Endometriosis: Symptoms, Causes & Treatment

Endometriosis is a chronic condition in which tissue similar to the uterine lining (endometrium) grows outside the uterine cavity. This tissue can grow on the ovaries, fallopian tubes, uterine ligaments, bladder, intestines, or other pelvic sites. When these tissues bleed during menstruation, there is no outlet for the blood, causing inflammation, severe pain, and adhesions that may lead to infertility.

Endometriosis affects approximately 10-15% of women of reproductive age worldwide, with higher prevalence among women with infertility. In the Middle East and Jordan, exact statistics are limited, but cases are increasing with improved diagnosis and medical awareness. The disease significantly impacts quality of life, causing debilitating pain during menstruation and intercourse, with psychological and social consequences.

Definitive diagnosis relies on laparoscopic surgery, though clinical examination, ultrasound, and MRI may provide strong indicators. Treatment ranges from hormonal medications to manage symptoms to surgery for lesion removal, depending on disease severity and fertility desires.

Symptoms of endometriosis vary greatly among women and do not correlate with disease severity—some women with advanced lesions may be asymptomatic, while others with small lesions experience severe symptoms. Without treatment, symptoms typically worsen over time.

• Severe Menstrual Cramps (Dysmenorrhea): Sharp lower abdominal and pelvic pain starting days before menstruation and continuing for several days after.
• Painful Intercourse (Dyspareunia): Pain during or before intercourse, especially around menses, may affect intimate relationships.
• Chronic Pelvic and Lower Back Pain: May occur independent of menstrual cycle in some cases.
• Heavy Menstrual Bleeding or Prolonged Periods: May lead to anemia due to significant blood loss.
• Severe Constipation or Diarrhea: Particularly during menstruation, may accompany bowel pain.
• Infertility or Difficulty Conceiving: Often the presenting symptom; adhesions obstruct egg or sperm movement.
• Chronic Fatigue and Exhaustion: Due to heavy bleeding, anemia, and chronic pain.
• Pain During Urination or Defecation: When lesions affect the bladder or bowel.
• Bloating and Gas: Particularly before menstruation due to inflammation and adhesions.
• Depression and Anxiety: Secondary to chronic pain, infertility struggles, and reduced quality of life.

• Retrograde Menstruation: Backward flow of menstrual blood through the fallopian tubes into the pelvic cavity, where the tissue adheres and grows.
• Stem Cell Metaplasia: Transformation of peritoneal cells (pelvic lining) into endometrial-like cells under inflammatory and hormonal influence.
• Lymphatic and Vascular Dissemination: Transport of endometrial cells via blood and lymphatic vessels to distant pelvic sites.
• Immune System Dysfunction: Impaired immune response allows abnormal cells to proliferate unchecked.
• Elevated Estrogen Levels: Ectopic endometrial lesions produce local estrogen, promoting their growth and persistence.
• Chronic Inflammation: Elevated inflammatory markers perpetuate lesion growth and pain.
• Progesterone Resistance: Ectopic endometrial tissue shows reduced progesterone sensitivity, limiting inhibition of growth.

• Age: Primarily occurs between ages 25-40, though possible at any age after menarche.
• Family History: Having a mother or sister with endometriosis increases risk 6-10 fold.
• Early Menarche: Starting menstruation before age 12 increases lifetime exposure.
• Short or Heavy Menstrual Cycles: Cycles shorter than 27 days or heavy bleeding increase retrograde menstruation.
• Nulliparity or Low Parity: Never having been pregnant or having few children increases risk.
• High BMI: Obesity elevates estrogen and inflammatory markers.
• Copper IUD Use: May increase retrograde menstruation risk through certain mechanisms.
• Environmental Toxin Exposure: Dioxins and other pollutants may impair immune and hormonal function.
• Chronic Stress: Promotes systemic inflammation and pain sensitization.

Diagnosis of endometriosis relies on careful clinical assessment, as symptoms alone are insufficient. Evaluation begins with detailed medical and gynecologic history, followed by physical examination and possibly additional investigations. Definitive diagnosis requires histological confirmation through laparoscopy or surgery.

• Physical Examination: Includes abdominal and pelvic palpation, identifying masses, nodules, or tenderness in specific areas. The physician may feel hard nodules or adhesions behind the uterus.
• Ultrasound (US): Two-dimensional or three-dimensional pelvic imaging may reveal ovarian endometrial cysts. Transvaginal ultrasound has superior sensitivity compared to transabdominal approach.
• Magnetic Resonance Imaging (MRI): More accurate than ultrasound for detecting deep or extensive lesions, particularly deep infiltrating endometriosis. Positive predictive value approximately 90%.
• Laparoscopy: Gold standard for diagnosis. Allows direct visualization of lesions and biopsy confirmation. Treatment can be performed simultaneously with lesion excision.
• CA-125 Blood Test: Tumor marker may be elevated in endometriosis, but lacks specificity and may be elevated in other conditions. Normal value <35 U/mL. Limited utility in initial diagnosis.
• Other Laboratory Tests: May include estrogen and progesterone levels, though without specific diagnostic value for endometriosis.

Medications

• Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): Ibuprofen or naproxen for menstrual pain control, ideally started before menses. Effective in approximately 60% of cases, but do not halt disease progression.
• Hormonal Contraceptives: Combined estrogen-progestin pills, patches, or vaginal rings reduce bleeding and inflammation. Continuous use prevents menstruation and may arrest lesion growth. Effective in 60-70% of cases.
• GnRH Agonists: Leuprolide, nafarelin, or goserelin suppress ovarian estrogen production, halting menstruation and lesion growth. Limited to 3-6 months due to side effects (hot flashes, vaginal dryness, bone loss). Often paired with add-back hormonal therapy.
• GnRH Antagonists: Elagolix or relugolix newer agents with fewer side effects than agonists; suppress estrogen via different mechanism.
• Progestins: Medroxyprogesterone acetate (Depo-Provera), levonorgestrel-releasing IUD (Mirena), or oral progestins reduce pain and bleeding.
• Aromatase Inhibitors: Letrozole or anastrozole reduce local estrogen production. Reserved for advanced or refractory cases.

Procedures and Surgery

• Laparoscopic Excision: Gold standard surgical approach. Complete lesion removal under laparoscopy. Improves pain in 60-90% and enhances fertility prospects. Recurrence occurs in 20-40% of cases.
• Ablation: Thermal destruction of lesions. Less effective than excision long-term but faster and more economical. Suboptimal long-term outcomes.
• Oophorectomy: Ovarian removal in severe, recurrent cases approaching menopause. Results in immediate menopause and surgical sterilization.
• Hysterectomy: For severe, treatment-refractory cases when fertility is not desired. May not fully resolve pain if ovaries are retained (10-15% persistent pain).

Lifestyle and Psychological Support

• Rest and Relaxation: Adequate sleep (7-9 hours) and relaxation techniques like yoga or meditation may reduce pain and inflammation.
• Moderate Exercise: Brisk walking or swimming 30 minutes daily, 5 days weekly, may alleviate pain and inflammation. Avoid strenuous activity during menses.
• Dietary Modifications: Increase fiber, fruits, vegetables, and omega-3 rich fish. Reduce red meat, saturated fats, alcohol, and caffeine. Low FODMAP diet may benefit some.
• Heat Therapy: Hot water bottles on the abdomen or pelvis provide rapid pain relief during acute episodes.
• Psychological Counseling: Work with mental health professionals to address depression, anxiety, and stress from chronic disease.
• Support Groups: Joining endometriosis support groups (online or locally in Jordan) provides emotional support and practical advice from other women.

• Infertility and Secondary Infertility: Occurs in 30-50% of women. Adhesions, fallopian tube occlusion, and chronic inflammation impede egg and sperm movement. Assisted reproductive technologies (IVF) may be necessary.
• Anemia: From chronic heavy bleeding. Hemoglobin drops below normal threshold (12 g/dL in women), causing fatigue and weakness. Iron supplementation may be required.
• Severe Adhesions: May cause bowel or ovarian torsion requiring emergency surgery. Signs include acute sharp pain and vomiting.
• Bowel and Bladder Involvement: Deep infiltration of endometrial tissue may cause severe urinary or defecatory pain and, rarely, bowel obstruction.
• Malignancy: Rare (0.5-1%) transformation to cancer (particularly clear cell or endometrioid carcinoma), especially with age and chronic inflammation.
• Depression, Anxiety, and Psychological Disorders: Chronic pain, infertility struggles, and life impact may trigger severe depression and anxiety. Suicide attempt rates slightly elevated in endometriosis patients.
• Sexual Dysfunction: Intercourse pain leads to avoidance of sexual activity, straining marital relationships and sexual satisfaction.

• Reduce Menstrual Duration: Continuous hormonal contraceptive use (without hormone-free intervals) may reduce retrograde menstruation. Not proven to prevent onset but may slow progression.
• Regular Physical Activity: Women exercising 4+ hours weekly have lower risk. Exercise reduces estrogen and inflammation levels.
• Limit Alcohol and Caffeine: Both promote inflammation. Reduction may lower risk.
• Healthy Diet: Rich in fruits, vegetables, and omega-3 fish; low in red meat. May reduce chronic inflammation.
• Avoid Environmental Toxins: Dioxin and other pollutant exposure increases risk. Reducing animal fat consumption (where pollutants accumulate) may help.
• Weight Management: Avoid obesity; maintain healthy BMI (18.5-24.9) as elevated weight raises estrogen and inflammation.
• Pregnancy and Breastfeeding: Each pregnancy reduces risk; prolonged breastfeeding halts menstruation. Not applicable as deliberate prevention but offers protective effect.
• Early Diagnosis and Monitoring: Women with severe symptoms or family history should seek early diagnosis to prevent disease progression.