Endometriosis: What is it and How Can it Impact Fertility?

Endometriosis is a medical condition that has received much news coverage recently. The disease process involves the abnormal growth of tissue like the lining (endometrium) of the uterine cavity outside the womb (uterus). A related condition is when that abnormal tissue grows inside the muscle wall of the uterus (adenomyosis).

How is Endometriosis Diagnosed?

Although public awareness of endometriosis has grown in recent years, achieving a timely diagnosis remains challenging. On average, it can take close to nine years from the onset of symptoms to a confirmed diagnosis.

Unfortunately, many people are still lost without a satisfactory answer. Many people ‘doctor shop’ in desperation to find an answer before finally arriving at the correct diagnosis. Identifying endometriosis is rarely straightforward. There is no single clinical sign that conclusively confirms its presence. Instead, it is often recognised through a constellation of symptoms, which may include:

• Recurring menstrual pain (dysmenorrhoea)
• Changes in bowel habits, such as constipation or diarrhoea
• Sharp, localised pelvic pain
• Persistent lower back discomfort
• Pain within the vagina
• A sensation of heaviness or fullness in the pelvis
• Pain during bowel movements
• Discomfort or pain during, or shortly after, sexual intercourse (deep dyspareunia)

These symptoms can vary in intensity and pattern, making early recognition difficult. A thorough medical history, combined with targeted investigations, is essential to avoid prolonged delays in diagnosis and to ensure appropriate care is initiated.

How is endometriosis treated?

Treatment for endometriosis often involves medicine or surgery. The approach you and your health care team choose will depend on how serious your symptoms are and whether you hope to become pregnant.

Typically, medicine is recommended first. If it does not help enough, surgery becomes an option.

Pain medicines

Your health care team may recommend pain relievers that you can buy without a prescription. They can help ease painful menstrual cramps.

Your care team may recommend hormone therapy along with pain relievers if you are not trying to get pregnant.

Hormone therapy

Sometimes, hormone medicine help ease or get rid of endometriosis pain. The rise and fall of hormones during the menstrual cycle causes endometriosis tissue to thicken, break down and bleed.

Hormone therapy is not a permanent fix for endometriosis. The symptoms could come back after you stop treatment.

Therapies used to treat endometriosis include:

• Hormonal contraceptives: Birth control pills, shots, patches, and vaginal rings help control the hormones that stimulate endometriosis. Many have lighter and shorter menstrual flow when they use hormonal birth control. Using hormonal contraceptives may ease or get rid of pain in some cases. The chances of relief seem to go up if you use birth control pills for a year or more with no breaks.
• Gonadotropin-releasing hormone (GnRH) agonists and antagonists: These medicines block the menstrual cycle and lower estrogen levels. This causes endometriosis tissue to shrink. These medicines create an artificial menopause. Taking a low dose of estrogen or progestin along with Gn-RH agonists and antagonists may ease menopausal side effects. Those include hot flashes, vaginal dryness, and bone loss. Menstrual periods and the ability to get pregnant return when you stop taking the medicine.
• Progestin therapy: Progestin is a hormone that plays a role in the menstrual cycle and pregnancy. A variety of progestin treatments can stop menstrual periods and the growth of endometriosis tissue, which may relieve symptoms. Progestin therapies include a tiny device placed in the uterus that releases levonorgestrel (Mirena, Skyla, others), a contraceptive rod placed under the skin of the arm (Nexplanon), birth control shots (Depo-Provera), or a progestin-only birth control pill (Camila, Slynd).
• Aromatase inhibitors: These are a class of medicines that lower the amount of estrogen in the body. Your health care team may recommend an aromatase inhibitor along with a progestin or combination birth control pills to treat endometriosis.

Conservative surgery

Conservative surgery removes endometriosis tissue. It aims to preserve the uterus and the ovaries. If you have endometriosis and you are trying to become pregnant, this type of surgery may boost your chances of success. It also may help if the condition causes you terrible pain — but endometriosis and pain may come back over time after surgery.

Your surgeon may do this procedure with small cuts, also called laparoscopic surgery. Less often, surgery that involves a larger cut in the abdomen is needed to remove thick bands of scar tissue. But even in severe cases of endometriosis, most can be treated with the laparoscopic method.

During laparoscopic surgery, your surgeon places a slender viewing instrument called a laparoscope through a small cut near your navel. Surgical tools are inserted to remove endometriosis tissue through another small cut. Some surgeons do laparoscopy with help from robotic devices that they control. After surgery, your health care team may recommend taking hormone medicine to help improve pain.

Fertility treatment

Endometriosis can lead to trouble getting pregnant. If you have a challenging time conceiving, your health care team may recommend fertility treatment. You might be referred to a doctor who treats infertility, called a reproductive endocrinologist. Fertility treatment can include medicine that helps ovaries make more eggs. It also can include a series of procedures that mix eggs and sperm outside the body, called in vitro fertilization. The treatment that is right for you depends on your personal situation.

Hysterectomy with removal of the ovaries

Hysterectomy is surgery to remove the uterus. Taking out the uterus and ovaries was once thought to be the most effective treatment for endometriosis. Today, some experts consider it to be a last resort to ease pain when other treatments have not worked. Other experts instead recommend surgery that focuses on the careful and thorough removal of all endometriosis tissue.

Having the ovaries removed, also called oophorectomy, causes early menopause. The lack of hormones made by the ovaries may improve endometriosis pain for some. But for others, endometriosis that remains after surgery continues to cause symptoms. Early menopause also carries a risk of heart and blood vessel diseases and certain metabolic conditions.

In people who do not want to get pregnant, hysterectomy sometimes can be used to treat symptoms linked with endometriosis. These include heavy menstrual bleeding and painful menses due to uterine cramping. Even when the ovaries are left in place, a hysterectomy may still have a long-term effect on your health. That is especially true if you have the surgery before age 35.

To manage and treat endometriosis, it is key to find a health care professional with whom you feel comfortable. You may want to get a second opinion before you start any treatment. That way, you can be sure you know all your options and the pros and cons of each.