Index of Topics

Adhesions
What Are Adhesions?
What Causes Adhesions?
How are Adhesions Treated?
Adenomyosis
Diagnosis and Treatment of Adenomyosis
Endometriosis; Diagnosis
Classification of Endometriosis
Diagnosing Endometriosis
Endometriosis; General
What Causes Endometriosis
Endometriosis of the Intestine (Bowel)
Peritoneal Pockets
Endometriosis of the Lung
Endometriosis and Tampons
Is there any connection between IUD use and endometriosis?
Ovarian Cysts
Uterus Tipped to the Side
Endometriosis, Estrogen Replacement of Cancer
Endometriosis after Pregnancy
Endometriosis; Infertility
Does Endometriosis Increase the Risk of Miscarriage?
Endometriosis; Pelvic Pain
Can Endometriosis be confused with PID?
Endometriosis; Recurrence
Recurrent Endometriosis After Hysterectomy
Recurrent Endometriosis After Hysterectomy #2

Adenomyosis

Diagnosis and Treatment of Adenomyosis

Question:
Dr. Cook, a friend of mine was talking about a myomectomy for adenomyosis.... to me that is just not logical...... if they remove part of the uterus in order to remove the adenomyosis...#1 who's to say they got it all and #2 if the uterus can no longer function to have children what's the point in keeping it? I mean it doesn't produce hormones...but with doctors in the past doing Hysts left and right is that a valid reason to keep a diseased organ?

Answer:
This is a good example of a situation that can have different correct answers dependent upon the patients circumstances and personal philosophy. To make the correct decision the patient must have a good understanding of her situation and the pros and cons of the various treatment alternatives. With that in mind lets start with a few definitions.

The shape of the uterus is similar to an upside down pair (the stem would be coming out of the cervix in this example). Most of the uterus is made up of smooth muscle. It's job is to hold the baby during pregnancy and to push the baby out during delivery. The inside of the uterus is lined by a thin layer of glands, called the endometrium, similar to the Teflon lining on cookware. During pregnancy, the embryo implants into the endometrium, which provides the necessary nutrients to the developing embryo until the placenta (afterbirth) develops. The endometrium thickens up in response to estrogen secretion the first two weeks of the menstrual cycle. After ovulation the primary hormone production of the ovaries changes from estrogen to progesterone. Progesterone helps to stabilize the endometrium and ready it for implantation. If pregnancy does not occur, both the estrogen and progesterone production drop and the endometrium is shed as the woman has her menses.
Endometriosis is a condition where endometrial tissue is found outside of the uterus. Adenomyosis is defined as endometriosis within the muscle wall of the uterus. Many years ago endometriosis was known as endometriosis exteri (external to the uterus) and adenomyosis was known as endometriosis interi (inside of the uterus). Adenomyosis is usually a result of the endometrium invading into the muscle wall of the uterus. The adenomyosis is usually not a discrete lesion, but often sends out a diffuse network of branching endometrial glands extending from the endometrium throughout the muscle wall of the uterus. There is no real beginning and end of these lesions. If a cross-section of a uterus with adenomyosis is examined, one will see varying concentrations of endometriosis with in the muscle. An area with a high concentration of endometriosis and little remaining muscle tissue is known as an adenomyoma. A fibroid, also known as a leiomyoma, is a smooth muscle tumor in the wall of the uterus. When removed fibroids have a look similar to a rubber ball. There is a definite beginning and end to a fibroid.

The most common symptoms of patients with adenomyosis are painful periods with a very heavy flow and potentially anemia (low blood count) as a result. A normal uterus is fairly hard and firm. A uterus with adenomyosis is usually slightly enlarged and is soft or squishy to the feel. A careful history and physical exam should raise the possibility of adenomyosis. A sonogram (ultrasound) and laparoscopic evaluation may also be helpful in making the diagnosis. Newer generation MRI's can often identify adenomyosis. Examination of the surgical specimen under a microscope is the only method to make an absolute diagnosis of adenomyosis.
The treatment options for adenomyosis are similar to those of endometriosis:

1. Observation is an acceptable option if the symptoms are not severe.

2. Medical treatment includes birth control pills and GnRH agonists such as Lupron or Synarel. The pills will lighten the period and thus symptoms. The GnRH agonists will temporarily alleviate the symptoms and reduce the size of the adenomyosis. They will not eliminate the adenomyosis nor prevent continued growth once the GnRH is discontinued.

3. Conservative surgical treatment with preservation of the uterus. It is impossible to remove all of the adenomyosis and preserve the uterus. Removal of fibroids (a different condition from adenomyosis) and reconstruction of the uterus during a myomectomy is successful because fibroids are discrete lesions which can be completely removed. Small microscopic fibroid "seedlets" can remain and are one reason fibroids can recur after a myomectomy. If fibroids do recur after a myomectomy, it is usually many years later. In contrast the adenomyosis is so diffuse that an adenomyomectomy (removal of the adenomyosis with reconstruction of the uterus) will reduced the amount of adenomyosis present but by the nature of the lesion a significant amount usually remains in the uterus. Chances are, the patient will need to undergo additional surgery within a couple of years. A woman who is trying to get pregnant or the unusual case with a single well defined adenomyoma may be candidates for conservative surgical treatment. Conservative surgical treatment may also be an acceptable option for a woman who philosophically does not want a hysterectomy and does not mind undergoing repeated surgeries to maintain what is admittedly a diseased organ.

4. Definitive surgical treatment with hysterectomy. This is the only option to truly remove or cure the patient of this medical problem. A patient with adenomyosis can also have endometriosis. If endometriosis is present it should be treated prior to actually removing the uterus. The ovaries are responsible for hormone production and will continue to do so after a hysterectomy. Having a hysterectomy is never a decision which should be taken lightly. Too many hysterectomies have been performed in the past, but others wrongs should not influence or prevent you from doing what is right for you. This is a medical condition which, if symptomatic, will usually require the removal of a diseased organ (hysterectomy) to obtain relief from the symptoms while avoiding the real possibility of repetitive surgeries.

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Endometriosis; Diagnosis

Classification of Endometriosis

Question:

Dr. Cook, can you please explain the endometriosis classification system.

Answer:

OVERVIEW OF CLASSIFICATION SYSTEMS
First, let's clear up some terminology. Classification is defined as "arrangement according to some systematic division into classes or groups". Stage is defined as "the level or degree in a process of development, growth or change". The endometriosis classification system contains four stages (Stage I, Stage II, Stage III, & Stage IV) of disease severity. The purpose of a classification system is to identify the relative the severity of a disease process. The more severe the disease, the greater the health risk to the patient. Mild disease would be less serious than severe disease. The ramifications of increasing disease severity is obvious when used in staging cancer. The more severe the stage, the more likely that the disease has spread and the less likely the patient will survive. Endometriosis is not a cancer and it does not threaten your physical survival. Although those of you who have dealt with endometriosis personally, either yourself or others in your life, understand the toll it can take on your life in so many different ways.

The two primary problems women experience with endometriosis are infertility and pelvic pain. An ideal endometriosis classification system would determine the severity of disease based upon the degree of infertility or pelvic pain and would predict the probability of success of any given treatment. The difficulty arises in the fact that we, as a medical profession, do not have a level of understanding of this disease to know how to measure these parameters. If we knew exactly how endometriosis effected fertility, then we could create a test that would measure the amount of this change. The same goal applies to endometriosis related pelvic pain. This approach would determine the severity of endometriosis as it relates to infertility or pelvic pain.

The current classification system was created with the goal of predicting a patients future fertility based on her stage of endometriosis. Unfortunately, at this time the current endometriosis classification system does not predict a woman's chance of pregnancy. The pregnancy rate of a woman treated with Stage IV endometriosis is the same as a woman treated for Stage I disease. This classification system was not intended to, nor is it successful in, predicting the amount of pain a woman experiences. It does not predict the chance of pain relief following treatment.

HISTORY OF THE ENDOMETRIOSIS CLASSIFICATION SYSTEM
Many different endometriosis classification systems have been proposed since the initial system of Wicks and Larson (1949), which was based on the microscopic appearance of endometriosis. In 1951, Huffman proposed a classification system, similar to the staging system used for cervical cancer, which was based on the size and location of the endometrial implants. The current classification system is, by and large, an evolution of this Huffman's staging system. During the 1970's multiple endometriosis classification systems were proposed. These numerous classification systems led to confusion and a lack of consensus. This prompted the American Fertility Society (AFS) to appoint a committee with representatives from many of the previous classification systems to create an a uniformly acceptable endometriosis classification system.

The original AFS classification system was published in 1979. The stated goal of this classification system was to predict the chance of conception after treatment of endometriosis. This classification system was never intended to predict the amount of pain a patient experienced as a result of endometriosis, nor the chance of pain relief after treatment of the endometriosis. The AFS classification system used a point system for staging endometriosis. A certain number of points were assigned in various categories. These categories included the degree of endometriosis present on the ovaries, peritoneum, cul-de-sac obliteration, etc. The cumulative number of points determined the stage (mild, moderate, severe or extensive) of endometriosis. Dr. John Rock and colleagues published a couple of studies in the early 1980's which evaluated the AFS classification system. They felt that there were two major limitations of this system. They were concerned that the weighting of the various categories did not correctly reflect the impact on fertility. Second, the cutoff points of the total AFS score for each stage were arbitrarily assigned. It was felt that these factors limited the ability of the AFS classification system to predict the chance of pregnancy after treatment of the endometriosis.

The revised AFS (R-AFS) classification was approved in 1985. This included changes that attempted to correct the limitations of the initial classification system. This is a more detailed system which recognizes the difference between superficial and invasive disease and changed the terminology of the four stages to minimal, mild, moderate and severe. The American Fertility Society was renamed the American Society for Reproductive Medicine (ASRM) in 1995. The Endometriosis Classification for Infertility Subcommittee of the ASRM collected data from several centers to evaluate the the R-AFS classification system and pregnancy rates. The study was published in the May issue of Fertility and Sterility. The authors concluded that there was no correlation between stage of endometriosis as determined by the R-AFS classification system and pregnancy rates. The last sentence of the article states "At the very least, our results suggest that fine-grained distinctions between patients with respect to point scores, although useful for documentation, are not clinically useful with respect to the prognosis". (chance of pregnancy) There was data accumulating that suggested that the appearance of the endometrial implants might correlated with their biologic activity and thus pregnancy rates. The additional recommendation of recording the appearance of the endometrial implants was made in 1996.

CURRENT ENDOMETRIOSIS CLASSIFICATION SYSTEM
The "Revised American Society for Reproductive Medicine Classification of Endometriosis: 1996" is currently the most widely used system to stage endometriosis. Figure 1 is the chart of this classification system produced by the American Society for Reproductive Medicine. This is what your physician uses when calculating you stage of endometriosis. Figure 2 provides examples and guidelines for use of the classification system. This material is reprinted by permission from the American Society for Reproductive Medicine (Fertility and Sterility, 1997, Vol. 67, No. 5, Pages 819 - 820).
Figure 1. Revised American Society for Reproductive Medicine Classification System: 1996
Reprinted by permission from the American Society for Reproductive Medicine (Fertility and Sterility, 1997, Vol. 67, No. 5, Page 819)
Figure 2. Examples and Guidelines for the R-ASRM 1996 Endometriosis Classification System
Reprinted by permission from the American Society for Reproductive Medicine (Fertility and Sterility, 1997, Vol. 67, No. 5, Page 820)

This classification system is basically the R-AFS system based upon the size, location, depth of invasion of endometrial implants and the amount of scar tissue involving the ovaries and fallopian tubes. In addition the appearance of the endometrial implants are classified as red, white and black. The red lesion category includes red, red-pink and clear lesions. The white lesion category includes white, peritoneal defect and yellow- brown lesions. The black lesion category includes both black and blue lesions.

Perhaps the addition of the physical appearance of the endometriotic lesions will help improve the accuracy of the classification system in predicting the chance of pregnancy following treatment of endometriosis. The classification system does not apply to patients with endometriosis related pain. As the mechanisms by which endometriosis causes infertility and pain are better understood, a more refined and useful classification system will be possible. Until that time, the classification system provides a means to concisely document the surgical findings. A video tape of the surgery will provide the most accurate record and should be included as a part of the medical record of all patients undergoing laparoscopic evaluation and treatment. This will allow "re-staging" of a patient's endometriosis as the current classification system is refined and future classification systems are created.

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Diagnosing Endometriosis

I have received a lot of questions recently. In an attempt to keep up, I will occasionally group similar questions together.

Question:
#1)
I've been having pain in my lower pelvic region and my gynecologist has ruled out ovarian cysts through sonograms, but he doesn't believe that it's endometriosis because I don't have any lower back pain. Do you think that I could possibly have endometriosis and need to have a laparoscopy done?

#2)
Is it possible to miss a diagnosis even after having laproscopy?

#3)
My wife is suffering from Pelvic pain since June 2000. She was given Duphaston for 3 month but did not get relief. Now one doctor is suggesting Nasarel and another doctor is suggesting operation. I am confused. What should I do?

#4)
Is there any other method to discover endometriosis than laparoscopy? How about MRI

Answer:

#1)
Absolutely. The only way to diagnose endometriosis is during a laparoscopy. Persistent pelvic pain that is progressive or is interfering with your life, preventing you from your normal activities, is an indication for laparoscopic evaluation. A lot of women have endometriosis without back pain.

#2)
Yes. I have personally seen this situation. When a patient comes to me with a history of pelvic pain and a "normal" laparoscope, I will often perform another laparoscopy to double check (this is where a video tape of the previous surgery is helpful). I have found that the patients history of symptoms is more accurate than a previous laparoscopy. I have performed laparoscopy 6 weeks after a patient has had "normal" findings at a lapraroscope by another physician, only to find endometriosis - proven by pathology report. She either had rapid formation and growth of endometriosis over a couple of weeks or the endometriosis was missed at the previous surgery.

#3)
The medications you are referring to function to shut down estrogen production by the ovaries. This group of medications can have significant side effects including bone loss, osteopenia and even osteoporosis. Even if the decision is made to use these medications, a laparoscopic diagnosis of endometriosis should be made first. However, the endometriosis is usually treated at the time of the laparoscopy, eliminating the need for the use of this medications and their associated side effects.

#4)
For the most part, no laparoscopy is the method of diagnosing endometriosis. If there are large volumes of endometriosis, i.e. larger than 2cm (about 1 inch) then MRI may be helpful. An endometrioma can be diagnosed with an MRI. The problem is that the average lesion of endometriosis is not large enough to be seen with the MRI. In other words if an MRI shows endometriosis, great, but most women with endometriosis will have normal MRI findings.

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Endometriosis; General

What Causes Endometriosis?

Question:
Dr. Cook what is endometriosis and what causes it?

Answer:

Endometriosis is defined as the presence of endometrial tissue outside of the uterus. The uterus is where the baby grows during pregnancy and when it is time to deliver, it pushes the baby out. Most of the uterus is made up of muscle, but it is lined on the inside by a thin layer of glands called the endometrium. This thin layer of glands provides the nutritional support to the developing fetus prior to the development of the placenta (after-birth). The endometrial lining responds to the estrogen during the first two weeks of the menstrual cycle, growing in thickness. You can think of the estrogen as fertilizer for the endometrial lining. After ovulation, during the second half of the cycle, the other female hormone, progesterone, helps to stabilized and mature the endometrial lining. If the woman is not pregnant, both the estrogen and progesterone level drop at the end of the cycle, the endometrial lining sloughs off and her period starts the next day. The menses are made up of the endometrial lining, blood and clots. Most of the menses comes out below, but some flows back up through the fallopian tubes and inside the body. Endometriosis is formed when some of this tissue implants and starts to grow. We don't completely understand why some women develop endometriosis and others do not. It is probably related to both the amount of tissue that a woman's body has to get rid of each month and an inability of her body to recognize or get rid of the endometrial tissue inside of the body cavity. The research to date points to a selective decrease in the immune system. Several studies as well as our own personal experience has shown a decrease in the natural killer cell function (a type of white blood cell).

Retrograde menstruation (backward flow) with implantation of endometrial tissue, as discussed in the previous paragraph, is the cause of endometriosis in the vast majority of cases. Endometrial tissue can spread or form via other less common mechanisms. Extra pelvic endometriosis (endometriosis outside of the pelvic cavity) has been reported in virtually every organ of the body. Most of these rare endometrial implants formed as a result of spread of endometrial tissue through the blood stream (hematogenous spread). Endometriosis has also been reported in the lymph nodes (e.g. obturator lymph nodes). Thus lymphatic spread can cause endometriosis. Endometrial tissue can spread during surgery. The most common example of surgical spread is endometriosis which is found in the abdominal wall following a C-Section. Endometriosis has also been reported in the belly button. This usually presents with bleeding from the navel with menses. Finally, endometriosis can form as a result of what is called coelomic metaplasia. Basically coelomic cells are those formed as a fetus and metaplasia means one cell type turns into another cell type. In other words some of the primitive cells turn into endometriosis in adult life. This probably accounts for the case of endometriosis reported in men. All of the men were on estrogen therapy, I believe for prostatic cancer, which probably stimulated the transformation of the coelomic cells into endometriosis. (Ladies please do NOT slip your significant other a few birth control pills if he is not understanding of your pain)

In conclusion, endometriosis is the presence of endometrial tissue outside of the uterus. Back flow of menstrual tissue through the fallopian tubes with implantation of endometrial tissue is probably the cause of endometriosis in the vast majority of cases.

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Endometriosis of the Intestine (Bowel)

Question:

My doctor did a laparoscopy and found endometriosis and adhesions throughout my abdominal region. I had known from the first day after my surgery in March (performed by my general gyn) that the laparotomy I had was a total failure and Dr. X was able to confirm that after this surgery. Both of my ovaries were attached to my uterus and my right ovary and ureter was also attached to the uterus. My right ovary was very diseased and had to be removed along with the right tube. Endometriosis was found all over the small bowel and Dr. X was not able to remove that. He is recommending that I find a general surgeon somewhere who specializes in surgery of the bowel. He feels that a bowel resection will be necessary. Are you or any of the other physicians at Athena skilled in performing that type of operation? This is a very scary thing for me to comprehend right now and I will probably seek whatever alternatives are available to me before choosing surgery again. However, I have been through many of the treatments such as continuous birth control and Lupron. The only thing that Lupron helped me with was temporary relief of my bowel symptoms last year, but they eventually came back while still on the injections. Is there anything that you can recommend for me at this point?

Answer:

First, I am glad that you persisted and listened to your body and kept going until you found someone who could help you. I am sorry though that at the end of your most recent surgery you have still not gotten your problem fixed and you are now faced with yet another surgery.

BOWEL ANATOMY 101
The intestines (bowel) are made up of two basic parts, the small intestine and the large intestine. The small intestine is about 9 feet long and the large intestine is about 3.5 feet long. The small intestine connects the stomach to the large intestine. The small intestine fills the area from the from the bottom of the ribs to the top of the uterus. It has no set course and looks a bit like a bunch a spaghetti. The large intestine connects the small intestine to the anus. From the anus the large intestine follows a course behind the vagina, cervix and uterus, and makes an upside down "U", up the left side of the body, across the upper abdomen just below the ribs and down the right side of the abdomen ending near the hip bone on the right. The appendix is a small worm like structure projecting off of the large intestine close to where the large and small bowel connect. The contents of the small bowel are primarily liquid while those of the large bowel are primarily solid. The bowel wall is made up of three basic layers; (1) the serosa, (2) the muscle wall and (3) the mucosa. The serosa is outside lining of the bowel wall. It is very thin, similar to saran wrap. Most of the bowel wall is made up of muscle. This is the middle layer. The inside lining of the bowel is called the mucosa and is also quite thin.

ENDOMETRIOSIS OF THE BOWEL
Endometriosis has been reported to grow in almost every organ in the body outside of the reproductive organs. The bowel is the most common non reproductive organ involved with endometriosis.

INVASION
The degree of invasion of the bowel wall by endometriosis is one factor that will determine the type of symptoms that the patient will experience. If the bowel endometriosis is superficial, involving only the outside serosal surface, the most common symptoms are bloating, nausea and loose stools with menses. At the other extreme, if the endometriosis has invaded all the way through the bowel wall including the inside mucosa, then the patient will usually experience rectal bleeding with her period. While it is common for the endometriosis to invade through the outside serosa and the middle muscle wall, it is unusual to invade through the inner mucosal layer. This probably accounts for the high failure rate of barium enemas and colonoscopsies in diagnosing bowel endometriosis. The location of the bowel will be the primary determining factor of the type of symptoms when the muscle wall of the bowel is involved with endometriosis.

LARGE BOWEL
The pelvic portion of the large bowel (the rectum and the sigmoid colon) is the most commonly involved part of the intestine. The close proximity of this portion of the bowel to the vagina and cervix often results in painful intercourse. Bowl movements can also be very painful since the bowel contents are solid in this portion of the bowel. The portion of the intestine where the large and small bowel connect is located in the area between the belly button and the right hip bone. This is in the same area as the appendix. Involvement of the bowel in this area or the appendix can result in right sided pain. Bowel endometriosis can also result in adhesions (scar tissue). These adhesions can involve other loops of bowel resulting in a partial obstruction (blockage), the ovary, fallopian tube or even the ureter. These adhesions can also result in pain. Endometriosis of the large bowel rarely results in obstruction of the bowel.

SMALL BOWEL
Endometriosis of the small bowel usually results in bloating and pain which is associated with eating. Often patients with small bowel endometriosis have restricted the amount and type of foods that they eat. The symptoms are slowly progressive over time and the patient may not even realize the extent to which she has altered her diet. Small bowel endometriosis often results in a partial bowel obstruction. As the bowel swells following a meal the bowel kinks, and like a kinked garden hose the contents do not get through until enough pressure builds up to push by the narrowed portion.

TREATMENT OF BOWEL ENDOMETRIOSIS
All of my patients undergoing surgery have a preoperative bowel preparation. It is impossible to tell preoperatively if bowel endometriosis is present. The laser laparoscope is a wonderful surgical instrument for treating bowel endometriosis. This combination provides the magnification and precision necessary for me to remove the endometriosis from the bowel, without having to perform a bowel resection in the vast majority of cases. Situations in which the crude electrosurgery would result in the need for bowel resection are easily handled by laparoscopic laser surgery. This is true for both the large and small bowel. In the rare cases that the endometriosis has completely replaced a section of bowel, the diseased segment of bowel is removed by one of the bowel surgeons of my team and the normal ends of the bowel are reconnected.

THE TEAM APPROACH TO THE TREATMENT OF ENDOMETRIOSIS
Endometriosis is a dreaded disease which has no respect for the boundaries of the various medical subspecialties. This is why it is so important to use a team approach in the treatment of individuals with endometriosis. For example: The urologist may help if the endometriosis involves the bladder or the bowel surgeon may help if the bowel is involved or the thoracic surgeon may help if a thoracoscopy is needed to diagnose and treat endometriosis of the lung. Proper preoperative evaluation and preparation in conjunction with the team approach should result in the complete treatment of the individual with endometriosis.

NON SURGICAL TREATMENT OF BOWEL ENDOMETRIOSIS
At this point in time there is no non surgical treatment of bowel endometriosis. Lupron, birth control pills etc, may slow the growth of endometriosis, but they will not get rid of the endometriosis nor the associated fibrosis or adhesions. Invasive bowel endometriosis is a serious condition which can lead to an acute surgical emergency (bowel obstruction).

CONCLUSION
In summary, you probably are looking at another surgery to treat the endometriosis of your intestine. Using laser treatment, the vast majority of bowel endometriosis can be treated without having to perform a bowel resection. Yes, at Athena we are skilled in treating bowel endometriosis. I hope we have the opportunity to help you feel better!

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Peritoneal Pockets

Question:

What is a peritoneal pocket and what possible effect can it have on fertility. My doctor found two of said "pockets" but saw no endometriosis.

Answer:

Peritoneal pockets should be considered endometriosis until proven otherwise. Peritoneum covers the inside of the body much like the skin covers the outside of the body. Peritoneum normally has the appearance of saran wrap. It is stretched over the organs resulting in a flat contour. Peritoneal pockets can be of varying depths, ranging from slight indentations to very deep narrow pockets.

Peritoneal pockets are also referred to as Allen Masters Syndrome. Dr. Allen and Dr. Masters published an article back in 1955 titled "Traumatic laceration of uterine support". They felt that the trauma of pregnancy caused peritoneal pockets which resulted in pain and abnormal vaginal bleeding. De Brux published a report in 1968 documenting endometriosis in half of the peritoneal pockets he studied. Dr. Donald Chatman then followed up in 1981 with a larger study which noted 68% of peritoneal pockets with endometriosis and an even larger study five years later showing endometriosis in 79% of peritoneal pockets. Thus endometriosis is associated with peritoneal pockets in the majority of cases.

In its mild form peritoneal pockets can result in minor changes in the contour of the pelvic peritoneum. On occasion this is the only appearance of endometriosis. The surgeon must have a good understanding of the normal contour of the pelvic peritoneum and a high index of suspicion that this mild variation in contour alone can truly represent endometriosis. Deep pockets can be missed if a systematic approach is not used to literally explore every nook and cranny. If a deep pocket is found the base of the pocket should be grasp with a locking instrument. This identifies the base of the pocket during the dissection process. If this is not done portions of the peritoneum can easily be lost during the dissection and removal. If some of the peritoneum lining the pocket which contains endometriosis is left behind this can result in recurrent endometriosis.

To answer your specific question, statistically, your doctor probably did see endometriosis. Since peritoneal pockets usually are endometriosis, this finding can have the same effect on fertility as endometriosis.

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Updated August 22, 2002
Endometriosis of the Lung

Question:

I've been told that endometriosis can spread outside of the pelvic area and I even heard of a woman with endometriosis who's lung collapsed every time she had a period. Can endometriosis really spread to the lungs?

Answer:

Yes, while it is rare, endometriosis can grow in the lung. This is also known as thoracic endometriosis. There are two basic types of thoracic endometriosis. Thoracic endometriosis can be divided into pleural endometriosis (the lining of the lung) and parenchymal endometriosis (the lung itself). The majority of cases of pulmonary endometriosis occur in the pleura rather than the lung itself (about 5:1 - pleura:parenchyma).

PLEURAL ENDOMETRIOSIS:
The vast majority of patients with pleural endometriosis experience difficulty breathing (shortness of breath), pain, and pneumothorax (collapsed lung) or pleural effusion (water on the lung). Over 90% of cases are right sided. It is not uncommon to find small holes in the diaphragm. The majority of patients with pleural endometriosis also have pelvic endometriosis, raising the question if spread of the endometriosis is via the small holes in the diaphragm.

PARENCHYMAL ENDOMETRIOSIS:
Most patients with parenchymal endometriosis cough up blood but few have difficulty breathing or pain. Few of these patients have pelvic endometriosis but usually have a history of pelvic surgery or vaginal delivery. The theory is that the endometrial cells spread through the blood vessels as emboli.

TREATMENT OF THORACIC ENDOMETRIOSIS:
In the past diagnosis of thoracic endometriosis has been difficult and treatment often involved either medical suppression of the endometriosis (e.g. danazol or GnRH agonists) or surgery in the form of a thoracotomy (big incision between the ribs) and obliteration of the pleural space (in order to prevent the lung from collapsing) without actually diagnosing or removing the endometriosis. The patient's history plays a key role in the diagnosis of thoracic endometriosis. Traditionally a chest x-ray or ventilation/perfusion study (a study which looks at both the air flow and blood flow through the lung) have helped in the diagnosis of endometriosis. MRI's have now advanced to the point that they can help locate and diagnose endometriosis. Thoracoscopy (laparoscopy of the thorax/pleural space) can help diagnose and treat pleural endometriosis (greater than 80% of thoracic endometriosis). Normally, when a patient undergoes general anesthesia, a breathing tube is placed through her mouth and down the bronchus and placed on a ventilator during the surgery. This tube is removed as she wakes up. To perform a thoracoscopy, a special double lumen breathing tube is placed through the patient's mouth, with one tube in the right lung and one tube in the left lung. At rest a person can easily get all the air they need through one lung. The side which contains the endometriosis, lets say the right, is collapsed by blocking off the tube on that side and the patient is ventilated (breaths) through the open tube, the left lung in this case. The collapsed lung opens up the pleural space and the thorascope is introduced into the pleural space. The pleural cavity is inspected and any endometriosis, scarring or fibrosis is removed. The thorascope is then removed and the incision is closed and the lung is re-inflated. Laparoscopy should also be performed to look for endometriosis in the pelvis, abdominal cavity, diaphragm, etc.

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Endometriosis and Tampons

Question:

Dr. Cook, is it true that tampons cause endometriosis?

Answer:

There are concerns that chemicals (dioxin) in tampons may increase a woman's risk of developing endometriosis. Medical studies that would provide a definitive answer to this question have not been performed. No difference was observed in the few studies that have looked at the incidence of endometriosis in tampon users and nonusers. The Tampon Safety and Research Act of 1997 (H.R. 2900), introduced by Congresswoman Carolyn B. Maloney November 7, 1997, would provide the necessary research to investigate this issue.

The primary concern, regarding tampon use and endometriosis, is presence of dioxin in tampons. Rayon, a synthetic fiber, is very absorbent and is used in most tampons. Chlorine is used to bleach the rayon during the manufacturing process to give the tampons a "clean" white appearance. The chlorine bleaching process used in the production of the majority of tampons reportedly produces a toxic byproduct known as dioxin. Proctor & Gamble, the makers of Tampax, state the chlorine bleaching process does not produce detectable levels of dioxin. Dioxin (TCDD; 2,3,7,8-tetracholorodibenzo-p-dioxin) is thought to be toxic at very low doses. Dioxin is also a byproduct of pesticide production and PVC (polyvinyl chloride) pipes. Studies have suggested links between dioxin and cancer, behavioral effects and learning disorders, decreased male sex hormone, diabetes, immune system toxicity, sperm loss and endometriosis

Several studies have looked at the relationship between endometriosis and dioxin. Reir et. al. published a study in 1993 and again in 1995 documenting an increased incidence of endometriosis in rhesus monkeys following exposure to dioxin. The monkeys were exposed to dioxin over a period of 4 years. Ten years later they underwent laparoscopic evaluation for endometriosis. There were three groups of monkeys in this study; a control group (no exposure to dioxin), a low dose group (5 ppt dioxin) and a high dose group (25ppt of dioxin). Thirty three percent of the monkeys in the control group had endometriosis, but none with moderate or severe endometriosis. The incidence of moderate to severe endometriosis was 43% in the low dose dioxin group, and 71% in the high dose dioxin group. There was clearly an increase incidence of endometriosis with exposure to dioxin and an increased severity with the dose of dioxin. An Israel study published in 1997 evaluates the potential association of dioxin and endometriosis in infertile women. The study group was comprised of infertile women with endometriosis and the control group was infertile women without endometriosis. Eighteen percent of women in the endometriosis group tested positive for dioxin while only 3% were positive for dioxin in the non-endometriosis group. However, in contrast to the monkey study, the concentration of dioxin did not correlate with the severity of endometriosis.

Lamb and Berg published a study in 1985 examining the potential role of tampons in women with endometriosis. The rate of tampon use in 470 women with endometriosis (82%) was compared to that of the general population (75 to 83%). While there was no statistical difference in the rate of tampon use in this study, the age at initial tampon use was statistically earlier in the endometriosis group. In a 1993 case control study, Darrow et. Al. compared tampon use in 104 women with laparoscopically confirmed endometriosis to 100 friends of the patients. Compared to their friends, women with endometriosis under the age of 30 were, on average, 3.6 times as likely to have a history of tampon use of greater than or equal to 14 years.

As is evident from the above paragraph, the medical literature is pretty weak when it comes to the issue of endometriosis and tampon use. There is also the theoretical concern of tampons increasing the resistance of outflow of the menstrual fluid that could result in an increase in the amount of retrograde menstruation. As I have discussed previously, the leading theory of the cause of endometriosis is retrograde menstruation. A lot of women use tampons and thus a definitive answer is needed to the question of tampon use and the possible increased risk of endometriosis. A bill has been submitted in congress to help promote medical research to answer this question.

The Tampon Safety and Research Act of 1977; "A bill to provide for research to determine the extent to which the presence of dioxin, synthetic fibers, and other additives in tampons and similar products used by women with respect to menstruation pose any risks to the health of women, including risks relating to cervical cancer endometriosis, infertility, ovarian cancer, breast cancer, immune system deficiencies, pelvic inflammatory disease, and toxic shock syndrome, and for other purposes" was introduced by Representative Carolyn Maloney, 11/07/97. This bill was referred to the subcommittee on Health and Environment November 14, 1997 where it remains to this day.

In Summary, the chlorine bleaching process traditionally used in the production of tampons creates dioxin. Many health problems including endometriosis have been linked to low dose dioxin exposure. The presence of dioxin in tampons may pose a health risk, but the degree and significance of this risk is unknown. Dioxin is concentrated in fat tissue and thus is found in food sources such as red meat and fish. Elimination of dioxin from tampons may be beneficial to your health but will not eliminate your exposure to this chemical. Until the necessary medical studies are available, such as those proposed in the Tampon Safety and Research Act of 1977, the medical community will not be able to provide you with hard facts. Feminine pads are an alternative to tampons. While most pads are bleached with chlorine and may result in dioxin production, this product is placed on the outside of the body and thus reduces your exposure. If you decide to use tampons, you will have to weigh the evidence and decide for yourself whether you are comfortable using traditional tampons or would prefer to use natural tampons.

Dioxin free tampons are available. If you feel more comfortable using an unbleached tampon, I have included some links and phone numbers that you might find helpful. I have no association with any of the companies listed nor am I endorsing any of their products.

Natural Tampons
Terra Femme Tampons
Tampax Naturals
Glad Rags 800-700-4523
Natracare 800-796-2872

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Is there any connection between IUD use and endometriosis?

Question:

Is there any connection between IUD use and endometriosis? Does the IUD worsen or contribute to it in any way?

Answer:

IUD use may increase the risk of developing endometriosis. We know that heavier menstrual flow is associated with an increased risk of developing endometriosis. Intrauterine devices increase the menstrual flow and thus we presume, retrograde menstruation. Several studies have looked at the possible association between IUD use and endometriosis.

The most recent article was a U.S. study published in 1995. This was a case control study of 3384 women undergoing laparoscopy for tubal sterilization. 126 patients had endometriosis. 504 patients without endometriosis were randomly selected from the group. Long duration of IUD use was associated with an odds ratio of 3.0. Therefore this study demonstrated an increased incidence of endometriosis in patients with history of IUD use.

A Chinese study was published in 1994 which did not support the relationship between IUD use and endometriosis. This was a case control study of 203 women with endometriosis.

A study out of Italy in the same year showed a relative risk of 1.3 for ever users of IUD compared to never users of IUD. A review article was published by Italian authors in 1993. Most of the previous studies reviewed demonstrated either an increased risk of endometriosis with IUD use or no effect. Two previous articles demonstrated a lower risk of endometriosis in previous users of the IUD.

A British study followed 17, 032 women for up to 23 years. This study showed a decrease risk of endometriosis in current users of IUD (relative risk of 0.4) and an increased risk (relative risk of 1.4) in IUD users 49 to 72 months previously compared with never users of IUD

Finally a 1975 article reported a case of endometriosis of the omentum following perforation of the uterus by a Lippes Loop.

In Summary, IUD use probably results in a slight increase risk of endometriosis. This is but one of many potential side effects which should be considered prior to choosing to use the IUD as a method of contraception. Patients with a known history of endometriosis may be better served by another form of contraception.

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Ovarian Cysts

Question:

I had a CT scan done and it turns out I have a huge cyst on my right ovary. It appears to be the same as the one that was on my left ovary that my doctor removed during surgery three weeks ago. It is 5cm big, and what worries me is that it wasn't there during surgery three weeks ago. My doctor thinks it might me an endometrioma. Can you tell me more about ovarian cysts.

Answer:

If this cyst was not present three weeks ago, the chances of this being an endometrioma is almost zero. Let's review the basic types of ovarian cysts (not including pregnancy cysts). These include (1) functional cysts, (2) endometriomas, (3) benign ovarian cystic tumors and (4) malignant ovarian tumors. Other structures which can be mistaken for ovarian cysts include paratubal cysts (not uncommon, usually not harmful), hydosalpinx (water in blocked tubes) and peritoneal inclusion cysts (cystic pockets of the inside lining of the body).

FUNCTIONAL CYSTS
Functional cysts include the developing follicular cyst, the hemorrhagic corpus luteum cyst and the unrupture follicular cyst (also called a simple cyst). The developing follicular cyst is found in the ovary during the first two weeks of the menstrual cycle. This is the egg sac, including the egg, the support cells and the surrounding fluid. Normally these cysts enlarge to about one inch. The egg is then released during ovulation and the cystic fluid drains out of the ovary and thus the cyst goes away. This cycle of events happens almost every month in a woman with normal menstrual cycles. These cysts rarely cause pain unless the ovary is surrounded by adhesions (scar tissue). A hemorrhagic corpus luteum cyst forms when the egg breaks a small blood vessel in the ovary during ovulation. The broken blood vessel can bleed into the ovary and develop a blood clot or what is medically called a hemorrhagic corpus luteum cyst. This type of cyst can get pretty big and has an appearance similar to an endometrioma. A hemorrhagic corpus luteum cyst will appear suddenly and the body will reabsorb it over a month or two. The only way an endometrioma will disappear on a sonogram, other than surgery, is if it ruptures. Once in a while the developing egg is not released resulting in an unruptured follicular cyst. Ovulation does not occur. This condition probably occurs in most women once in a blue moon (the second full moon occurring in the same month). Unruptured follicular cysts occur more often when the ovary is surrounded by adhesions (it is more difficult for the egg to escape from the ovary) and is probably more common the first month after pelvic surgery since the hormone production fluctuates with the stress of surgery. Some women are genetically predisposed to developing this type of cyst. Some physicians believe this is one cause of fertility and is called luteunized unruptured follicular (LUF) syndrome in women who repeated do not release the egg. The majority of the time follicular cysts will eventually resolve on their own.

ENDOMETRIOMAS
An endometrioma is a cyst in the ovary lined by endometriosis. As the endometriosis grows and sheds every month, the chocolate fluid accumulates and the cysts grows. This type of cyst can be devastating to a woman's reproductive function. If left to grow it will tend to progressively destroy normal ovarian tissue. If it gets large enough or if trauma occurs (e.g. dog jumping on your lap or intercourse) the endometrioma can rupture and the contents spill into the pelvic cavity. The chocolate contents are very irritating to the body and can result in extensive adhesion formation, including damage to the fallopian tubes which is irreversible. Lupron does not treat endometriomas. If endometriomas are drained surgically they will recur. The surgeon must remove the entire lining of the endometrioma to eliminate the chance of that endometrioma recurring (it is possible for a new one to form). If a surgeon coagulates or laser vaporizes the lining of the endometrioma, removal of the lining is usually incomplete and it is only a matter of time before it fills back up.

BENIGN OVARIAN TUMORS
There are many types of benign ovarian tumors including dermoid cysts. Discussion of the various types of benign tumors is beyond the scope of this discussion. Suffice it to say, if you have a cyst that is present on your ovary and it doesn't go away after a couple of months, it should be investigated.

MALIGNANT OVARIAN TUMORS
Malignant ovarian tumors are cancer. These are more common in older women but are found in all age groups, including teenagers. Some of you have heard that endometriosis can turn into cancer. It is possible and I have seen a couple of cases in my career. But, I would like to emphasize that this is very rare. The important point is not to ignore an abnormal finding.

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Uterus Tipped to the Side

Question:

I have endometriosis and I am hoping that you might be able to provide me with some insight. I recently had a trans vaginal ultrasound done, the results came out with the following. My uterus,(which has always been tipped) is now not only tipped but it has moved to my left side, which is causing pain and a great deal of pelvic pressure. What causes this to happen? What, if anything can be done to move it back into place?

Answer:

In a patient with endometriosis, a uterus which is tipped to the side is often a sign of uterosacral ligament involvement with endometriosis. These ligaments (one on the right and one on the left) are low in the pelvis connecting the lower uterus to the lower back. They are also near the bowel and the top of the vagina. Because of their location, they often cause pain in the lower back, pain with deep penetration with intercourse and can cause bowel symptoms when involved with endometriosis. As these ligaments become involved with endometriosis they become scarred and shortened. If the left uterosacral ligament is involved more than the right it will tend to pull the uterus to the patients left. You may also notice leg pain, probably more on the left than the right. As the nerves coarse from the spine to the leg they pass through the pelvis. Endometriosis involving these nerves in the pelvis can result in pain radiating down the leg(s). Complete removal of the endometriosis will usually result in the uterus returning to the correct position and resolution of the associated symptoms.

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Endometriosis after Pregnancy

Question:

Is it true if you have had a child you can not have endometriosis? My doctor blows me off when I suggest endo as the reason for my chronic pelvic pain, she said you can't have it if you have had a child.

Answer:

No, this is not true. Some, but not all women, will have a decrease in symptoms following pregnancy. Unfortunately, even for women who do have a decrease in symptoms after pregnancy it is temporary. The notion that pregnancy cures endometriosis is an old wives tale. If a physician believes this then they are obviously not well informed about endometriosis and you may want to seek out another physician who is better informed.

If a woman does experience relief with pregnancy, breast feeding usually helps prolong the return of the symptoms. A woman usually does not have return of periods if breast feeding is the only source of food for the infant. The lack of periods usually helps to minimize the symptoms of endometriosis. Chronic pelvic pain whether before or after child birth warrants, evaluation and treatment.

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Endometriosis; Infertility


Does Endometriosis Increase the Risk of Miscarriage?

Question:
Is there a higher miscarriage rate in women with endometriosis who conceive? At what stage of your pregnancy can you regard yourself as safe from miscarriage. Are there any tests that can or should be performed during the high risk phase?

Answer:

We do not have a definite answer to the question "does endometriosis cause an increase in the miscarriage rate". Some physicians in the infertility field do feel there is an increase in the risk of miscarriage with endometriosis. Some feel there is no increase in the miscarriage rate. The reason we do not have a definite answer to this question, is that there are problems with the studies examining this issue. The most recent edition of the widely read textbook Clinical Gynecologic Endocrinology and Infertility states "In appropriately controlled studies the [miscarriage] rate was in the normal range in women with endometriosis who were not treated, and it is likely that previous studies were flawed by their choice of control [miscarriage] rates". In English what this means is that many of the earlier studies used historical controls. That is, the study looked at the miscarriage rates in patients prior to treatment of endometriosis compared to the miscarriage rates in the same patients after treatment of endometriosis. In these studies patients had lower miscarriage rates after treatment. One of the best studies was published back in 1986. In this study, half of the patients with endometriosis were treated surgically and the other half was not treated (either surgically or medically). Both the treated and untreated groups showed a significant decrease in the miscarriage rate. The miscarriage rate in the treated group was also significantly lower than the untreated group. Unfortunately, no study has been published which prospectively looks at two identical groups of women, with the exception of endo verses no endo, and followed their miscarriage rate.

The vast majority of miscarriages occur within the first three months of pregnancy. It is rare to have problems later than 10-12 weeks, but it possible. You are not entirely safe from "miscarriage" until the baby is in your hands after delivery.

I use the following approach with my patients during the first trimester, which can be considered the high risk phase. After a positive pregnancy test, I usually obtain what is called a quantitative beta hCG. This is a blood test that tells you the exact level of pregnancy hormone present. If the pregnancy is developing normally, the level should nearly double every other day. I usually perform a transvaginal sonogram (ultrasound) once the level beta hCG gets up in the range of about 3,000 . At this point a gestational sac should be visible inside the uterus in a normal pregnancy (some older sonogram machines may require a level of 6,000 to see a gestational sac). Two weeks later, usually about eight weeks from the last period, a repeat sonogram should demonstrate a fetus and heartbeat in a normal pregnancy. If everything looks OK at this point your chances are very good that that your pregnancy will continue and its time to pop open your non-alcoholic champagne. At a later time your OB will perform the routine tests for neural tube defects, diabetes, etc.

If the beta hCG level is not rising appropriately or if no gestational sac is seen as described above, then an ectopic (tubal) pregnancy must be considered and managed appropriately.

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Endometriosis; Pelvic Pain


Can Endometriosis be confused with PID?

Question:

Can endometriosis be confused with Pelvic Inflammatory Disease?

Answer:
Yes it is a possibility. Endometriosis and pelvic inflammatory disease can both cause pelvic pain. Pelvic inflammatory disease (PID) is a condition in which the fallopian tubes become infected, usually with chlamydia or a bacterial infection, including gonorrhea. There is no association between PID and endometriosis. While it is important to consider PID in the differential diagnosis of a patient with pelvic pain, all too often this is the assumed diagnosis in emergency rooms, especially in young single women. I would guess that a significant number of you with endometriosis have been told at one time or another that you have PID.
A person with PID usual