Many patients who we see at Texas Fertility Center are surprised to find out that the primary cause of their infertility is endometriosis. Although this condition is very common, there are still many misconceptions about endometriosis. Over the course of the next few weeks, I’d like to take a few minutes to discuss this disease and why it’s important that we diagnose and treat it.
First of all, what is endometriosis? In a nutshell, endometriosis is normal uterine lining in an abnormal location. Every month as your egg develops, the cells around the egg (“granulosa cells”) make estrogen. This estrogen causes your uterine lining to thicken. When you ovulate, the granulosa cells undergo some changes that cause them to make both estrogen and progesterone to stabilize the uterine lining and prepare it for pregnancy. If you are not pregnant, estrogen and progesterone production stop and the uterine lining dies and comes out. In 95% of women, some of the lining cells remain alive and – rather than progressing through the cervix and out, they flow backward through the fallopian tubes. They can then land on any of the pelvic organs (most commonly the ovaries, the intestine, or the lining of the abdominal cavity), they attach, and they continue to grow. Every month, as your normal uterine lining grows and then bleeds, the lining now in your abdomen or pelvis does essentially the same thing. These areas of endometriosis – called “implants” – get larger and larger and they also occasionally bleed.
Endometriosis is an extraordinarily common condition among women of reproductive age. Studies in the literature suggest that somewhere between 25% and 45% of ALL women of reproductive age have it. The incidence in women with infertility is even higher – up to 65% in some studies. While most women erroneously believe that you must have severe symptoms, such as pain, in order to have endometriosis, in fact this is not the case. Unlike most other medical conditions in which the severity of the patient’s symptoms and the severity of the disease are related, this is not the case with endometriosis. Women with absolutely no symptoms can have severe disease. Conversely, women with excruciating pain may just have one little area of disease.
The most common symptoms of endometriosis are dysmenorrhea – or pain with periods, dyspareunia – or pain with intercourse, infertility, and pelvic pain in general. Although almost all women have some sort of cramping with their periods, dysmenorrhea is more than just your run of the mill cramps. It is pain that is frequently not completely relieved with the usual treatments of non-steroidal anti-inflammatories (like Advil, Aleve, ibuprofen, etc.). Many women with endometriosis say that their pain and cramping starts a couple of days before their menstrual flow and then it lessens or goes away once their flow really peaks. Other women describe pain that coincides with menstrual bleeding.
Dyspareunia means any type of pain with sexual intercourse. For purposes of this discussion, however, there are two basic types of pain with sex – pain with entry and pain with deep penetration. Most women with endometriosis-related dyspareunia describe pain with deep vaginal penetration. This pain may be sharp or dull and it is frequently cyclic – being most severe near the end of the monthly cycle, just before or during menstrual bleeding. Sometimes the pain is also severe in the middle of the cycle, around the time of ovulation. Oftentimes the pain is positional, and many women clearly recognize that certain sexual positions that they may have enjoyed in the past are now frequently problematic. Usually positions in which the woman can control the depth of vaginal penetration are the least bothersome whereas others may become “off limits”. Some women say that the pain is related to the angle of penetration – frequently being most severe with the penis is directed either anteriorly toward the bladder or posteriorly toward the rectum. Endometriosis may also interfere with a woman’s ability to enjoy orgasm. Part of the pleasurable sensation of an orgasm is mild contraction of the uterus that accompanies the orgasm itself. For many women with significant endometriosis, that uterine contraction is unbearable. This unfortunate condition can lead women to avoid sex altogether, leading to feelings of inadequacy and creating a strain on their marriage.
For all of these reasons, it is important to diagnose and treat endometriosis appropriately, as all of these symptoms are preventable and/or treatable. Over the course of the next several weeks, we’ll discuss many more aspects of endometriosis, so please keep checking our blog or call your TFC nurse with any questions that you may have.