By NBH, FACOG, AACS, AACG

What is endometriosis? Endometriosis is a gynecological medical condition in which cells from the lining of the uterus (endometrium) are located outside the uterus on the lining of the pelvis, ovaries, bowel or any place in the abdominal cavity. Its main symptom is pelvic pain in various degrees. It is a common finding in women with infertility.

At the Natural Bio Health clinics located in Austin, Odessa, San Antonio and College Station, Texas, we often treat women who suffer from endometriosis or other issues that may or may not be related to other conditions, including heavy menstrual  flow, painful periods, migraines, PMS and PCOS.

*As explained below, progesterone therapy can be used to address many symptoms and even solve the underlying hormonal issue which is often low levels of progesterone.

What are the symptoms of endometriosis?

*Symptoms of endometriosis-related pain may include any of the following:

• dysmenorrhea – painful, sometimes disabling cramps during menses; pain may get worse over time (progressive pain), also lower back pains linked to the pelvis
• chronic pelvic pain – typically accompanied by lower back pain or abdominal pain
• dyspareunia – painful sex
• dysuria – urinary urgency, frequency, and sometimes painful voiding
• Other symptoms include constipation and chronic fatigue

*Many, if not most patients also suffer from some degree of PMS and there are also subsets of women and young girls whose  main symptom is heavy menstrual flows. There can also be pain with ovulation, pain associated with adhesions, pain caused by inflammation in the pelvic cavity, and during exercise, pain from standing or walking. But the most desperate pain is usually with menstruation and many women dread having their periods. Pain can also start a week before menses, during menses and even a week after menses, or it can be constant.

Other disorders are often associated with endometriosis

Endometriosis often also coexists with leiomyoma or adenomyosis, as well as autoimmune disorders. A 1988 survey conducted in the U.S. found significantly more hypothyroidism, fibromyalgia, chronic fatigue syndrome, autoimmune diseases, allergies, and asthma in women with endometriosis compared to the general population

Complications associated with endometriosis including infertility

Complications of endometriosis include internal scarring adhesions, pelvic cysts, chocolate cysts of the ovaries, ruptured cysts, and bowel and ureteral obstruction resulting from pelvic adhesions. Infertility can be related to scar formation and anatomical distortions due to the endometriosis; however, endometriosis may also interfere in more subtle ways: cytokines and other chemical agents may be released that interfere with reproduction, peritonitis from bowel perforation can occur. Ovarian endometriosis may complicate pregnancy by decidualization, abscess and/or rupture. Pleural implantations are associated with recurrent right pneumothoraxes at times of menses, termed catimenial pneumothorax.

How can endometriosis be diagnosed?

Endometriosis is usually diagnosed by laparoscopy.  However, at the time of a routine physical examination, a rectal/vaginal examination can reveal small areas of nodules that are very painful. Generally, this is diagnostic of endometriosis but doesn’t give you the stage of or the degree of involvement. Some women may have no physical findings because the implants are on the ovaries or high up in the pelvic side wall and can’t be reached with the digital finger.

An ultrasound of the pelvis can diagnose an endometrioma of the ovary which is considered to be stage 4 or severe endometriosis. Colon or intestinal involvement can be suspected when there are painful bowel movements or bloody stools.  These stages of endometriosis are considered severe stage 4 and require a surgical intervention.

What causes endometriosis?

As stated above, endometriosis is a condition whereby the endometrial cells that line the uterine cavity are located outside the uterus on the lining of the pelvic, ovaries, bowel, or any place in the abdominal cavity. *There are several theories as to the reasons for this occurring.

• Retrograde menstruation: A popular one is the one of “retrograde menstruation.” This occurs with each menstrual period where the blood containing the endometrial glands that are being sloughed off, go back into the fallopian tubes into the pelvic cavity and implant on the walls of the peritoneum, etc. This process requires the stimulation with estrogen to grow. It is usually associated with cervical stenosis (the opening to the uterus is very small preventing the blood to come out readily so it backs up into the tubes).
• Müllerianosis: A competing theory states that cells with the potential to become endometrial are laid down in tracts during embryonic development and organogenesis. These tracts follow the female reproductive (Mullerian) tract as it migrates downward at 8–10 weeks of embryonic life. Primitive endometrial cells become dislocated from the migrating uterus and act like seeds or stem cells. This theory is supported by fetal autopsy.
• Coelomic metaplasia: This theory is based on the fact that coelomic epithelium is the common ancestor of endometrial and peritoneal cells and hypothesizes that later metaplasia (transformation) from one type of cell to the other is possible, perhaps triggered by inflammation.
• Vasculogenesis: Up to 37 percent of the microvascular endothelium of ectopic endometrial tissue originates from endothelial progenitor cells, which result in de novo formation of micro vessels by the process of vasculogenesis rather than the conventional process of angiogenesis

• The retrograde theory is the more likely to be the cause. In my 32 years of clinical experience, and having performed thousands of laparoscopies in those patients who happened to be menstruating at the time of the laparoscopy, I could see the blood in bottom of the pelvic cavity.

Why do endometrial cells outside the uterus grow?

*First there is likely a defect in one’s immune system to where the abnormal endometrial cells are not destroyed. Second, the endometrial cells, although not exactly the cell type but likely a “side population” similar to the endometrial cells, are stimulated by estrogen just as the endometrial lining is every day. This commonly associated with a deficiency of progesterone sometimes called a “luteal phase defect.”

What can be done to help prevent endometriosis?

 *Assuming that retrograde menstruation is the most likely cause of endometriosis and is associated with estrogen dominance, then the best treatment for estrogen dominance and for the heavy flows would be cyclic progesterone.

*Progesterone has the ability to compact the uterine lining therefore decreasing the amount of blood flow. Second, by adding progesterone the second part of the cycle when it is deficient, this, in turn, will treat the estrogen dominance that is likely causing the endometrial implants to be stimulated to grow. It’s important to make it clear that progesterone will not cure endometriosis but by preventing the estrogen dominance one can decrease the likelihood of it progressing and may prevent endometriosis in young women or teenagers who are plagued with heavy menstrual flows.

Disclaimer: There is no single scholarly article to back up the claims in this blog.  Instead, the information is gleaned from multiple sources and on personal experience.  Nevertheless, it is believed to be factually accurate.