ASK DR. BAUGHAN                                             May 8, 1998

WEEDS

I received a letter asking me to write about endometriosis.

Endometriosis is a peculiar disease.  The endometrium is the lining of the inside of the uterus.  It responds to the monthly stimulation of female hormones by first thickening and growing new tissue and blood vessels before a woman ovulates (releases an egg).  After ovulation, other hormones lead to changes so that the endometrial tissue would be ready for a fertilized egg to attach if the woman became pregnant.  If the woman does not become pregnant, the endometrial lining sloughs off during her menstrual period.

One definition of a weed is “a plant that is growing where you do not want it to grow.”  The plant may be a perfectly good plant in itself, but if it is growing where we do not want it, then it is called a weed.  Endometriosis is a condition where endometrial tissue grows where it is not supposed to.  It may grow on the outside of the fallopian tubes, ovaries, bladder, intestines, or the lining of the abdominal wall.  Why it does this we do not know.  We suspect endometrial tissue might spill out the ends of the fallopian tubes during menses, but we do not know what allows it to take hold to other tissue.  Under the microscope, this tissue might look like normal endometrial tissue, but it can eventually cause plenty of havoc.  This tissue responds to the monthly cycle of hormones just like the tissue inside the uterus, but the blood has no where to go.  As the tissue grows, bleeds, and contracts, the woman may feel pain, cramping, irregular bleeding, or discomfort with intercourse.  Endometriosis may distort and scar the ovaries and fallopian tubes, making it difficult for the woman to get pregnant.  Cysts may form on the ovaries or elsewhere in the pelvis.  Endometriosis may become so extensive that it is like weeds that have taken over a garden and choked out the other plants.  I cannot think of other diseases where “normal” tissue in the wrong place causes so much trouble.

We can suspect endometriosis by its symptoms.  Sometimes we can feel small nodules on a pelvic exam or see them on an ultrasound, but the conclusive diagnosis often requires actually seeing the patches of endometriosis in the pelvis with a laparascope through a small incision in the abdomen.  If there are only a few patches visible, sometimes they can be removed through the scope.  However, this gives no guarantees that it will not return in the future.

The other treatments for endometriosis are aimed at suppressing endometrial tissue from developing.  Unfortunately, the treatments suppress the tissue inside the uterus as much as the “misplaced” tissue in the pelvis.  Birth control pills given continuously can keep the endometrial tissue minimal.  Danazol suppresses endometrial growth; unfortunately, it is expensive, and after a while, a woman can have some hair growth and other masculinizing effects since her estrogen has been blocked.  Other medicines block the release of hormones in the brain that stimulate endometrial tissue.  These work well on the endometriosis, but they induce a menopausal state while taking them.  The woman will not have periods at all, may have hot flushes, and cannot get pregnant while on the medicine.

The goals of the treatments are to get the endometriosis to shrink up enough that when they are stopped, the woman may be able to get pregnant before the endometriosis comes back.  Or at least she may have a period of relief from pain for months to years.  If the woman does not wish to become pregnant, surgery to remove the affected tissue and the ovaries may need to be done.  Unfortunately, some women have had enough scarring that even after surgery, they may continue to have pain.  Another unfortunate burden of this disease is often the guilt or shame the woman feels if she cannot get pregnant.  But the woman did nothing to cause this.  It has nothing to do with sexually transmitted diseases or any other behaviors.  We used to think delaying pregnancies into the twenties or thirties was a possible “cause,” but now we think it is simply that we may not find it until a woman wants to get pregnant.  As far as we currently know, it is a matter of endometrial tissue growing where it is not supposed to be.