Endometriosis is basically misplaced endometrium (or uterine lining). The uterine lining is rich in blood supply and nutrients, and is prepared by the body for the implantation of the fertilized egg. Every month, at the end of the cycle, the blood supply to the endometrium is cut off by the declining levels of hormones: the lining dies from lack from lack of oxygen and is passed in the form of a period. The formation of a new lining begins at this time. The uterus is able to tolerate this traumatic cyclic loss of its lining without injury, except for cramps.

When this uterine lining gets onto other body surfaces, these cyclic changes can cause scars, infertility and pain. The most common place that this occurs is in the pelvis and on the peritoneum (the lining of the abdominal cavity).

How does it get there? There are several theories. The most likely way is that menses flows the wrong way and goes out the tubes instead of out the cervix, and then it implants on the pelvic lining and sets up house. The other two theories of causation are: 1) the peritoneum itself may just change into endometrium for unknown reasons because they both start out from the same area of the developing female fetus. 2) the endometrium is being carried off by blood vessels. This would explain how endometriosis can get into the vaginal wall and occasionally as far away as a woman's lungs!

Endometriosis can be treated with both medicine and surgery. The medicines include: birth control pills, which create an imitation pregnancy (natural pregnancy can also help); Danazol, which is an estrogen blocker that will mimic menopause; and now Lupron and Syneril, which block the brain's ability to turn on the ovaries. Surgery can also be used to burn away endometriosis and repair the scaring and adhesions that it has caused.

The choice of treatment depends on the symptoms, the side effects of the treatment and the patient's desires. The birth control pill (BCP) is probably the simplest treatment, but it is less effective than the others, especially in more severe cases. The reality is that many women are treating endometriosis they don't even know they have by being on the pill. That's why I feel BCPs are the ideal contraceptive in those who can take them because, as it delays pregnancy, it protects fertility. Danazol works by blocking estrogen. Unfortunately, it also has some male hormone like side effects, such as increased hair growth, oily skin, acne, decreased breast size as well as occasional deepening of the voice. There is also some evidence that Danazol may enhance the body's own ability to eliminate it's own endometriosis. This medication is not cheap. Three pills a day for six months, at about two dollars a pill, adds up. The other two medicines I mentioned. Lupron and Syneril, work in the brain. The brain controls the ovaries by controlling hormones released from the pituitary gland called gonadatropins. The brain stimulates the pituitary to release these hormones with pulse-like secretions of something called gonadatropin releasing hormone (GNRH). Lupron and Syneril are medicines that mimic GNRH, but they are given in such a high dose they overload the pituitary and basically short it out! This stops the release of gonadatropins from the pituitary and stops ovarian function causing the endometrium both inside the uterus and outside to dry up. It's just like the menopause. Unfortunately, the medical menopause has the same problems as natural menopause: hot flashes, bone loss and vaginal atrophy. Both these medications are $300-$500 per month and for six months that really adds up, but they work well. Lupron is a shot given once a month and Syneril is a nasal spray you use twice a day.

Before I prescribe Danazol, Lupron or Syneril, I what to be sure that endometriosis is present. I do this with laparoscopy (belly-button surgery). I can also treat the problem with laparoscopy, so I is both diagnostic and therapeutic. I usually do the surgery with the laser laparoscope as an out patient, and recovery is generally quite rapid. Unfortunately, surgery has the limitation of only being able to treat visible areas of endometriosis. It can not destroy areas that are very early and not seen at the time of surgery. I will frequently advise a medical therapy after surgery to treat any residual areas not destroyed and also as a measure to stop recurrences.

These different treatments are all tested and true. The choice of which one is based on many things, but there is a therapy that will successfully treat most women with this problem. This is a more technical article than I usually write. I can offer more information at my office, I even have a video there for anyone who wants to view it.


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