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The Department of Gynecology and Obstetrics
Reproductive Endocrinology & Infertility

Endometriosis

Endometriosis is a benign disorder characterized by the presence of endometrial tissue (the tissue that lines the uterus) outside the uterine cavity where it becomes attached to reproductive or abdominal organs. The patches of endometrial tissue swell with blood during menstruation as if they were still in the uterus. Because this blood is trapped within the tissue and cannot be shed through the vagina, blood blisters form, and they may develop further into cysts, scar tissue, or adhesions (fibrous bands that link together other tissues that are normally separated). Cysts may range from the size of a pinhead to the size of a grapefruit; cysts, scars, and adhesions may all lead to infertility. The cause of endometriosis is unknown. Hereditary factors may be involved. Hormonal changes or recent pelvic surgery may promote endometriosis

Endometriosis is a common disorder, most prevalent between the ages of 25 and 40. Symptoms vary and are not strictly correlated with the severity of the disease; they may worsen with time, but tend to diminish during pregnancy and cease with menopause. Many women have no symptoms at all. Treatment depends on the severity of symptoms, the age of the woman, and whether she wishes to have children.

A pelvic examination may reveal a suspicion of endometriosis. The doctor presses upon the uterus and ovaries to feel for any abnormalities. A definitive diagnosis requires direct visualization and biopsy or sampling of the extrauterine endometrial tissue. This is usually done by laparoscopy (the insertion of a thin, lighted viewing instrument into the abdomen through a small incision).

While endometriosis cannot be prevented, women should have regular pelvic examinations once they reach age 18 or become sexually active, to aid in early detection and treatment of any reproductive system abnormalities.

Call a doctor if you experience severe pain and heavy bleeding during menstruation, with or without additional symptoms of endometriosis.

Symptoms of endometriosis include:

Pain in the vagina, lower abdomen, and lower back. Pain often begins just prior to monthly periods, continues during menses, and worsens just after the cessation of blood flow.

Abnormal or heavy menstrual bleeding.

Vaginal pain during sexual intercourse (see Dyspareunia for more information).

Diarrhea, constipation, or pain during bowel movements.

Bleeding from the rectum or blood in the urine during menses.

Nausea and vomiting just prior to monthly periods.

Infertility. (Endometriosis is one of the most common causes of infertility.)

Treatment options include:

Young women with endometriosis who wish to bear children may be advised to have children sooner rather than later.

Over-the-counter pain relievers may be taken for mild menstrual pain.

Danazol, progestins, or Gn-RH (gonadotropin-releasing hormone) agonists may be administered to halt menstruation for three to six months in an effort to shrink endometrial tissue.

Surgical removal of the tissue may be required to relieve severe symptoms or to allow impregnation. Tissue may be destroyed by heat (electrocautery) or removed with lasers during laparoscopy (usually done on an outpatient basis under local anesthesia).

A hysterectomy, the surgical removal of the uterus (and sometimes other reproductive organs), may be advised in severe cases. Hormone replacement is required if both ovaries are removed.

Endometriosis, a common gynecological condition that occurs during the reproductive years, affects an estimated 10 percent of all women. That makes it more prevalent than AIDS, or even cancer. It is a leading cause of infertility, and although some women with endometriosis experience no symptoms, it causes debilitating pain in others.

At Johns Hopkins, we use the very latest technology to diagnose and treat endometriosis. We also rely on a team of experts that extends beyond the gynecology department to manage this and other conditions that result in pelvic pain. Our multidisciplinary team includes professionals in urogynecology, gastroenterology, anesthesiology, physical therapy and other disciplines.

A thorough medical history and pelvic examination are the first steps in diagnosing endometriosis; a doctor can often feel the endometrial implants upon palpation (pelvic examination by the doctor's hands), and symptoms will often indicate endometriosis. But diagnosis of endometriosis is generally considered uncertain until proven by laparoscopy.

Laparoscopy, both a diagnostic and treatment technique, is a minor surgical procedure done under anesthesia in which the patient's abdomen is distended with carbon dioxide gas to make the organs easier to see and then a laparoscope (a tube with a light in it) is inserted into a tiny incision in the abdomen. The surgeon moves the laparoscope around the abdomen to check the condition of the abdominal organs and see the endometrial implants. Sometimes tissue samples are taken to confirm the diagnosis. A laparoscopy informs the physician on the location/s, extent and size of the growths and facilitates informed, long-range decisions about treatment and pregnancy.
At Johns Hopkins, we use the very latest technology to diagnose and treat endometriosis. We also rely on a team of experts that extends beyond the gynecology department to manage this and other conditions that result in pelvic pain. Our multidisciplinary team includes professionals in urogynecology, gastroenterology, anesthesiology, physical therapy and other disciplines.

As a first line of therapy, your doctor may prescribe low-dose oral contraceptive pills. They work by suppressing ovulation and menstruation, thereby keeping symptoms under control. Evidence also suggests that this treatment may reduce the endometriotic implants.

If you are diagnosed with endometriosis while undergoing laparoscopy, your doctor may remove the endometerial tissue during the procedure. Laparoscopy has several benefits: it provides many women with symptomatic relief for a number of years; increases a patient's fertility and subsequent chance of pregnancy; and results in minimal scarring and a speedier recovery period than a hysterectomy.

Hysterectomy, or complete removal of the uterus, is sometimes used to treat endometriosis. But it is only recommended for those patients suffering from severe, chronic pelvic pain whom are unconcerned about future fertility.

Hormones are sometimes used to treat endometriosis, particularly the gonadotropin-releasing hormone (GnRH) agonists. They work by reducing the amount of estrogen naturally produced by the body. Hormone treatment does result in menopausal symptoms, however.

Elucidating the causes of pelvic pain and finding innovative treatments for this pain are priorities among Johns Hopkins gynecological researchers. Currently, our researchers are collaborating with the National Institutes of Health in a project that investigates the development of endometriosis. Ongoing efforts are underway to identify less invasive methods of diagnosing endometriosis.

We are also pioneering the very latest in gynecological surgical techniques. For instance, a Johns Hopkins gynecological surgeon is among the first persons ever to use robotic surgery for gynecological purposes: currently, he is performing tubal reanastomosis---a procedure to reconnect the fallopian tube following tubal sterilization---a procedure to reconnect the fallopian tube following tubal sterilization---robotically. Robotic laparoscopic myomectomies and hysterestomies are slated for the near future.

Here's how robotic surgery works. The surgeon acts as an operator of the robot, whose three "arms" are connected to delicate laparoscopic instruments. Refined movements of the surgeon's fingers translate directly to the laparoscopic tools attached to the robot.

Robotic surgery offers several benefits. It provides better visualization for the surgeon, and the robot has a much better range of motion than the human hand. Because it is minimally invasive surgery, patients lose less blood and recover much quicker than they do with traditional surgery.