Living with Endometriosis
Endometriosis simply refers to a condition in which the innermost uterine membranes, designed to thicken, organize, and then detach each menstrual cycle, implant into non-uterine areas. The most likely areas are within the abdominal cavity, which is surrounded by a layer of thin tissue called the peritoneum. This peritoneum covers most of the abdomen, even the organs within it, because this tissue reflects onto these organs and then reflects back—that is, covering the organ(s) and again continuing wrapping the contents of the abdominal cavity.
Peritoneum is a common place for endometriosis to lodge, and when it does so on the peritoneum that covers the ovaries, it can invade the tissue and swell into what is called a “chocolate cyst,” or alternatively, an “endometrioma” (mass of endometriosis). The descriptive name, chocolate cyst, is because the fluid trapped within it is old, broken down bloody menstrual-like debris which has deteriorated into a thick fluid that looks like chocolate syrup. No one quite knows how or why chocolate cysts come to be, but they are some of the most worrisome diseases in gynecology: they are a common cause of menstrual pain, painful intercourse, and jeopardy of a relationship in which intimacy becomes prohibitively painful. Another cause for concern raised by chocolate cysts is the relationship between endometriosis and infertility, and chocolate cysts—an advanced aspect of the disease—can increase fertility difficulties.
A particularly insidious problem is “silent” endometriosis, in which women live their lives without knowing they have it because of an absence of symptoms. This wastes much valuable time in that fertility is continuing to decline, and when pregnancy finally is attempted, the disease may be so progressed that the chances of conception have become severely compromised. The fact that more women who have infertility are diagnosed with endometriosis may be simply because many women are only first diagnosed with it —as a bad surprise—when they begin an investigation with a healthcare professional for inability to get pregnant. Unfortunately, these women had no idea and, worse, they now have to deal with worse disease and less chance of conception.
Unique Presentations and Individualized Care
Treatment options really depend on many factors, determined on a case-by-case basis. Any two patients seeing a physician for endometriosis will present with two very different situations, depending on age, severity, fertility desire, and pain. Age becomes a major because the severity and extent of disease, involvement with other organs, distortion to the reproductive anatomy, and the desire for pregnancy all must be weighed against the proverbial “biological clock,” making older women more of an emergency. These patients may require expedient surgical excision, rather than the more conservative and expectant measures (e.g., hormonal suppression) for which younger women may opt. Thus, the practice of gynecology, as applied to the subspecialty of endometriosis, is individualized for each patient.
Certainly minor involvement, especially in younger women or in older women who are finished their families or who not seeking pregnancy, makes a good argument for medical (non-surgical) treatment. Pain, however, can change everything. It is a subjective determinant of treatment, because pain is perceived differently by everyone. Aside from any fertility considerations, pain that impairs one’s quality of life indicates a need for more aggressive treatment, whereas minimal pain can be managed according to how much discomfort a person can tolerate before feeling the benefits of surgery outweigh the continued pain that comes without surgery.
Endometriosis is classified as to its extent:
- No evidence of endometriosis (disease is absent).
- Mild or slight (minimal endometriosis implants).
- Moderate (increased spread and extent of disease).
- Severe (heavy, intense involvement).
A source of confusion is that while there is a lot of evidence that endometriosis is related to infertility, it does not necessarily equal infertility. However, in those in which it co-exists with infertility, there are felt to be two mechanisms at work:
- Anatomical damage to the organs of reproduction.
- Negative impact on the oocyte (egg) at a microscopic level.
1. Anatomical Damage
The fallopian tubes, the connection between the uterus and the ovary through which the egg travels, can be part of the sustained anatomical damage. This is an important aspect of the disease, because the descending egg meets the ascending sperm and is fertilized at about the mid-tube portion. If anywhere along this route there is kinking, scarring, or blockage, fertilization may not occur.
The tubes, however, are much more than simple conduits. They provide the crucial environment through the complex process of fertilization, maintaining the health and well-being of the fertilized egg as it travels toward the uterus where it will implant for the full pregnancy. Besides infections, endometriosis is another major reason for interference with the tubes’ function. Such damage will prevent pregnancy.
2. Negative Impact at the Microscopic Level
The microenvironment in which egg, sperm, and the even of fertilization process itself takes place is being recognized more and more for its importance to the whole process of conception and survival of the fertilized egg until implantation. Besides alterations to the external nurturing environment, there appears to be evidence that endometriosis creates a detrimental influence on oocyte quality as well, negatively affecting shape, quality, and even its internal components such as its nucleus and cytoplasm. Furthermore, endometriosis also seems to interfere with implantation of the fertilized egg into the uterine lining. These are are each a cause of failure to conceive or implant but, when taken together, can create a particularly difficult road to pregnancy.
While the strategy may ensue unchanged throughout the treatment process, the woman can change, making necessary on-going mid-course corrections. Although this short list seems simple, the subtle influences of the desire for fertility, the quality of life as measured against pain, sexual dysfunction, and age complicate it considerably and must be taken into account in order to individualize the optimum strategy for each unique woman coming for help.