Q: In the past several years, since turning 25, I have had gradually worsening pain before and during each menstrual period. My doctor believes that my pain may be due to endometriosis, and she has recommended a laparoscopy. I am hesitant to undergo this procedure unless it will help to eliminate or reduce my pain. What do you advise?
A: Endometriosis is the growth of endometrial tissue (the tissue that normally lines the uterus) outside the uterine cavity in such places as the fallopian tubes, ovaries, other organs in the pelvis, and even more widely throughout the abdomen. Endometriosis is a common, non-cancerous disorder most prevalent in women ages 25 to 40, many of whom have it but not the symptoms.
The most common symptom is pain in the vagina, lower abdomen and back that may precede the onset of menstrual bleeding and continue during menstruation and even afterward. Other possible symptoms are heavy bleeding during periods and pain during sexual intercourse. Endometrial growths, or implants, on the lower part of the intestine may cause changes in bowel movements and pain during bowel movements. Perhaps the most troubling feature of endometriosis is the possibility of infertility.
The only way to confirm the diagnosis of endometriosis when it is suspected is by direct examination of pelvic organs. Laparoscopy, which involves the insertion of a lighted viewing instrument into the abdomen through a small incision, is the least invasive way to see these organs and make a definitive diagnosis of endometriosis. (The procedure is done on an out-patient basis using local anesthesia.) Making the diagnosis is worthwhile because several approaches are now available to treat the disorder.
Non-surgical treatments aim to reduce blood flow during menstrual periods or stop menstruation completely for at least three to six months. This is accomplished by administering oral contraceptives or a progestational agent, such as danazol. These interfere with the release of pituitary hormones that stimulate the production of estrogen by the ovaries.
In the absence of estrogen, menstrual periods cease and the implants of endometrial tissue tend to atrophy. (It is critical not to take this medication if you are pregnant.)
When medical measures fail and severe symptoms continue, it may be necessary to destroy endometrial implants through laparoscopic surgery.
If you are married and wish to have children, it would be a good idea to plan an early pregnancy in case the endometriosis worsens and causes infertility.
Dr. Margolis is professor of medicine and biological chemistry at the Johns Hopkins School of Medicine.