Endometriosis develops when tissue similar to the lining of the uterus grows outside the uterus and implants elsewhere. While the condition can affect more than 11% of American women between 15 and 44, it is particularly common among women in their 30s and 40s, according to the U.S. Office on Women’s Health. Endometriosis may make it harder to get pregnant, but there are treatment options that can improve your chances of conceiving.
We sat down with OBGYNs Suzy Lipinski, M.D., with Obstetrix® of Colorado, and Keren Kohath, D.O., of Obstetrics and Gynecology of San Jose, both part of Pediatrix® Medical Group, to learn more about the condition and how it is treated.
Q: What are the symptoms of endometriosis?
Dr. Lipinski: Endometriosis can present in many different ways. Most commonly is pelvic pain and intense cramping during periods. Some patients will have nausea and vomiting due to the severity of the cramps. For others, it can lead to pain during intercourse. Urinary urgency or frequency or pain with bowel movements can also occur, as well as chronic pain and fatigue.
Symptoms can relate to where the endometriosis implants. There have been cases of implants on the diaphragm or even further from the uterus. This can lead to pain in unusual locations. Some patients may not have any symptoms or may not recognize them. Still, endometriosis may be found during surgery or treatment for other conditions.
Many patients with endometriosis will also have other related conditions, such as chronic bladder pain syndrome, irritable bowel syndrome or migraine headaches. Patients with severe symptoms often need to see a gastroenterologist or urologist in addition to their OBGYN so all aspects can be addressed. Patients who have suffered a long time with pelvic pain can have dysfunction of their pelvic floor muscles, so pelvic floor physical therapy may also be needed.
Dr. Kohath: Pelvic pain can occur during menstruation or at other times. Other symptoms include heavy menstrual bleeding, bleeding between periods and pain with urination. Some patients may also experience infertility and gastrointestinal symptoms such as bloating and constipation.
Q: How is endometriosis diagnosed?
Dr. Lipinski: Endometriosis is more common than most people realize. Diagnosis is complicated since endometriosis isn’t always seen by ultrasound, CT scan or other imaging tests. Often, diagnosis is a “suspected diagnosis” based on clinical symptoms, and treatment is started to address those symptoms. The gold-standard way to diagnose the condition is through laparoscopic surgery when a small camera is inserted into the abdomen. The implants can be seen during surgery, and heat can be used to destroy them. On rare occasions, implants or collections of endometriosis are large enough to be seen by ultrasound or other imaging. However, this is not the most common way to find endometriosis. Laboratory tests to identify endometriosis are under development but aren’t commercially available yet.
Dr. Kohath: The gold standard is laparoscopy, but diagnosing endometriosis begins with a thorough review of medical history and pelvic examination. Imaging studies cannot definitively diagnose endometriosis but can be used to detect cysts or other signs suggestive of this diagnosis.
Q: What are the risk factors for endometriosis?
Dr. Lipinski: Family history is a big risk factor. Starting periods at a young age, short menstrual cycles and heavy flow are also common risk factors. About 3% of women have an abnormal shape to their uterus, which can alter the flow of menstrual discharge and cause the blood to flow out of the fallopian tubes into the abdomen. However, this “backflow” happens in about 90% of women to a small degree. Obesity and never having been pregnant are also risk factors.
Dr. Kohath: More specifically, risk factors of endometriosis include a family history of endometriosis in a mother or sister, menstruation starting before age 11, cycles (the time between each period) that are less than 27 days and heavy and prolonged bleeding cycles.
It is important to note that having multiple children, increased time spent breastfeeding and regular exercise are associated with a decreased risk of developing endometriosis.
Q: How can endometriosis impact fertility?
Dr. Lipinski: About 30% to 50% of women with endometriosis will have some measure of infertility. For those patients seeking infertility treatment, 25% to 50% will be diagnosed with endometriosis. The cause of endometriosis-related infertility isn’t exactly known. It is thought that in the early stages of the condition, infertility is caused by inflammation and abnormal interactions with the immune system that impair implantation and the development and release of the egg. In later stages of endometriosis, damage to the fallopian tubes or pelvic scarring or obstruction can play a role.
Dr. Kohath: Many factors involving endometriosis can influence fertility, including adhesions and inflammation in the pelvic cavity that can distort pelvic anatomy, which may interfere with the fertilization of the egg and its implantation in the uterus. Endometriosis can also reduce ovarian reserve (the quantity and quality of your eggs), thereby reducing the probability of conception. Fertility can also be affected by changes in sexual intimacy due to chronic pelvic pain.
Q: How is endometriosis treated?
Dr. Lipinski: Endometriosis is common and it is treatable. Patients should not suffer in silence. If you are experiencing pelvic pain, see your OBGYN for a workup and to discuss treatment options.
Mild to moderate symptoms can be treated without a formal diagnosis of endometriosis. Non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or naproxen can be used to treat pain. Blocking the body’s ability to produce hormones is also beneficial. It can be achieved with traditional birth control pills, Depo-Provera injections or an intrauterine device (IUD) that releases progestin.
For those with more severe pain or debilitating symptoms, physicians may recommend surgery for diagnosis and treatment. Once endometriosis is confirmed, medications called gonadotropin-releasing hormone (GnRH) agonists, which block hormone production in the pituitary gland, can be used for aggressive hormone suppression. While these medications are expensive and do have side effects, they can be very effective for those with severe disease.
If you have infertility, seeing an infertility specialist for a workup and treatment based on your specific issues is best. Some patients may require a hysterectomy (removal of the uterus) with or without the removal of tubes and ovaries. This treatment is a last resort after other treatment options have failed.
Dr. Kohath: Treatment of endometriosis should be individualized based on symptoms and reproductive plans with the goal of improving pain, alleviating gastrointestinal and urinary symptoms and improving quality of life.
Treatment options include medication to manage pain, hormonal therapy, surgery and complementary therapies, such as pelvic floor physical therapy, acupuncture, diet modification and relaxation techniques.
Q: Can a woman still get pregnant if she has endometriosis?
Dr. Lipinski: Yes. While endometriosis can cause infertility, it does not guarantee infertility. If you’re having difficulty getting pregnant, seeing your primary OBGYN for an initial workup is a great start. If a couple has been trying to conceive for 12 months (or 6 months for those over age 35), a workup is indicated. OBGYNs will ask about endometriosis symptoms and other possible causes of infertility. If a patient has endometriosis and does not want to be pregnant, they should use contraception since having endometriosis doesn’t mean you can’t get pregnant.
Dr. Kohath: Endometriosis may make it more challenging to become pregnant for some individuals, but many with endometriosis have achieved successful pregnancies.
While some patients may conceive naturally, others should seek a reproductive specialist for individualized care.
To find a Pediatrix OBGYN or other provider, please visit pediatrix.com/find-care.