Pelvic pain - endometriosis; Endometrioma
Endometriosis occurs when cells from the lining of your womb (uterus) grow in other areas of your body. This can cause pain, heavy bleeding, bleeding between periods, and problems getting pregnant (infertility).
Every month, a woman's ovaries produce hormones that tell the cells lining the uterus to swell and get thicker. Your uterus sheds these cells along with blood and tissue through your vagina when you have your period.
Endometriosis occurs when these cells grow outside the uterus in other parts of your body. This tissue may attach on your:
- Lining of your pelvic area
It can grow in other areas of the body, too.
These growths stay in your body, they do not shed when you have your period. But, like the cells in your uterus, these growths react to the hormones from your ovaries. They grow and bleed when you get your period. Over time, the growths may add more tissue and blood. The buildup of blood and tissue in your body leads to pain and other symptoms.
No one knows what causes endometriosis. One idea is that when you get your period, the cells may travel backwards through the fallopian tubes into the pelvis. Once there, the cells attach and grow. However, this backward period flow occurs in many women. Researchers think that the immune system in women with endometriosis may cause the condition.
Endometriosis is common. Sometimes, it may run in families. Endometriosis probably starts when a woman begins having periods. However, it usually is not diagnosed until ages 25 to 35.
You are more likely to develop endometriosis if you:
- Have a mother or sister with endometriosis
- Started your period at a young age
- Never had children
- Have frequent periods, or they last 7 or more days
- Have a closed hymen, which blocks the flow of menstrual blood during the period
A common gynecological problem in women occurs when cells that are supposed to form in the uterus of a woman, attach themselves to tissue in other places of the body, causing pain, irregular bleeding, and problems with getting pregnant, or infertility. Let's talk about endometriosis in a little more detail. Every month, a woman's ovaries produce hormones that tell the cells lining the uterus, or womb, to swell and thicken. The body removes these extra cells from the womb lining, or endometrium, when you get your period. But if these cells, called endometrial cells, implant and grow outside the uterus, endometriosis results. The growths are called endometrial tissue implants. Women with endometriosis typically have tissue implants on the ovaries, or bowel, rectum, bladder, or on the lining of the pelvic area. We don't know what causes endometriosis. One theory is that the endometrial cells that shed when you get your period travel backwards through the fallopian tubes into the pelvis, where they implant and grow. This is called retrograde menstruation. This backward menstrual flow occurs in many women, but many think the immune system may also be different in women with endometriosis. Symptoms of endometriosis include painful periods, pain in your lower belly before and during menstruation, cramps before and during menstruation, pain during sex, painful bowel movements, as well as pelvic or lower back pain. To treat endometriosis. . . The goal of treatment is to improve pelvic pain, reduce pelvic masses, or improve fertility. If you have mild symptoms and do not want to have children, you may choose to have regular exams every 6 to 12 months so your doctor can make sure the disease isn't getting worse. Treatment options also include pain medicines, hormone medicines to stop the disease from getting worse, or surgery to remove the area of endometriosis or even the entire uterus and ovaries if you have severe pain that does not get better with other treatments. Hormone therapy doesn't cure endometriosis, but it can relieve some or all of your symptoms. Unfortunately, removal of the uterus, fallopian tubes, and both ovaries may eliminate symptoms, but it also eliminates fertility. A combination of limited surgery and assisted reproduction techniques may improve fertility. So, if you have any questions about endometriosis, please see your doctor.
Pain is the main symptom of endometriosis. You may have:
- Painful periods.
- Pain in your lower belly before and during your period.
- Cramps for a week or 2 before and during your period. Cramps may be steady and range from dull to severe.
- Pain during or following sexual intercourse.
- Pain with bowel movements.
- Pelvic or low back pain that may occur at any time.
You may not have any symptoms. Some women with a lot of tissue in their pelvis have no pain at all, while some women with milder disease have severe pain.
Exams and Tests
Learning how to manage your symptoms can make it easier to live with endometriosis.
What type of treatment you have depends on:
- Your age
- Severity of your symptoms
- Severity of the disease
- Whether you want children in the future
There are different treatment options.
If you have mild symptoms, you may be able to manage cramping and pain with:
- Exercise and relaxation techniques.
- Over-the-counter pain relievers. These include ibuprofen (Advil), naproxen (Aleve), and acetaminophen (Tylenol).
- Prescription painkillers, if needed, for more severe pain.
- Regular exams every 6 to 12 months so your doctor can make sure the disease is not getting worse.
These medicines can stop endometriosis from getting worse. They may be given as pills, nasal spray, or shots. Only women who are not trying get pregnant should have this therapy. Hormone therapy will prevent you from getting pregnant. Once you stop therapy, you can get pregnant again.
Birth control pills. With this therapy, you take pills for 6 to 9 months without stopping. Taking these pills relieves most symptoms. However, it does not prevent scarring or treat any damage that has already occurred.
Progesterone pills or injections. This treatment helps shrink growths. However, side effects can include weight gain and depression.
Gonadotropin-agonist medicines. These medicines stop your ovaries from producing the hormone estrogen. This causes a menopause-like state. Side effects include hot flashes, vaginal dryness, and mood changes. Treatment is usually limited to 6 months because it can weaken your bones.
Your provider may recommend surgery if you have severe pain that does not get better with other treatments.
- Laparoscopy helps diagnose the disease and can also remove growths and scar tissue. Because only a small cut is made in your belly, you will heal faster than other types of surgery.
- Laparotomy involves making a large incision (cut) in your belly to remove growths and scar tissue. This is major surgery, so healing takes longer.
- Laparoscopy or laparotomy may be a good option if you want to become pregnant, because they treat the disease and leave your organs in place.
- Hysterectomy is surgery to remove your uterus, fallopian tubes, and ovaries. If your ovaries are not removed, symptoms may return. You would only have this surgery if you have severe symptoms and do not want to have children in the future.
Hormone therapy and laparoscopy cannot cure endometriosis. However, in some women, these treatments may help relieve symptoms for years.
Removal of the uterus, fallopian tubes, and both ovaries (a hysterectomy) gives you the best chance for a cure.
Endometriosis can lead to problems getting pregnant. However, most women with mild symptoms can still get pregnant. Laparoscopy to remove growths and scar tissue may help improve your chances of becoming pregnant. If it does not, you may want to consider fertility treatments.
Other complications of endometriosis include:
- Long-term pelvic pain that interferes with social and work activities
- Large cysts in the pelvis that may break open (rupture)
In rare cases, endometriosis tissue may block the intestines or urinary tract.
Very rarely, cancer may develop in the areas of tissue growth after menopause.
When to Contact a Medical Professional
Call your provider if:
- You have symptoms of endometriosis
- Back pain or other symptoms reoccurring after endometriosis is treated
You may want to get screened for endometriosis if:
- Your mother or sister has the disease
- You are unable to become pregnant after trying for 1 year
Birth control pills may help to prevent or slow down the development of the endometriosis.
ACOG Practice Bulletin No. 110: noncontraceptive uses of hormonal contraceptives. Obstet Gynecol. 2010;115(1):206-218. PMID: 20027071
Brown J, Pan A, Hart RJ. Gonadotrophin-releasing hormone analogues for pain associated with endometriosis. Cochrane Database Syst Rev. 2010;(12):CD008475. PMID: 21154398
Burney RO, Giudice LC. Endometriosis. In: Jameson JL, De Groot LJ, de Krester DM, et al, eds. Endocrinology: Adult and Pediatric. 7th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 130.
de Ziegler D, Borghese B, Chapron C. Endometriosis and infertility: pathophysiology and management. Lancet. 2010;376(9742):730-738. PMID: 20801404
Giudice LC. Clinical practice. Endometriosis. N Engl J Med. 2010;362(25):2389-2398. PMID: 20573927
Lobo R. Endometriosis: etiology, pathology, diagnosis, management. In: Lentz GM, Lobo RA, Gershenson DM, Katz VL, eds. Comprehensive Gynecology. 6th ed. Philadelphia, PA: Elsevier Mosby; 2012:chap 19.
Last reviewed on: 9/26/2015
Reviewed by: Daniel N. Sacks MD, FACOG, obstetrics & gynecology in private practice, West Palm Beach, FL. Review Provided by VeriMed Healthcare Network. Internal review and update on 09/01/2016 by David Zieve, MD, MHA, Isla Ogilvie, PhD, and the A.D.A.M. Editorial team.