Published: Feb. 19, 2009
Updated: Sept. 9, 2011
The Duke Center for Endometriosis Diagnosis & Treatment offers unique, expert care to diagnose and treat endometriosis.
Endometriosis is a condition where endometrial tissue, normally found in the uterus’ lining and shed during a menstrual period, is found elsewhere in the body.
Endometriosis lesions can be found anywhere in the pelvic cavity -- on or in the ovaries, the fallopian tubes, and on the pelvic sidewall. Other common sites include the uterosacral ligaments, the cul-de-sac behind the uterus, and in the recto-vaginal septum.
In addition, these lesions can be found in other places within the pelvis including on the bladder, large or small bowel, and appendix.
The main manifestations of endometriosis are pelvic pain, adhesions, and infertility. Endometriosis is found in 15-80 percent of women with chronic pelvic pain, and in 21-65 percent of women investigated for infertility.
The most common symptom of endometriosis is pelvic pain. For many women, the pain of endometriosis is so severe and debilitating that it impacts their lives in significant ways. For other women, the pain of endometriosis is somewhat more mild.
The pain often occurs with the menstrual period, but a woman with endometriosis may also experience pain at other times in her cycle, such as with intercourse and bowel movements.
Other symptoms of endometriosis include diarrhea, constipation, abdominal bloating, irregular bleeding, and fatigue.
Endometriosis can also cause scar tissue and adhesions to develop that can distort a woman’s internal anatomy. In advanced stages, this can be severe, and internal organs such as the uterus, ovaries, and bowel may be stuck together.
There is no easy test to diagnose endometriosis. In one study, the average time from the onset of symptoms to the surgical diagnosis of endometriosis was 12 years. The best way to definitively diagnose endometriosis is to perform laparoscopic (“keyhole”) surgery and to take a biopsy of the tissue.
Surgery is an expensive, invasive procedure. Further, if the surgeon is not a specialist or experienced in recognizing endometriosis, he or she may not accurately diagnose whether endometriosis is present or not. It has been recommended that, when possible, “see and treat” laparoscopy is performed so that endometriosis is both diagnosed and treated during the same surgery.
Other tests the gynecologist may perform include ultrasounds, MRI scans, and gynecological examinations. While none of these tests can definitively rule out the presence of endometriosis, they can indicate whether the disease is present.
At Duke, treatment for endometriosis includes pain medications, hormonal suppression, or surgery.
Pain medications and hormonal suppression treat the symptoms of endometriosis. An example of hormonal suppression is when a doctor prescribes a combination of birth control pills that create a sort of “chemical pregnancy,” or, alternately, when he or she prescribes gonadotropin agonists or antagonists that create a “chemical menopause.” These medications are used to suppress the endometriosis, which can alleviate symptoms, but they do not treat infertility.
Surgery is the only treatment that removes the disease and restores normal anatomy, which is potentially curative for women who suffer from endometriosis.
The goal of surgical excision is to completely cut out all visible endometriotic implants. Excision can be performed using any number of modalities including monopolar scissors, bipolar electrosurgery, and the carbon dioxide (CO2) laser.
The surgeon will select the modality that gives the greatest confidence in removing all the endometriotic implants wherever they are found -- even over vital organs including the bladder, parts of the bowel, and the ureters.
The aim of ablation is to destroy the endometriotic implants by burning or coagulating them.
There has only ever been one well-designed trial that examined whether excision was superior to ablation for the treatment of endometriosis. Published in the journal Fertility and Sterility in December 2010, the authors of this study concluded that they were “unable to demonstrate a significant difference in pain reduction between ablation and excisional treatments”.
Although excision is not proven to be superior to ablation, excision of areas thought to have endometriosis has a number of potential advantages -- the lesion is excised down to normal tissue ensuring its complete removal, less charred areas which can lead to adhesions are produced, and the specimen removed is sent to pathology for a definitive diagnosis. This allows us to be absolutely certain that what we saw at the time of surgery really was endometriosis.
“Definitive therapy” for endometriosis is considered to be removal of the uterus (so that the woman no longer has the pain associated with her periods) and removal of both ovaries (to remove the hormonal stimulation of endometriosis). However, removing the uterus and ovaries does not eliminate the disease itself.
Some have proposed that complete excision of endometriosis itself be considered a form of definitive therapy since the goal is to remove all areas of endometriosis.
Pain is a very complex phenomenon that involves the perception of a noxious stimulus -- in this case, endometriosis. This pain stimulus can arise within tissues or organs surrounding the endometriosis lesion, as well as from the lesion itself.
For example, the pelvic floor muscles can go into spasm because the endometriosis is causing you to hurt. Other organs may cause pain that mimics or resembles the pain of endometriosis making the diagnosis of the true source of pain often challenging.
At the Duke Center for Endometriosis Diagnosis and Treatment, our doctors believe in a team approach to treatment for these patients. This may involve the care of a variety of health care providers, including your surgeon, physical therapists, and pain management specialists.
A minimally invasive approach to these operations itself (such as laparoscopy) has been shown to reduce your chances of adhesions. In addition to good surgical technique that minimizes blood loss and charring, our surgeons frequently utilize fluids or barriers that may help to reduce the chances of the development or recurrence of adhesions.