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School of Medicine
Many women have unexplained chronic pelvic pain for years before they are diagnosed with endometriosis. They are often told they must remove their ovaries to live a pain-free life. At Johns Hopkins, our expert physicians will do their best to save a woman’s ovaries, while helping her manage her pain, so she can maximize her chances of conceiving her own child.
Endometriosis is a benign disorder characterized by the presence of endometrial tissue (the tissue that lines the uterus) outside the uterine cavity where it becomes attached to reproductive or abdominal organs. The patches of endometrial tissue swell with blood during menstruation as if they were still in the uterus.
Because this blood is trapped within the tissue and cannot be shed through the vagina, blood blisters form, and they may develop further into cysts, scar tissue, or adhesions (fibrous bands that link together other tissues that are normally separated). Cysts may range from the size of a pinhead to the size of a grapefruit; cysts, scars, and adhesions may all lead to infertility.
Endometriosis is a common disorder, most prevalent between the ages of 25 and 40. Symptoms vary and are not strictly correlated with the severity of the disease; they may worsen with time, but tend to diminish during pregnancy and cease with menopause. Many women have no symptoms at all. Treatment depends on the severity of symptoms, the age of the woman, and whether she wishes to have children.
The cause of endometriosis is unknown. Hereditary factors may be involved. Hormonal changes or recent pelvic surgery may promote endometriosis
- Pain in the vagina, lower abdomen, and lower back. Pain often begins just prior to monthly periods, continues during menses, and worsens just after the cessation of blood flow.
- Abnormal or heavy menstrual bleeding
- Vaginal pain during sexual intercourse
- Diarrhea, constipation, or pain during bowel movements
- Bleeding from the rectum or blood in the urine during menses
- Nausea and vomiting just prior to monthly periods
- Infertility. Endometriosis is one of the most common causes of infertility.
A pelvic examination may reveal a suspicion of endometriosis. The doctor presses upon the uterus and ovaries to feel for any abnormalities. A definitive diagnosis requires:
- Direct visualization of endometrial tissue
- Biopsy or sampling of the extrauterine endometrial tissue. This is usually done by laparoscopy (the insertion of a thin, lighted viewing instrument into the abdomen through a small incision).
If you are diagnosed with endometriosis while undergoing laparoscopy, your doctor may remove the endometrial tissue during the procedure. Laparoscopy has several benefits:
- It provides many women with symptomatic relief for a number of years
- Increases a patient's fertility and subsequent chance of pregnancy
- Results in minimal scarring and a speedier recovery period than a hysterectomy
- Your doctor may prescribe low-dose oral contraceptive pills. They work by suppressing ovulation and menstruation, thereby keeping symptoms under control. Evidence also suggests that this treatment may reduce the endometriotic implants. Over-the-counter pain relievers may be taken for mild menstrual pain.
- Danazol, progestins, or Gn-RH (gonadotropin-releasing hormone) agonists may be administered to halt menstruation for three to six months in an effort to shrink endometrial tissue.
- Surgical removal of the tissue may be required to relieve severe symptoms or to allow impregnation. Tissue may be destroyed by heat (electrocautery) or removed with lasers during laparoscopy (usually done on an outpatient basis under local anesthesia). A hysterectomy, the surgical removal of the uterus (and sometimes other reproductive organs), may be advised in severe cases. Hormone replacement is required if both ovaries are removed.
- Minimally-invasive robotic surgery is available at Johns Hopkins for treatment of endometriosis. The benefits of using a robot increase the likelihood of all of the endometrial tissue being removed, causing less scarring and pain.
At Johns Hopkins, we use the very latest technology to diagnose and treat endometriosis. We also rely on a team of experts that extends beyond the gynecology department to manage this and other conditions that result in pelvic pain. Our multidisciplinary team includes professionals in:
- Physical therapy
When she is planning to have children is the most critical question physicians at Johns Hopkins will ask. This will define future treatments and the approach to treatment.
In our physicians’ experience, too often women are offered surgery as a way to minimize their pain by removing the ovaries. At Johns Hopkins, our physicians will always try the conservative treatment option, saving the ovaries, which can save child bearing potential.
Our physicians will operate on the ovaries conservatively and rely on experienced colon rectal surgeons who can provide assistance and guidance during the surgery. Further, Johns Hopkins provides minimally invasive surgery for removing cysts.
While endometriosis cannot be cured, our physicians can help women learn to manage the pain without unnecessary sterilization. Further fertility treatments are available at the Johns Hopkins Fertility Center.
Understanding the causes of pelvic pain and finding innovative treatments for this pain are priorities among Johns Hopkins gynecological researchers. Currently, our researchers are collaborating with the National Institutes of Health in a project that investigates the development of endometriosis. Ongoing efforts are underway to identify less invasive methods of diagnosing endometriosis.