New research reveals endometriosis is a disorder of estrogen production on a cellular level. Endometriosis is caused by the presence of endometriosis implants, cells outside the uterus that normally live inside the uterus (the endometrium).
Evolution of the understanding of endometriosis offers hope for new treatments such as estrogen blockers and progesterone blockers.
In women with endometriosis, the processing of estrogen is abnormal, both within the cells lining the uterus (the endometrium), and in endometriosis implants outside the uterus.
Endometriosis implants have an abnormal amount of an enzyme called “aromatase”. This enzyme converts estrogen-precursor molecules to estrogen. Endometriosis implants also have high levels of estrogen receptors. Therefore endometriosis implants can both synthesize estrogen independent of the ovarian hormones; and they are more sensitive to estrogen.
Endometriosis implants are thus “self-perpetuating”. Endometriosis located outside the uterus can re-generate itself and spread through self-stimulation, whether or not the uterus and ovaries are present. This explains why some women who have hysterectomy for endometriosis have recurrent pain after total hysterectomy. Hysterectomy and oophorectomy (removal of ovaries) “debulks” endometriosis tissue present in the uterus and ovaries, but it does not remove endometriosis implants present outside the uterus.
Endometriosis implants outside the uterus and the endometrium produce high levels of inflammatory chemicals called “cytokines” and “prostaglandins”. By releasing prostaglandins and cytokines, molecules responsible for cramping during normal periods, endometriosis can inflame the nearby tissues and nerves, resulting in chronic pain at any time of the menstrual cycle.
“Location, Location, Location”: Endometriosis Resembles Real Estate
Location of endometriosis implants is key to their symptoms and other clinical manifestations.
Endometriosis is usually found in three places:
- the tissue lining the pelvis and ligaments that support the uterus (pelvic peritoneum, uterosacral ligaments)
- the ovary (a collection of endometriosis cells and fluid called an “endometrioma”)
- in the wall between the vagina and rectum (recto-vaginal septum)
Although these are the common locations of endometriosis can occur almost anywhere in the body. I have seen endometriosis on the intestines, and even had a patient with endometriosis in her lungs. Every time she menstruated she coughed up blood!
The location of endometriosis implants explain why some people with minimal endometriosis can have a lot of pain; while others with large cystic endometriosis can have no pain. For example, you can have a few small endometriosis implants on or near the pelvic nerves and have a great deal of pain; while another person can have a large cyst of endometriosis on the ovary and have no pain. The ovary has a different nerve supply and can apparently “tolerate” bulkier endometriosis.
Endometriosis that grows on and into the pelvic nerves can cause referred pain anywhere along the path the nerve innervates. For example, endometriosis on or near the obturator nerve, which supplies the inner thigh, can cause pain down the leg, and even in the groin/labial area. Endometriosis along the pudendal nerve, which innervates the lower vagina and external female genitalia, can cause pain anywhere along that nerve’s distribution. About 5-10 percent of women have symptomatic endometriosis, the most common cause of chronic pelvic pain.
Endometriosis in the ligaments supporting the uterus can be particularly troublesome because it can infiltrate the pelvic nerves, in close proximity.
Traditional Treatment for Endometriosis Focused on Suppressing the Growth of Endometriosis Implants
The main-stays of endometriosis treatment have been:
- suppression of menses with progesterone
- use of anti-inflammatory medications (e.g. ibuprofen) to reduce pain
- laparoscopic removal of endometriosis implants
- Use of Lupron (suppresses ovarian hormone production) to create a short-term “menopause” and withdraw hormonal support to endometriosis implants
- removal of uterus, tubes, and ovaries (total hysterectomy with bilateral salpingoophorectomy)
While each of these has their place in treating endometriosis, none of these is completely effective at eradicating endometriosis. (See the related post, Pros and Cons of “Traditional” Treatment for Endometriosis–not yet an active link).
In fact, endometriosis is now seen as a chronic disease. The goal of endometriosis treatment should be to control manifestation and progression of the disease, preferably without resorting to the extreme of hysterectomy.
For more information on managing endometriosis, see these posts:
Pros and Cons of “Traditional” Treatment for Endometriosis (not yet an active link)
- Do you have endometriosis?
- What treatments have worked for you, including “traditional” (allopathic)and complementary/alternative medicine?
- Have you tried yoga for treatment of chronic pain? If so, what has your experience been?