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Examining The Puzzle of Endometriosisby Dr. James L. Ivers, Lowell General Hospital Endometriosis has often been referred to as one of the "most puzzling conditions that affect women." Small wonder. Because while many aspects of endometriosis are clearly understood and well documented, many others remain a mystery. Most significant among these is whether endometriosis can cause infertility in women. Even among those doctors who believe that it does cause infertility, there is still no precise explanation as to how the infertility is actually brought about. What's more, there is no clear consensus on the exact cause of the disease itself. Take the infertility issue. Determining a link between endometriosis and infertility depends largely on who you ask. If you were to question an "academic" group of doctors - those involved in teaching and research - you'd find that about 80% of them believe that mild to moderate endometriosis has no significant bearing on infertility. However, question an equal number of doctors who are actually in practice and you'll get about the same percentage to conclude that mild to moderate endometriosis does contribute to infertility. Then again, it is possible that as many as 15% to 20% of all female infertility problems are related to endometriosis. (It should be noted that whether or not endometriosis contributes to infertility is somewhat of a moot point; if a woman is diagnosed with the condition she will be treated for it regardless of her doctor's position on this controversy.) Clearly, there is still much to learn about endometriosis, which affects approximately one in every 10 women of reproductive age in the United States. We do, however, already know a great deal about it, including the fact that it is one of the most common gynecological disorders. Before discussing the endometriosis-infertility link further, it is important to understand exactly what this disease is, as well as some of its common symptoms. Endometriosis is a condition which occurs when endometrial tissue - which lines the uterus and is shed during menstruation - grows outside the uterus. The exact cause is still unknown; however, the most common theory deals with "retrograde menstruation." During menstruation there is a "retrograde" flow of blood and tissue from the endometrial cavity - that is, it flows backwards into the fallopian tubes rather than into the vagina, then into the pelvis and abdominal cavity. This occurs in almost every woman but, for still-unknown reasons, this endometrial tissue, in some women, implants itself on the surfaces of the pelvic organ and begins to thrive, tapping into the surrounding blood supply and proliferating with each menstrual cycle. Essentially, there is a classic "triad'' of symptoms associated with this disorder. These are painful periods, painful sexual intercourse (specifically, lower abdominal pain rather than vaginal pain), and infertility. Unfortunately, endometriosis can often be asymptomatic; in such cases it is discovered only when a woman undergoes surgery for unrelated reasons, such as a tubal ligation or even an appendectomy. While there is no "typical" victim of endometriosis, certain physical factors put women at varying risk for contracting the disease. The incidence of endometriosis increases with age (although I have seen it in women as young as 15 years old) up until the onset of menopause. Further, the more pregnancies that a woman has - add the earlier in life she becomes pregnant - the less susceptible she is to endometriosis. Conversely, women who postpone their first pregnancy until their late 30's or early 40's - which many professional women are doing - are more susceptible. While the endometrial growths are usually not microscopic, neither are they palpable on physical examination or visible via ultrasound or X-rays. An accurate diagnosis of endometriosis can only be made through a procedure known as a laparoscopy. In this procedure, a laparoscope - a thin, light-transmitting microscope - is inserted, under anesthesia, through a woman's naval and into her abdominal cavity. This procedure allows the physician to examine the abdominal organs and check the size and extent of the endometrial growths, if any. It can also help rule out other conditions with similar symptoms, such as ovarian cancer. As I mentioned earlier, the medical community is split on whether or not endometriosis causes infertility. Further, even among those who do not espouse this position, there is no definitive answer as how the infertility is caused. In severe instances of endometriosis, there can actually be a mechanical obstruction of the internal female genitalia and extensive pelvic adhesions which can obstruct the fallopian tubes and prevent the egg and sperm from fertilizing. However, this extreme scenario represents only about 5% of all cases of endometriosis. Among those doctors who believe that endometriosis can cause infertility, the prevailing belief is that the inflammation produced by the endometriosis-and not the endometriosis per se-causes the problem. The inflammatory reaction that results in the woman's pain generates a variety of chemical substances, including some called prostaglandins. It is theorized that these prostaglandins have an adverse effect on the motility of the fallopian tubes, which contrary to popular belief, are not simply hollow tubes but rather are motile organs that actively transport the fertilized egg to the uterus as well as nourishing it. In some as-yet-undefined manner, the prostaglandins affect these crucial functions of the fallopian tubes, renderig it unable to properly deliver the fertilized egg to the uterus for development. Treatments for endometriosis are varied, as their success rates. There are still a few doctors who rely on "old" treatments: high doses of birth control pills. This treatment, however is rarely used anymore: besides being relatively ineffective for anything but ver mild endometriosis, the pill can have very significant side effects. The standard treatment for endometriosis is Danacrine or Danazol. These drugs-different names products-inhibit certain stimulatory hormones which are responsible for hormone production and ovulation. Essentially, they put a woman into an "artificial" menopause without the menopausal symptoms. She stops having periods for a length of time she is on the medication-usually about six months. Not only does the cessation of menstrual flow prevent further spread of the disease, the ovaries are rendered virtually dormant and very little hormone-which the endometrial tissue requires for survival-is produced. In this low-hormone state the endometrial implants atrophy and shrivel, eventually getting absorbed by the body's immune system. For mild to moderate cases of endometriosis, there is a 90% cure rate through drug therapy. Other medications are available which, while slightly different chemically, produce a similar effect In cases of severe endometriosis or in those instances when drug therapy is ineffective, laser surgery through the laparoscope is performed. Some doctors will take a more aggressive stance, skipping the medication and going directly to surgery; others are even more aggressive, utilizig both lasers ad medication in tandem. Obviously, should you display any of the symptoms of endometriosis, you should consult your physician. While some aspects of the disease remain unclear, it is an eminently treatable condition. __________________________________________________ Dr.James L. Ivers runs his own OB/GYN practice in Chelmsford. He is also the Director of Gynecological Services at the Lowell Community Health Center and has been affiliated with Lowell General Hospital for two years. |
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