sides. See effect of surgical operation by clicking on the image.
More possible symptoms of endometriosis:
nausea, migraine, fever;
too frequent and/or too strong menstrual bleeding (especially when the uterine muscle is affected, so-called adenomyosis);
passing blood with urine or stool during menstruation (this can hint to involvement of bladder and/or rectum);
chronic, cycle-independent lower abdominal pain.
As a disease of the inner lining of the abdominal cavity, endometriosis can only be diagnosed by inspecting the pelvis visually and by taking samples for tissue examination. This is done by laparoscopy under anaesthesia (see the Surgery section). Important note: the laparoscopy should always be done in a properly equipped hospital, where a «see and treat»-approach is feasible during the same intervention.
Pictures on the right (click to see high resolution):
Advanced grade III endometriosis with typical «chocolate cyst» in the left ovary, the chocolate-like fluid being thickened menstrual blood from many menstrual cycles. The cyst is being opened, rinsed …
… and, according to the individual situation, removed entirely or inactivated with electrical current or laser. The healthy ovarian tissue recovers quickly; the patient shown on the right conceived a healthy baby within six weeks !
Current knowledge emphasises proper and complete surgery, which makes hormonal suppression rarely necessary. If a direct fertility treatment by IVF is planned because of severe endometriosis, the menstrual cycle is suppressed by contraceptive pills or GnRH analogs for approximately two months. This treatment is nowadays possible without menopausal symptoms like hot flashes, thanks to so-called add-back treatment with low-dosed estrogen.
Young women without desire to conceive should use a continuous hormonal contraception to avoid menstrual bleeding (like birth control pill taken without pause, or progesterone-releasing coil). The course of endometriosis is largely unpredictable. Many women will be cured (often after a pregnancy), others have painful relapses over many years.