Endometriosis - When Everything Is Not in Its Place

Pelvic pain

The puzzle that is us.

We are all “put together” a certain way. Indeed, our physiology is very complex, from the beginning of our existence as a fertilized egg to full adulthood. The number of things that make us—us—seems to be infinite, as researchers are continually discovering new things within things, new proteins and enzymes in the blood, new receptors and neurotransmitters in the central nervous system, new processes in cells, and new actions within organs and tissues.

When the puzzle pieces don’t fit.

As complicated as we are, from our very atoms to our organ systems, it is a miracle that we exist as properly functioning persons at all. It is also amazing that when things run amuck, those are the things that are considered unusual. That is, being completely healthy is considered the norm, and not being healthy is considered unusual enough to be abnormal. This is ironic when our complexity is considered. On the contrary, it is our complexity that makes the list of illnesses and diseases so long; the sheer math makes possible countless unwholesome events on an unlimited number of levels. If everything is designed and has evolved to fit together, things that fall out of place can makes things uncomfortable at best and life-threatening at worst.

Tissue out of place does not play well with others.

Your “endometrium,” your innermost lining of your womb (uterus), is just as complex as any other tissue. Its function is especially complicated by the fact that it is directed in its duties—preparations for and allowing of implantation of a fertilized egg—by your hormonal cycle. This cycle involves hormonal stimulation to build it up, then to mature it, and then—if it’s not used (if pregnancy does not occur)—being separated away and discarded. You see this as your “period,” of course. This tissue that prepares for implantation is not merely a bed for tucking in the fertilized egg, but a dynamic layer of cells with function and a life-cycle. In other words, it’s always “busy.” Luckily, your uterus is the perfect place for it, the two co-existing as dual co-players in the cycle of life.

When it—or tissue like it—is found anywhere other than where it’s supposed to be—a condition called “endometriosis,” the neighbors will complain, because it still tries to do its thing around other tissues that don’t tolerate its dynamic physiology very well.

There goes the neighborhood.

You can think of your abdomen as a gated community. It is surrounded by a wall (the lining called “peritoneum”) that is designed to protect your organs within. The peritoneum has immunologic capabilities, especially in its ability to migrate to areas of trouble and wall them off. Endometriosis is one such thing that be a significant area of trouble. Besides being a “gated” community, your abdominal cavity is also a bit snobby. It does not take kindly to troublemakers making a lot of commotion, especially if it disturbs the other organs and tissues going about their usual business (bladder holding and releasing urine, intestines moving feces down the line, ovaries trying to make hormones and ovulate eggs for conception, fallopian tubes remaining patent for the eggs to travel, and the rectum holding and pushing feces for periodic elimination.

Endometriosis makes commotion in the otherwise quiet and peaceful neighborhood by provoking a significant inflammatory response. Bloody tissue meant to be discarded on a tampon, when trapped in an inescapable container (like your abdomen), is very irritating and sets the peritoneum into motion to wall it off. This causes things to stick to each other, not only physically displacing them, but taking them out of their comfort zone for optimal function. For instance, a fallopian tube kinked by a peritoneal “adhesion” may make smooth passage of a fertilized egg impossible. An ovarian cyst of endometriosis, called an endometrial cyst, can block ovulation or interfere with hormonal production. A mass of endometriosis between your uterus and rectum, called an “endometrioma,” can cause the “frozen pelvis” seen as a cause of chronic pelvic pain and painful intercourse. The inflammation over the rectum can make bowel movements excruciating or on the bladder make a full or emptying bladder send pain signals.

It gets weirder.

There is considerable debate about how endometriosis occurs—that is, how tissue like the lining of your uterus comes to be in another location altogether. The direct approach seems the most logical—as when it is theorized that “retrograde menstruation,” the backwards sloughing of endometrium, causes migration not onto a tampon or napkin, but back up the tubes to drip into your abdomen where it stays. It has also been found in places where needles have been placed—like when an amniocentesis is done during pregnancy, the path of the needle tract can sometimes exhibit endometriosis.

But what about places other than your abdomen? One of the strangest things about endometriosis is its presence remote from the abdomen. The lungs, the brain, even the belly button have been places where endometriosis has been found. Monthly episodes of coughing up blood, umbilical spotting, and even mini-strokes have been identified due to endometriosis elsewhere in the body. Explanations for these very strange presentations vary from embryonic stem cells remaining to produce endometriosis later in the wrong spots to blood or lymphatics carrying endometrial cells to these exotic locations.

Putting the pieces back together.

Endometriosis is an unsolvable puzzle, indeed, because the pieces don’t fit together. The tissue is foreign anywhere else other than where it should be, and its dynamic biochemistry makes it a hazard to organs that are not designed to function among the inflammation and exaggerated immune responses it causes. Unlike traditional puzzles, however, the key to solving it is to remove, completely, the pieces that don’t fit. This is a metaphor for the treatment for the condition of endometriosis—that is, surgically excising the abnormally-placed tissue so that the other organs can resume normal function again. Today, surgery to remove endometriosis has matured from a major life-threatening procedure to the minimally-invasive laparoscopic and robot surgeries available today, making recovery short and discomfort minimum.

Removing endometriosis from the lung and brain, certainly, is more difficult, and its presence in these places emphasizes how abnormal things can become when the pieces don’t come together in the way they were meant. Thankfully, those situations are as rare as they are weird, and most endometriosis can be pursued and eliminated because of the usual place it invades, your abdomen, immediately accessible via minimally invasive procedures.

Ulas Bozdogan, MD

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