New Hope for Women with Endometriosis

About five million women in the United States have endometriosis; this makes it one of their most common health problems. Endometriosis occurs when tissue like that which lines the inside of uterus grows outside the uterus, usually on the surfaces of organs in the pelvic and abdominal areas. The tissue forms lesions, which can cause pain and infertility. These endometrial lesions are most often found on or under the ovaries, behind the uterus, on the tissues that hold the uterus in place, on the lining of the abdominal cavity, or on the bowels and bladder. The lesions can form scar tissue, sometimes called adhesions.

"Endometriosis can occur in several different ways, but the most common way women get endometriosis is that tissue from the lining inside the uterus, which should be shed during each menstrual period, backs up through the fallopian tubes. The tissue implants itself and starts to grow in places that it is not supposed to grow," explains Gloria Halverson, MD, Associate Professor of Obstetrics and Gynecology at the Medical College of Wisconsin, who practices at the Obstetrics and Gynecology Clinic at Froedtert & Medical College Clinics.

Symptoms, Diagnosis Can Be Perplexing
"You have to have a high index of suspicion when dealing with this disease," says Dr. Halverson. "Endometriosis is a real masquerader. Some patients with endometriosis, even severe endometriosis, have no symptoms." There are four symptoms, however, which most often cause women to come to Dr. Halverson for help. These are severe cramps with menstrual periods, pain with sexual intercourse, general pelvic pain, and infertility.

The only way to diagnose endometriosis with certainty is laparoscopy, a minor surgical procedure where a telescope is inserted under the navel to see inside the pelvis. "Lesions of endometriosis are what we look for first," says Dr. Halverson. "The lesions can be red, white, brown, black, or clear." Dr. Halverson also looks for the adhesions which occur in some patients with endometriosis. "Not everybody with endometriosis has adhesions," she notes.

Treatment is Individualized
The treatment for endometriosis varies, depending upon the patient's age, her desire for pregnancy, her need for pain relief, and her response to treatment. "You have to tailor treatment to the individual patient," says Dr. Halverson. "Not everyone has the same needs, so we customize the treatment for each woman."

This might include infertility treatment. "Endometriosis can cause infertility in two ways," explains Dr. Halverson. "First of all, the lesions put out chemicals that are toxic to the egg and sperm. And the second way is that pelvic adhesions can bind the fallopian tube or coat the ovary so that the tube can't pick up the egg."

Treatment with anti-estrogen drugs can help the symptoms of endometriosis. "Estrogen makes the lining of the uterus grow, so most of the drugs we use work against estrogen, either by shutting it off or by neutralizing it," says Dr. Halverson.

Although traditional surgery is sometimes necessary, Dr. Halverson most often uses the laparoscope with a laser, to perform very precise surgery on some patients. "We either vaporize the lesion, or we excise it." Surgery can also remove or reduce scar tissue, restoring anatomy in the process.

As a last resort, Dr. Halverson might perform a hysterectomy, in which the cervix and uterus are removed. If the damage is severe, the ovaries and fallopian tubes are also removed.

Research is Underway
Dr. Halverson and others in the Obstetrics and Gynecology department are currently involved in a molecular genetic study of endometriosis with Sun-Wei Guo, PhD, regarding genetic changes during endometriosis. The purpose of the study is to find the root causes of endometriosis, find out what the genetic difference is between endometrial tissue and normal tissue, and confirm that endometriosis does, in fact, originate in the uterine lining. Dr. Halverson says that the findings of this study might help find better ways to diagnose or even to treat endometriosis.

In women who participate in the study, small samples of tissue are taken from the normal pelvic or abdominal wall area, the normal uterine lining, and the areas of endometriosis. "We're finding that in people with endometriosis, the genetics of the cells of the lesions are different from the surrounding tissue," says Dr. Halverson. "We don't yet know if they start out different, or change during endometriosis."

A blood sample is taken from participants, as the study is also looking to see if there are identifying blood markers that exist in patients with endometriosis. "If we can find blood markers, we won't always have to do a laparoscopy for diagnosis," says Dr. Halverson.

New Drugs Under Investigation
There are also several new drugs under investigation for treating endometriosis. "This is exciting," says Dr. Halverson, "because we haven't had too much new to offer until recently."

One new development is the use of the Mirena IUD (intrauterine device) to treat endometriosis. The Mirena IUD contains levonorgestrel, a progesterone-like hormone. The IUD is normally used for birth control, says Dr. Halverson, but, "We can put it in the uterus and it will give high amounts of the hormone to neutralize the estrogen locally in the pelvis, without giving as many side effects to the whole body."

Another drug being investigated to treat endometriosis is letrozole (Femara), which is used to treat breast cancer. Letrozole is in a class of medications known as aromatase inhibitors. "Letrozole decreases the amount of estrogen made throughout the body," explains Dr. Halverson. Just as it can slow or stop the growth of some breast tumors that need estrogen to grow, it might also slow or stop the growth of endometriosis lesions.

"These drugs are not experimental but are FDA-approved for other uses. What is experimental is using them to treat endometriosis," Dr. Halverson points out. Endometriosis affects women of all ages and lifestyles. Women often have a difficult time getting an accurate diagnosis, and commonly have symptoms for two to five years before finding out they have the disease. "It can be devastating to their quality of life," says Dr. Halverson. "It can be emotionally devastating if it causes infertility, it can be disabling for a part of every month, it can keep them from enjoying sexual relations, it can be totally disabling when it is severe."

"Endometriosis is a lifelong condition," she says, "but we can successfully control the symptoms."

P. J. Early
HealthLink Contributing Writer

This article includes information from he US Department of Health & Human Services, the National Institutes of Health, and "A Molecular Study of Endometriosis," Sun-Wei Guo, PhD, Medical College of Wisconsin Professor of Pediatric Endocrinology.

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.