Endometriosis is a condition affecting 10 percent to 20 percent of women; it is a condition that can cause debilitating pelvic pain and infertility. The disease has long been under-recognized and under-treated.
Today, women, foundations, and physicians are leading a new movement—in the United States and worldwide—to properly diagnose and treat women with this disease. Most recently, a worldwide study found the economic burdens of the disease to be significant. The economic burden may not be important to a suffering individual, but the realization that a particular disease leads to significant loss of working days and health-care expenditures results in increasing awareness of its impact. This, in turn, leads to dollars spent on research to improve treatments—and ultimately to help women.
Endometriosis is a condition in which the tissue that normally lines the uterus, termed the endometrium, is found outside the uterus. This tissue, which is referred to as ectopic endometrial tissue, is located predominantly in the pelvis. It can be on the top of the rectum, the ovaries, the Fallopian tubes, or the bladder. This tissue can also be found in other parts of the abdomen, the lungs, and even the brain. The misplaced endometrial tissue is responsive to the monthly cycles in a woman’s hormone that result in bleeding each month. This bleeding into the pelvis or abdomen can lead to pain (usually pelvic), scarring of tissues, and infertility.
The symptoms of endometriosis can range from mild pelvic pain just before and during a woman’s period to crippling pain throughout the month. Other symptoms associated with endometriosis include bladder pain, rectal pain, pain with intercourse and sex, rectal bleeding, or urinary tract bleeding. Some women with significant endometriosis have no pain at all.
Getting a Diagnosis
No one really understands the cause of endometriosis and whether it can be prevented. Endometriosis should be suspected when a woman has severe pain with her periods, heavy periods, or any of the symptoms noted below. Without recognition and diagnosis, treatment cannot be initiated. Women must talk to their physicians if they are having debilitating pain with their periods or significant pelvic pain. What was once labeled as “bad period pain” may indeed be due to endometriosis, and no longer should women be expected to suffer in silence during these days of each month.
Endometriosis is typically diagnosed by a surgical procedure called a laparoscopy, or belly-button surgery. During this surgery, a thin, lit tube is placed into the pelvic and abdominal cavity; these regions are inspected and biopsies of any abnormal areas are taken. Pictures are usually taken in order to document the amount and location of the disease. Endometriosis of the ovaries, called endometriomas, can also be diagnosed on an ultrasound.
Treatment for endometriosis typically consists of hormonal treatments such as birth-control pills, progestins, ovarian suppression of hormone production, or surgical resection. Surgical resection may consist of resection of disease only, removal of a portion of an ovary, or hysterectomy with or without removal of the ovaries.
Treatment of the condition is dependent on treatment goals (whether to relieve pain or to treat infertility) and desires for future fertility. Treatment options can be varied and controversial. Most recently there has been a growing movement in favor of resection of the disease. Clinicians are also employing, with more frequency, pelvic-floor physical therapy techniques, along with diet and nutrition interventions to help women. Newer data also suggest that treatment with a type of drug usually used to treat breast cancer—aromatase inhibitors—may also be effective in helping to control endometriosis pain. Unfortunately, many women with severe pain will ultimately resort to narcotics.
While endometriosis is a very common condition, it can be quite difficult to treat. A general gynecologist most often treats mild and moderate endometriosis with birth-control pills, other hormones, and/or Lupron (a drug that temporarily shuts down the ovaries). Lupron may be given alone or with “add back” estrogen or progestin.
Moderate and severe endometriosis is generally treated by physicians and gynecologic surgeons who have a special interest in the condition. This may be a physician with additional training in reproductive endocrinology, gynecologic oncology (due to the complex nature of the surgery related to the disease), or those with additional training and skills in minimally invasive surgery.
If you suspect that you may have endometriosis based on the symptoms listed below, review this with your physician.
- Painful periods
- Lower back pain which occurs in a cyclical nature
- Pain with intercourse
- Pain after sex
- Pain with bowel movements or urination (this may be worse with your period)
- Heavy periods or bleeding between periods
- Fatigue, diarrhea, constipation, bloating, or nausea during periods
If, based on the symptoms above, you suspect that you may have endometriosis, review this with your physician. Make sure that you get answers to your questions and solutions to your problems.
As “Cervical Health Awareness Month” kicks off, we thought it was a great opportunity to encore this piece that Dr. Elizabeth Poynor, co-chair of WVFC’s Medical Advisory Board, wrote to launch the month in January 2010. Stay tuned for more health articles appearing in the next few weeks.
The United States Congress has designated January as Cervical Health Awareness Month. Cervical cancer screening, especially the Pap smear, has been one of the great triumphs in cancer prevention. Worldwide, cervical cancer remains one of the leading causes of death in women because many areas of the world do not have well-executed screening programs.
In North America, where Pap smear screening is well established, cervical cancer is one of the more uncommon cancers. It is important, however, to continue to emphasize the importance of screening and cervical health so we don’t become complacent about this largely preventable disease.
The Pap smear was designed to pick up early pre-cancerous changes in the cervix. It is not designed to detect cancer cells, cells from the uterus or the ovaries. While Pap smear screening recommendations have recently been under debate in this country, it is generally recommended that women start Pap smear screening soon after becoming sexually active, and yearly thereafter. As I wrote in a previous WVFC article:
Two protocols for women’s cancer screening—mammograms and Pap smears—have been credited as two of our greatest triumphs, leading to lower cancer death rates for both breast and cervical cancer. With cervical cancer, the story appeared pretty straightforward: In the United States, the cervical cancer death rate declined by 65 percent between 1955 and 1992, in large part due to the effectiveness of Pap smear screening. The death rate continues to decline each year.
If abnormal cells are detected on the Pap smear, a colposcopy will be recommended. A colposcopy is a microscopic examination of the cervix, and biopsies will be taken of abnormal areas that are seen.
Treatment of the abnormal Pap smear will be dependent on the biopsy results; it may consist of observation, with more frequent visits to the medical office, or require larger biopsies. The latter could be a LEEP (loop electrosurgical excision procedure) or a conization of the cervix. These larger biopsies remove the abnormal cells and also gather more diagnostic data to assure that no invasive cancer is present. This type of management of women has throughout the years led to lower rates of cervical cancer.
One of the great newer advances in gynecologic oncology over the past 10 years has been the realization that the human papilloma virus (HPV) causes nearly all cervical cancers. HPV is a sexually transmitted virus that is extremely prevalent and infects approximately 80 percent of sexually active women at some point in their lifetime.
Over the past five years, the HPV vaccine has been introduced to younger women in the United States. These vaccines are extremely effective at preventing the transmission of the viral types that they are designed to protect against, although their overall impact on the burden of precancers and cancers of the cervix has yet to be determined. These vaccines have not been FDA-approved for women over the age of 26.
Unfortunately, as a practicing gynecologic oncologist, I still treat a significant amount of cervical cancer in my New York City practice. This is largely due to women who have not undergone proper screening. This highlights that although we have made monumental strides in the early detection and prevention of this cancer, it is still present. Signs and symptoms of cervical cancer include abnormal vaginal discharge, abnormal vaginal bleeding, including vaginal bleeding after intercourse, and pelvic pain.
If cervical cancer is diagnosed, treatment with a gynecologic oncologist should proceed. These are specialists devoted to the surgical and medical management of cervical and other gynecologic cancers. Recently, advances for the treatment of cervical cancer include surgeries to preserve fertility in younger women.
During January, medical practitioners and community organizations will highlight issues related to cervical cancer, HPV disease and the importance of early detection. The take-home message for women is: Get your Pap smear; review with your physician the use of HPV testing, and determine your path to effective cervical screening for the future; discuss any symptoms you may be having; and review the applicability of the HPV vaccine for your daughter.
Although cervical cancer is relatively uncommon in the United States, pre-cancerous changes of the cervix are not. It is through the proper management of these pre-cancerous changes that we have been able to decrease the amount of cervical cancer in our country. We eagerly await the coming news of the worldwide impact that the HPV vaccine will have rendered.