A Core Focus for the Center: Common, Nonmaligant Conditions of the Uterus
|Endometrial tissue that is outside of its normal location can provide the basis for a type of ovarian cyst called an endometrioma.|
The endometrium is the inside lining of the uterus, a unique layer of tissue that has a special ability to grow and recede cyclically, in response to estrogen. But the endometrium can sometimes grow or spread in abnormal ways. For many women, these changes cause no symptoms; for many others, these changes result in a one or more of several common conditions:
Chief among symptomatic endometrial conditions is endometriosis, an often-painful condition that can also affect fertility. The condition brings discomfort that in some women can significantly detract from quality of life. Endometriosis affects millions of women.
The clumps of uterine tissue that grow outside of the uterus (“implants”) and around reproductive and other pelvic organs in this disease get thicker during the menstrual cycle and then break down and bleed. But because this tissue is outside the uterus, the blood cannot be released normally. These areas can get irritated and sore. They can also form scar tissue or fluid-filled sacs that may be painful and that can affect fertility.
Tests that Aria's Center for Gynecology & Women's Health may employ to diagnosis endometriosis include pelvic ultrasound, MR imaging, hysterosalpingogram (an x-ray procedure performed in the radiology department, in which radiologists – working alongside one of the center’s gynecologists – inject a contrast die into the uterus and fallopian tubes to make imaging of these areas easier), hysteroscopy, and laparoscopy. Laparoscopy provides the most definitive diagnosis.
There are no treatments for endometriosis that are completely curative, but specialists have a number of procedures and other types of care that can be effective in controlling its symptoms and effects. Some patients will require a combination of treatments.
Medication therapy can aim at decreasing the inflammatory effects of endometriosis or at suppressing the natural hormone influence of a woman’s cycle on endometrial implants. For patients who want to address the pain of the condition beyond what over-the-counter medications can accomplish, various types of prescription nonsteroidal anti-inflammatory drugs (NSAIDs) or hormonal therapies can be effective.
Growth of endometrial tissue in areas of the pelvis and the abdominal organs can pose a vexing problem, requiring highly knowledgeable care and sometimes repeat intervention.
If these types of more conservative approaches are not effective, the staff may recommend minimally invasive surgery. If, during laparoscopic surgery, the center's surgeons identify endometrial or scar tissue, they can remove or ablate (destroy) it. They remove endometrial implants from such areas as the bowel, bladder, and uterus by cutting the tissue away or by using a laser beam or electric current to destroy it. Hormone therapy after surgery can help to prevent the endometriosis from growing back. Endometriosis recurs in some women in subsequent years, and laparoscopic surgery can sometimes be repeated in these cases. When patients have endometrial masses that are larger or more difficult to reach, the center’s gynecologic surgeons perform traditional, open abdominal surgery (laparotomy) to remove the tissue.
Laparoscopic surgery is best suited to women whose endometriosis is in its early stages. Advanced endometriosis can be treated surgically, in some cases by laparoscopy, in some cases by laparotomy, but this can entail a challenging and extensive operation.
To treat severe pain that cannot otherwise be resolved, some women undergo removal of their uterus and ovaries (hysterectomy and oophorectomy). Women who are close to menopause, however, may chose to manage their symptoms with medications, as symptoms of endometriosis usually decrease or stop after menstrual periods cease.
Women who want to get pregnant may need surgery to remove endometrial tissue. But patients who are having trouble getting pregnant will need to consult with their specialist about a complex set of factors and care options, that relate to the patient’s age, severity symptoms, and other considerations.
Sometimes the lining of the uterus can grow to cause abnormal projections or connections to itself within the uterus. These uterine polyps often have bulblike base (ranging in size from a few millimeters to a several centimeters) and a longer stalklike projection, sometimes with branches, that creates an abnormal connection (or stalk or base alone). They may have a hanging or flat orientation within the uterus. These estrogen-sensitive polyps may pull against or push into the uterus itself. They may compromise the opening of the fallopian tubes (affecting fertility) or even the opening of vagina at the cervix. (They are also thought to increase the risk of miscarriage in some women.)
In addition, uterine polyps are an important cause of dysfunctional menstruation, providing the basis for these symptoms in certain women who have abnormal uterine bleeding. These polyps can also be a risk factor for uterine cancer, as well. (Such cancer is much less likely in premenopausal women). Uterine polyps can become symptomatic in women of any age but are more likely to become evident in perimenopausal or postmenopausal women (in whom they can cause light bleeding). Risk factors for uterine polyps include age, menopause, presence of cervical polyps, and previous drug treatment with tamoxifen.
One imaging step that can be an important initial diagnostic for this condition is hysterosalpingogram (HSG), an x-ray procedure performed in the radiology department, in which the radiologist – working alongside one of the center’s gynecologists – injects a contrast die into the uterus and fallopian tubes to make imaging of these areas easier. Hysteroscopy is also a primary procedure for addressing uterine polyps, a test that permits gynecologists to directly see (through a scope), and evaluate the extent of, these polyps. (Pelvic ultrasound may also be an important diagnostic.) These surgical specialists can also hysterscopically remove the polyps to treat the condition. They introduce small instruments through the hysteroscopic tube that permit them to scrape the polyp away or to grasp the polyp and, with small scissors, cut it away. If the polyps return, the team can repeat this procedure.
Most uterine polyps are noncancerous but, when removed, they are sent to the lab for biopsy. If polyps are too extensive for hysteroscopic removal or show signs of being precancerous or cancerous, the team may recommend a hysterectomy.
Sometimes abnormal growth of endometrial tissue can result in the endometrium invading the muscle wall of the uterus. Called adenomyosis, this condition can cause discomfort due to swelling and pressure. The symptoms are usually more evident during the premenstrual portion of the menstrual cycle and the condition occurs most often in women over 30 (especially in their 40s) who have had a full-term pregnancy. Adenomyosis can also cause additional bleeding during periods.
The condition is a common cause of cyclical menstrual pain and is sometimes referred to as internal endometriosis. When endometrial tissue is in the muscle wall it can trap blood that would normally be released with the menses, resulting in cramping and prolonged bleeding. Adenomyosis can occur in the presence of fibroids (for which it is often mistaken), cysts, or other gynecologic conditions. Patients with the condition may also have endometriosis. Women who have previously had surgery to their uterus (fibroid removal, C-section, etc.) are more likely to develop adenomyosis than women who have not.
Adenomyosis can cause the uterus to become enlarged. However, so can fibroids, which produce similar bleeding symptoms, so the team must differentiate the two, usually using pelvic ultrasound.
Treatments are similar to those for endometriosis; however, because of the depth of the tissue growths, laparoscopic endometrial ablation may be of limited use. Hysterectomy is considered the only treatment that is dependably successful in relieving adenomyosis pain in most women. Some women, though, may chose conservative care, knowing that symptoms of the condition usually disappear after menopause.
The staff at Aria's Center for Gynecology & Women's Health has ample experience in treating endometrial abnormalities. The center also has collaborative relationships with fertility specialists that can be important for some women with these conditions. The center's experienced healthcare providers evaluate for this condition, order or perform testing, and arrive at a diagnosis, for women who have symptoms of endometriosis, uterine polyps, or adenomyosis. These clinicians can recommend the right course of care and can assist in thinking through decisions on treatment. The vast majority of patients with endometrial conditions can find a significant measure of symptom relief if they receive proper care.