Painful Periods? It May Be Endometriosis

Feeling abdominal pain, especially around your period? Endometriosis could be the culprit. We asked Lifescript's women’s health experts Robin Miller, M.D., and Janet Horn, M.D., to explain who’s at risk, what the most effective treatments are and how it affects fertility... 1. What is endometriosis? It's a condition in which the same cells that make up the uterus lining (known as endometrial cells) grow outside the uterus too. No one’s sure what causes this. These cells are most commonly found in the ovaries, fallopian tubes, ligaments holding the uterus in place, and the pelvic cavity lining. Although it’s rarer, they can also grow almost anywhere in the pelvis – such as the vagina, cervix, bladder and bowel. They’ve even been reported growing in other organs of the body, including the lung, liver, brain and skin. Normally, endometrial cells of the uterine lining are shed during the monthly menstrual cycle. Outside the uterus, they'll bleed out monthly wherever they're located. If these cells grow on organs that don’t have an exit from the body, the blood will remain, causing pain and, eventually, scar tissue. 2. What are its symptoms? The primary symptom is pain. It’s most commonly felt as painful periods or discomfort in the lower abdominal, pelvic and low back area any time throughout your cycle. Women also often have pain during or after sex, or with bowel movements or urination. Some also get gastrointestinal issues, including diarrhea or constipation, bloating or nausea. Others become extremely fatigued. 3. What are the risk factors? How common is it? Endometriosis is common. More than 5 million women in the U.S. have this condition. Risk factors include: Age. It’s most common in women of reproductive age, and unusual in postmenopausal women. Family history. Having a family member with endometriosis (a mother, sister or aunt) raises your chances. Ethnicity. Caucasians are more likely to get it than Asian or African-American women. Menstrual cycle characteristics. Women with long periods (more than seven days) or short cycles (more frequently than every 28 days) may face a higher risk. Starting your period at a very early age is another possible factor. Pregnancy history. Never giving birth or having your first child at an older age may make you more susceptible. Medical history. An infection of the reproductive tract (pelvic inflammatory disease) could damage your uterine cells, making you more susceptible to endometriosis. Also, a medical condition that prevents menstrual flow from exiting the body, such as a closed hymen, may also increase risk. Physical traits. Women who are tall and thin (with a very low BMI) are more likely to get endometriosis, according to some studies. 4. Can a woman have endometriosis without any symptoms? Yes. Symptoms aren't dependent on severity of the condition. Some women with severe endometriosis have no symptoms, while others with very mild cases suffer extreme pain. 5. How is it diagnosed? Would a doctor find it during a routine gynecological exam? Endometriosis can only be definitely diagnosed by pelvic laparoscopy [when your ob-gyn examines the pelvic organs using an instrument inserted into the navel]. If the endometrial implants [growths outside the uterus] are large enough, or if cysts form, they may be seen on a pelvic ultrasound or felt during a routine gynecologic exam. But endometriosis can still be present, even with a normal ultrasound or pelvic exam. 6. What are treatment options? Because pain is the most common symptom, treating the discomfort is important. In addition, endometriosis can lead to infertility, and should therefore be treated if a woman wants to leave open the option of pregnancy. The treatments for pain and infertility caused by endometriosis can be different. We will discuss treatment for the pain first. (See question 11 for a discussion of the treatments for infertility related to endometriosis.) Aspirin and non-steroidal anti-inflammatory drugs (NSAIDs) are usually prescribed first. If they don’t ease the pain, your doctor may try narcotics such as codeine. Hormone treatments [to lower or regulate female hormones circulating in your body] also help because estrogen makes endometriosis worse. But they have side effects and often offer only temporary relief. Here are the most common: The Pill How it works: The combined oral contraceptive pill (OC) turns off ovaries so you don't ovulate and have regular periods, which reduces hormones levels. Possible side effects: Bloating, breakthrough bleeding and acne. The pill can also increase chances of blood clots, especially in smokers, and may raise blood pressure. Progestins and progesterone How they work: Synthetic progestins and natural progesterone decrease endometrial tissue growth and probably inflammation. They can be given as pills, injections, nasal spray, or through an IUD (such as the Mirena IUD) that releases a small amount of progestin. Possible side effects: Progestins can cause weight gain, depression, headache, nausea, dizziness and sore breasts. Natural progesterone is safer, but can also make breasts tender and increase body weight. Gonadotropin-releasing hormone (GnRH) agonists and antagonists How they work: These medications, such as Lupron, essentially turn off the brain's stimulation of the ovaries. Possible side effects: Hot flashes, night sweats, body aches, vaginitis, depression, palpitations and loss of libido. Danazol How it works: This modified form of testosterone lowers estrogen and essentially induces a state of menopause. However, its many side effects make it hard to tolerate for any length of time. Possible side effects: Weight gain, acne, depression, voice changes, increased body hair and raised cholesterol levels. Aromatase inhibitors How they work: These drugs (such as Femara or Arimidex) block estrogen production and are often used to treat breast cancer as well as endometriosis. Possible side effects: Hot flashes and decreased libido. If hormonal treatments don’t work, your doctor may recommend surgery, often the definitive treatment for endometriosis. The endometrial implants and scar tissue caused by them can be removed through a small incision using a laparoscope with laser. Extensive endometriosis may require abdominal surgery. A hysterectomy may be the best way to treat it. However, this procedure doesn’t guarantee a complete cure, especially if endometriosis has spread to other areas in the pelvis. 7. Which treatment is best for me? Choice of treatment is usually based on severity of symptoms and age. For younger women, birth control pills and other hormonal treatments are the best options. However, more serious hormone treatments – such as the GnRH antagonist Lupron, danazol and aromatase inhibitors – can usually be used only for short periods due to side effects. They’re more appropriate for women who are done having babies and are in severe pain from endometriosis. If a woman wants to become pregnant and is infertile because of endometriosis, laparoscopic surgery is the best option. If she’s done having children, then a hysterectomy might be best. 8. Can endometriosis be cured? There’s no definitive cure, but it can be treated and, in some cases go into remission. However, many women find relief from pain symptoms through a multidisciplinary approach, which may include pain management with medications or hormones and/or surgery, along with complementary and alternative therapies (CAM), such as acupuncture or biofeedback. When the chronic pain from endometriosis leads to stress, CAM treatments such as massage therapy may help. (See Question 10 for further discussion of CAM therapies.) 9. Are there any promising new treatments? There is a new surgical treatment that can prevent formation of fibrous scar tissue. The pelvic cavity is rinsed with Adept, a special solution that is placed in the pelvic area to keep surfaces from rubbing together. It dissolves over time and allows surgery to remove endometriosis to be more effective. 10. What about alternative or complementary medical treatments? Nutritional therapy is very important. An anti-inflammatory diet such as the Mediterranean diet [rich in fruits, vegetables, “good fats” and whole grains] can help augment other treatments. Although there are no randomly controlled trials, some complementary therapies can help, such as acupuncture, homeopathy, osteopathy, and anti-inflammatory herbal remedies such as Zyflamend. Massage is important for relaxation, and biofeedback can help with pain control. Physical therapy for pelvic-floor relaxation should also be considered. Another option: support groups, which have helped many women. 11. Does endometriosis cause infertility? Does it pose any special risks during pregnancy? About 30%-40% of women with endometriosis are infertile. It’s one of the top three causes for female infertility. But this kind of infertility is often successfully treated using hormones and surgery. Some women with endometriosis can still have children, but their pregnancies should be considered high-risk. They’re more likely to have premature babies, complications with the placenta that leads to an increased frequency of C-sections, and a higher incidence of pre-eclampsia, a condition where high blood pressure and protein develop after the 20th week. 12. Is endometriosis linked with any other health problems? There may be a connection with some conditions, according to recent research. These include: Autoimmune diseases such as lupus, multiple sclerosis and hypothyroidism Allergies, asthma and chemical sensitivities Mitral valve prolapse Chronic fatigue syndrome and fibromyalgia Frequent yeast infections Certain cancers (ovary, breast, colon, kidney, thyroid, brain, melanoma and non-Hodgkin’s lymphoma) That means if you have endometriosis, you may also have one of the above. It doesn’t mean you will definitely get one of these conditions, or that endometriosis causes them. 13. Can I get cancer from endometriosis? Cancerous changes can occur in endometrial cells, just as in any other cells of your body. However, the rate of cancer occurring in endometrial cells is no higher than in other cells. And even though there may be a link or association between certain cancers and endometriosis, having endometriosis isn’t thought to increase your risk of getting ovarian or uterine cancer. For more information on women's health issues, visit the doctors' website, The Smart Woman's Guide to Midlife and Beyond . Do You Have Endometriosis? Can’t figure out your female problems? You may have endometriosis, a common gynecological condition in women that occurs during their reproductive years. Understanding the symptoms and how they impact you could take you one step closer to the answers and treatments you may need.