What is Endometriosis?

Endometriosis is when the tissue that makes up the uterine lining (the lining of the womb) is present on other organs inside your body. Endometriosis is usually found in the lower abdomen, or pelvis, but can appear anywhere in the body. Women with endometriosis often have lower abdominal pain, pain with periods, or pain with sexual intercourse, and may report having a hard time getting pregnant. On the other hand, some women with endometriosis may not have any symptoms at all.

Endometriosis is estimated to affect between 3% and 10% of reproductive-aged women. Endometriosis can only be truly diagnosed by a doctor performing a laparoscopy (a surgery where a doctor looks in the abdomen with a camera usually through the belly button) and taking a sample of a suspected abnormality. Thus, the proportion of women affected by endometriosis differs among women having surgery for different reasons. In women without symptoms who are having surgery for elective sterilization (having their tubes tied), 1-7% will actually have endometriosis diagnosed at the time of their surgery, as will 12-32% of women having surgery for pelvic pain, and 9-50% of women having surgery for infertility. Endometriosis is rarely found in girls before they start their period, but it is found in up to half of young girls and teens with pelvic pain and painful periods.

Symptoms

The primary symptom of endometriosis is pelvic pain, often associated with menstrual periods. Although many experience cramping during their menstrual periods, those with endometriosis typically describe menstrual pain that's far worse than usual. Pain also may increase over time.

Common signs and symptoms of endometriosis include:

• Painful periods (dysmenorrhea). Pelvic pain and cramping may begin before and extend several days into a menstrual period. You may also have lower back and abdominal pain.
• Pain with intercourse. Pain during or after sex is common with endometriosis.
• Pain with bowel movements or urination. You're most likely to experience these symptoms during a menstrual period. Excessive bleeding. You may experience occasional heavy menstrual periods or bleeding between periods (intermenstrual bleeding).
• Infertility. Sometimes, endometriosis is first diagnosed in those seeking treatment for infertility. Other signs and symptoms. You may experience fatigue, diarrhea, constipation, bloating or nausea, especially during menstrual periods.

The severity of your pain may not be a reliable indicator of the extent of your condition. You could have mild endometriosis with severe pain, or you could have advanced endometriosis with little or no pain.

Endometriosis is sometimes mistaken for other conditions that can cause pelvic pain, such as pelvic inflammatory disease (PID) or ovarian cysts. It may be confused with irritable bowel syndrome (IBS), a condition that causes bouts of diarrhea, constipation and abdominal cramping. IBS can accompany endometriosis, which can complicate the diagnosis.

Causes

Although the exact cause of endometriosis is not certain, possible explanations include:

• Retrograde menstruation. In retrograde menstruation, menstrual blood containing endometrial cells flows back through the fallopian tubes and into the pelvic cavity instead of out of the body. These endometrial cells stick to the pelvic walls and surfaces of pelvic organs, where they grow and continue to thicken and bleed over the course of each menstrual cycle.
• Transformation of peritoneal cells. In what's known as the "induction theory," experts propose that hormones or immune factors promote transformation of peritoneal cells — cells that line the inner side of your abdomen — into endometrial-like cells.
• Embryonic cell transformation. Hormones such as estrogen may transform embryonic cells — cells in the earliest stages of development — into endometrial-like cell implants during puberty.
• Surgical scar implantation. After a surgery, such as a hysterectomy or C-section, endometrial cells may attach to a surgical incision.
• Endometrial cell transport. The blood vessels or tissue fluid (lymphatic) system may transport endometrial cells to other parts of the body.
• Immune system disorder. A problem with the immune system may make the body unable to recognize and destroy endometrial-like tissue that's growing outside the uterus.

Risk Factors

Several factors place you at greater risk of developing endometriosis, such as:

• Never giving birth
• Starting your period at an early age
• Going through menopause at an older age
• Short menstrual cycles — for instance, less than 27 days
• Heavy menstrual periods that last longer than seven days
• Having higher levels of estrogen in your body or a greater lifetime exposure to estrogen your body produces
• Low body mass index
• One or more relatives (mother, aunt or sister) with endometriosis
• Any medical condition that prevents the passage of blood from the body during menstrual periods
• Disorders of the reproductive tract

Endometriosis usually develops several years after the onset of menstruation (menarche). Signs and symptoms of endometriosis may temporarily improve with pregnancy and may go away completely with menopause, unless you're taking estrogen.

Complications

Infertility

The main complication of endometriosis is impaired fertility. Approximately one-third to one-half of women with endometriosis have difficulty getting pregnant. For pregnancy to occur, an egg must be released from an ovary, travel through the neighboring fallopian tube, become fertilized by a sperm cell and attach itself to the uterine wall to begin development. Endometriosis may obstruct the tube and keep the egg and sperm from uniting. But the condition also seems to affect fertility in less-direct ways, such as by damaging the sperm or egg. Even so, many with mild to moderate endometriosis can still conceive and carry a pregnancy to term. Doctors sometimes advise those with endometriosis not to delay having children because the condition may worsen with time.

Cancer

Ovarian cancer does occur at higher than expected rates in those with endometriosis. But the overall lifetime risk of ovarian cancer is low to begin with. Some studies suggest that endometriosis increases that risk, but it's still relatively low. Although rare, another type of cancer — endometriosis-associated adenocarcinoma — can develop later in life in those who have had endometriosis.

Uterine fibroids

Uterine fibroids are noncancerous growths of the uterus that often appear during childbearing years. Also called leiomyomas or myomas, uterine fibroids aren't associated with an increased risk of uterine cancer and almost never develop into cancer.

Fibroids range in size from seedlings, undetectable by the human eye, to bulky masses that can distort and enlarge the uterus. You can have a single fibroid or multiple ones. In extreme cases, multiple fibroids can expand the uterus so much that it reaches the rib cage and can add weight.

Many women have uterine fibroids sometime during their lives. But you might not know you have uterine fibroids because they often cause no symptoms. Your doctor may discover fibroids incidentally during a pelvic exam or prenatal ultrasound.

Symptoms

Many women who have fibroids don't have any symptoms. In those that do, symptoms can be influenced by the location, size and number of fibroids.

In women who have symptoms, the most common signs and symptoms of uterine fibroids include:

1. Heavy menstrual bleeding
2. Menstrual periods lasting more than a week
3. Pelvic pressure or pain
4. Frequent urination
5. Difficulty emptying the bladder
6. Constipation
7. Backache or leg pains

Rarely, a fibroid can cause acute pain when it outgrows its blood supply, and begins to die.

Fibroids are generally classified by their location. Intramural fibroids grow within the muscular uterine wall. Submucosal fibroids bulge into the uterine cavity. Subserosal fibroids project to the outside of the uterus.

Causes

Doctors don't know the cause of uterine fibroids, but research and clinical experience point to these factors:

1. Genetic changes Many fibroids contain changes in genes that differ from those in typical uterine muscle cells.
2. Hormones Estrogen and progesterone, two hormones that stimulate development of the uterine lining during each menstrual cycle in preparation for pregnancy, appear to promote the growth of fibroids.

Fibroids contain more estrogen and progesterone receptors than typical uterine muscle cells do. Fibroids tend to shrink after menopause due to a decrease in hormone production.

3. Other growth factors Substances that help the body maintain tissues, such as insulin-like growth factor, may affect fibroid growth.
4. Extracellular matrix (ECM) ECM is the material that makes cells stick together, like mortar between bricks. ECM is increased in fibroids and makes them fibrous. ECM also stores growth factors and causes biologic changes in the cells themselves.

Doctors believe that uterine fibroids develop from a stem cell in the smooth muscular tissue of the uterus (myometrium). A single cell divides repeatedly, eventually creating a firm, rubbery mass distinct from nearby tissue.

The growth patterns of uterine fibroids vary — they may grow slowly or rapidly, or they may remain the same size. Some fibroids go through growth spurts, and some may shrink on their own.

Many fibroids that have been present during pregnancy shrink or disappear after pregnancy, as the uterus goes back to its usual size.

Risk factors

There are few known risk factors for uterine fibroids, other than being a woman of reproductive age. Factors that can have an impact on fibroid development include:

1. Race Although all women of reproductive age could develop fibroids, black women are more likely to have fibroids than are women of other racial groups. In addition, black women have fibroids at younger ages, and they're also likely to have more or larger fibroids, along with more-severe symptoms.
2. Heredity If your mother or sister had fibroids, you're at increased risk of developing them.
3. Other factors Starting your period at an early age; obesity; a vitamin D deficiency; having a diet higher in red meat and lower in green vegetables, fruit and dairy; and drinking alcohol, including beer, appear to increase your risk of developing fibroids.

Complications

Although uterine fibroids usually aren't dangerous, they can cause discomfort and may lead to complications such as a drop in red blood cells (anemia), which causes fatigue, from heavy blood loss. Rarely, a transfusion is needed due to blood loss.

Pregnancy and fibroids

Fibroids usually don't interfere with getting pregnant. However, it's possible that fibroids especially submucosal fibroids could cause infertility or pregnancy loss.

Fibroids may also raise the risk of certain pregnancy complications, such as placental abruption, fetal growth restriction and preterm delivery.

Ovarian cysts

Ovarian cysts are fluid-filled sacs or pockets in an ovary or on its surface. Women have two ovaries — each about the size and shape of an almond — on each side of the uterus. Eggs (ova), which develop and mature in the ovaries, are released in monthly cycles during the childbearing years.

Many women have ovarian cysts at some time. Most ovarian cysts present little or no discomfort and are harmless. The majority disappears without treatment within a few months.

However, ovarian cysts especially those that have ruptured can cause serious symptoms. To protect your health, get regular pelvic exams and know the symptoms that can signal a potentially serious problem.

Symptoms

Most cysts don't cause symptoms and go away on their own. However, a large ovarian cyst can cause:

1. Pelvic pain a dull or sharp ache in the lower abdomen on the side of the cyst.
2. Fullness or heaviness in your abdomen.
3. Bloating

Causes

Most ovarian cysts develop as a result of your menstrual cycle (functional cysts). Other types of cysts are much less common.

Functional cysts

Your ovaries normally grow cyst-like structures called follicles each month. Follicles produce the hormones estrogen and progesterone and release an egg when you ovulate.

If a normal monthly follicle keeps growing, it's known as a functional cyst. There are two types of functional cysts:

• Follicular cyst Around the midpoint of your menstrual cycle, an egg bursts out of its follicle and travels down the fallopian tube. A follicular cyst begins when the follicle doesn't rupture or release its egg, but continues to grow.
• Corpus luteum cyst When a follicle releases its egg, it begins producing estrogen and progesterone for conception. This follicle is now called the corpus luteum. Sometimes, fluid accumulates inside the follicle, causing the corpus luteum to grow into a cyst.

Functional cysts are usually harmless, rarely cause pain, and often disappear on their own within two or three menstrual cycles.

Other cysts

Types of cysts not related to the normal function of your menstrual cycle include:

• Dermoid cysts Also called teratomas, these can contain tissue, such as hair, skin or teeth, because they form from embryonic cells. They're rarely cancerous.
• Cystadenomas These develop on the surface of an ovary and might be filled with a watery or a mucous material.
• Endometriomas These develop as a result of a condition in which uterine endometrial cells grow outside your uterus (endometriosis). Some of the tissue can attach to your ovary and form a growth.

Dermoid cysts and cystadenomas can become large, causing the ovary to move out of position. This increases the chance of painful twisting of your ovary, called ovarian torsion. Ovarian torsion may also result in decreasing or stopping blood flow to the ovary.

Risk factors

Your risk of developing an ovarian cyst is heightened by:

• Hormonal problems These include taking the fertility drug clomiphene (Clomid), which is used to cause you to ovulate.
• Pregnancy Sometimes, the cyst that forms when you ovulate stays on your ovary throughout your pregnancy.
• Endometriosis This condition causes uterine endometrial cells to grow outside your uterus. Some of the tissue can attach to your ovary and form a growth.
• A severe pelvic infection If the infection spreads to the ovaries, it can cause cysts.
• A previous ovarian cyst If you've had one, you're likely to develop more.

Complications

Some women develop less common types of cysts that a doctor finds during a pelvic exam. Cystic ovarian masses that develop after menopause might be cancerous (malignant). That's why it's important to have regular pelvic exams.

Infrequent complications associated with ovarian cysts include:

• Ovarian torsion Cysts that enlarge can cause the ovary to move, increasing the chance of painful twisting of your ovary (ovarian torsion). Symptoms can include an abrupt onset of severe pelvic pain, nausea and vomiting. Ovarian torsion can also decrease or stop blood flow to the ovaries.
• Rupture A cyst that ruptures can cause severe pain and internal bleeding. The larger the cyst, the greater the risk of rupture. Vigorous activity that affects the pelvis, such as vaginal intercourse, also increases the risk.

Uterine prolapse

Uterine prolapse occurs when pelvic floor muscles and ligaments stretch and weaken and no longer provide enough support for the uterus. As a result, the uterus slips down into or protrudes out of the vagina.

Uterine prolapse can occur in women of any age. But it often affects postmenopausal women who've had one or more vaginal deliveries.

Mild uterine prolapse usually doesn't require treatment. But if uterine prolapse makes you uncomfortable or disrupts your normal life, you might benefit from treatment.

Symptoms

Mild uterine prolapse generally doesn't cause signs or symptoms. Signs and symptoms of moderate to severe uterine prolapse include:

1. Sensation of heaviness or pulling in your pelvis.
2. Tissue protruding from your vagina.
3. Urinary problems, such as urine leakage (incontinence) or urine retention.
4. Trouble having a bowel movement.
5. Feeling as if you're sitting on a small ball or as if something is falling out of your vagina.
6. Sexual concerns, such as a sensation of looseness in the tone of your vaginal tissue.

Often, symptoms are less bothersome in the morning and worsen as the day goes on.

Causes

Uterine prolapse results from the weakening of pelvic muscles and supportive tissues. Causes of weakened pelvic muscles and tissues include:

1. Pregnancy
2. Difficult labor and delivery or trauma during childbirth
3. Delivery of a large baby
4. Being overweight or obese
5. Lower estrogen level after menopause
6. Chronic constipation or straining with bowel movements
7. Chronic cough or bronchitis
8. Repeated heavy lifting

Risk factors

Factors that can increase your risk of uterine prolapse include:

1. One or more pregnancies and vaginal births
2. Giving birth to a large baby
3. Increasing age
4. Obesity
5. Prior pelvic surgery
6. Chronic constipation or frequent straining during bowel movements
7. Family history of weakness in connective tissue
8. Being Hispanic or white

Complications

Uterine prolapse is often associated with prolapse of other pelvic organs. You might experience:

• Anterior prolapse (cystocele) Weakness of connective tissue separating the bladder and vagina may cause the bladder to bulge into the vagina. Anterior prolapse is also called prolapsed bladder.
• Posterior vaginal prolapse (rectocele) Weakness of connective tissue separating the rectum and vagina may cause the rectum to bulge into the vagina. You might have difficulty having bowel movements.

Severe uterine prolapse can displace part of the vaginal lining, causing it to protrude outside the body. Vaginal tissue that rubs against clothing can lead to vaginal sores (ulcers.) Rarely, the sores can become infected.