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Endometriosis: What you need to know

Tommaso Falcone

Endometriosis affects 6% to 10% of women of reproductive age, according to the American College of Obstetricians and Gynecologists. And by some estimates, endometriosis has direct costs of $12,118 per patient, per year in the United States.

Yet despite its prevalence and cost, there is still a lot that the medical community does not know about it.

“Endometriosis is one of the most common conditions encountered in gynecological practice ... [and] a gynecological enigma since it is difficult to diagnose and treat,” Vineet V. Mishra, professor, department of obstetrics and gynecology, Institute of Kidney Diseases and Research Centre in India, and colleagues wrote in the Journal of Clinical and Diagnostic Research.

Perhaps adding to the confusion is that some signs of endometriosis are similar to other conditions, according to Tommaso Falcone, MD, who co-authored the American College of Obstetricians and Gynecologists’ guidance on the condition.

As a courtesy to its readers and to increase awareness, Healio Family Medicine asked Falcone to provide more information on endometriosis. – by Janel Miller

Question: Is the prevalence of endometriosis increasing?

Answer: I don’t think the numbers of cases are going up substantially, but awareness of the condition is. We are also able to make a quicker, more definitive diagnosis with laparoscopy, and that was not the case about 25 years ago. There are more women who are delaying childbearing now than there were a generation ago, which may be a small factor in increasing prevalence, but I don’t think it’s a significant amount.

Q: What are some of the risk factors for endometriosis?

A: The main risk factor is that it runs in families. If a woman has a first-degree relative with the endometriosis, a patient’s risk for the condition increases sevenfold to 10-fold. But there are other, more subtle risk factors. Women with longer, heavier periods, are at increased risk, as are women whose menstrual length is every 24 or 25 days instead of 28 days, and women with no children. There are also some softer risk factors, such as low BMI and alcohol use, but I say those cautiously, since not everyone who has low weight and drinks a glass of wine is going to develop endometriosis. And for some reason, and we don’t know why yet, certain women that have freckles for example are also at risk for endometriosis.

Q: Why is endometriosis so difficult to diagnose?

A: The average age at diagnosis is 28 years. But in many women, the condition probably exists earlier than that, in some cases, as much as 8 to 11 years before the condition is accurately diagnosed. The difficulty lies in the fact that many endometriosis symptoms are similar to other disease presentations. If a woman has pain outside of her period, it may be endometriosis, but it may also be irritable bowel syndrome, adhesions or scar tissue, or the entrapment of nerves on the abdominal wall. A woman may also say she has pain during sexual intercourse. These women may actually have a pelvic floor disorder, but if she has diarrhea or cramping or constipation, it could be endometriosis but it could also be irritable bowel syndrome or a cyst on an ovary. And she may also have pain with emptying her bladder, which could be endometriosis but could also be a kidney stone or a pelvic floor disorder. Any woman who comes into the office thinking she has endometriosis, or any doctor who thinks his patient has endometriosis, should first seriously consider an ultrasound to rule out ovarian cysts as the cause of her pain, since a laparoscopy is currently the only way to definitively diagnose endometriosis. Since this procedure carries the risk for surgical morbidity and possible decreases in the ovarian reserve, the pros and cons of laparoscopy must be carefully considered.

Q: What are treatment options for endometriosis?

A: There are three FDA-approved three drugs for endometriosis: Lupron, Depo-Provera, and norethindrone. It’s important to note though, that medical therapy is suppressive rather than curative. Therefore, regimens that are long-term and affordable with minimal side effects are recommended. If the patient wants to explore other treatment options, the pros and cons of surgery to remove the lesion should be discussed, as should nonsurgical procedures like the birth control pill or the Mirena IUD and complementary approaches such as acupuncture, massage therapy and exercise. The many molecular dissimilarities between endometriosis lesions and eutopic endometrium create difficulties in the development of new drug therapies and treatments.

Q: Is there any other advice about endometriosis that a primary care physician or family practitioner should know ?

A: Endometriosis can lead to infertility and also carries a low risk for epithelial ovarian cancer. Therefore, if a woman says her periods are painful, please don’t tell the patient all she needs is an aspirin. Take the woman’s physical symptoms and verbal cues seriously. I would recommend performing a very detailed medical history and conducting a thorough physical exam and ultrasound to see if it’s an ovarian cyst or that should be referred to a gynecologist. If the woman does indeed have endometriosis, suggest one of the treatment methods I discussed earlier.

References:

The American College of Obstetricians and Gynecologists Practice Bulletin. “Management of Endometriosis.”

Falcone T and Flyckt R. Obstet Gynecol. 2018;doi:10.1097/ACOG0000000000002469.

Mishra VV, et al. J Clin Diag Res. 2015; doi:10.7860/JCDR/2015/13687.6125.

Soliman, AM, et al. Hum Rep. 2018; doi:10.10193/humrep/dev335.

Rogers PAW, et al. Reprod Sci. 2009;doi:10.1177/1933719108330568.

Disclosure: Falcone reports no relevant financial disclosures. Healio Family Medicine was unable to determine Mishra’s relevant financial disclosures prior to publication.