Endometriosis is a very complex, painful, and not completely understood condition involving the growth of uterine tissue (endometrium) outside the uterus. Although endometriosis usually involves the pelvis, including the ovaries and fallopian tubes, endometrial tissue can also invasively grow into the bowel and urinary tract. Extrauterine endometrial tissue acts like the endometrial tissue inside the uterus--it thickens, bleeds, and breaks down each month. However, as distinguished from the normal endometrium in the uterus, the extrauterine endometrial tissue has no way to leave the body. The external endometrium then triggers an inflammatory response which results in scar tissue and adhesions (i.e., tissues and organs sticking to each other in abnormal ways). In turn, that leads to pain which can be severe, especially during menstruation. It may also result in organ impairment. For example, loss of a kidney or permanent renal function impairment may occur if abnormal endometrial or scar tissue wraps around a ureter and impairs outflow; or, infertility if abnormal bands of fibrous tissue impair the fallopian tubes or ovaries.
Abnormally severe dysmenorrhea (pelvic pain during menstruation), dyspareunia (painful intercourse), metrorrhagia (intermenstrual bleeding), pain during urination or bowel movements, infertility, and even constipation, fatigue, and nausea may be signs of endometriosis. The severity of the pain is not necessarily correlated to the severity of the endometriosis.
Endometriosis has various clinical manifestations. It is an estrogen-dependent disease and, in many cases, the implants of endometriosis can produce its own estrogen, which is not true of normal endometrium in the uterus. When endometriosis grows invasively, such as into the bowel or urinary tract, it attracts new ingrowth of blood vessels and nerves into the tissues it invades. This infiltrative type of endometriosis, called “deep infiltrative endometriosis,” is often cited as the type most associated with chronic pelvic pain.
Endometriosis may be difficult to diagnose and many women go for months or years without a correct diagnosis. Other potential diagnoses, like pelvic inflammatory disease (PID), polycystic ovarian syndrome (PCOS) or merely ovarian cysts, and even irritable bowel (IBS) can confound the diagnosis. Failure to diagnose and treat will result in unnecessarily prolonged pain and possibly irreversible damage.
Treatment options include hormones (orally, nasally, or by injection) to prevent the ovaries from producing hormones (particularly estrogen) in an effort to both slow endometrial growth and prevent new endometrial growth--which, in turn, leads to new pockets, scar tissue, and adhesions. Hormones, though, will not destroy existent extrauterine endometrial tissue so they are not curative.
Pain medication, with or without hormones, can also be used to treat endometriosis symptoms.
Surgical options include excision of the extrauterine endometrial tissue, ablation of the lesions (with or without cauterizing blood vessels), excision of scar tissue, lysis of adhesions, and even hysterectomy (removal of the uterus), salpingectomy (fallopian tube removal), and oophrectomy (ovary removal). Even hysterectomy with bilateral salpingo-oophrectomy may not cure the pain or prevent its return.
Specialized centers exist for the diagnosis and treatment of chronic pelvic pain and are staffed by gynecologists focusing on chronic pelvic pain, endometriosis, uterine fibroids, and PID.
Endometriosis medical expert witness specialties include gynecology, urogynecology, robotic gynecology, and anesthesiology.