Endometriosis: When Cramps Stop Being Normal

November 28, 2016 Gregory Sacher, MD

Abdominal and pelvic cramps are not uncommon and can be very normal for many women. But what happens when these cramps stop being normal? This could be a sign of a condition known as endometriosis.

What is Endometriosis?
Endometriosis is a condition in which the cells that should be in the lining of the uterus (endometrial cells) begin to grow on the outside of the uterus. This tissue does not belong outside the uterus. As a result, the tissue--also called an endometrial implant--can break down, bleed and cause symptoms like abdominal or back cramps, and nausea. The cells typically stay in the pelvic area, but can migrate to almost any other area of the body.

What are the Symptoms?
Some women with endometriosis have no symptoms while others have significant symptoms. The most common symptom of endometriosis is pain in the pelvic and/or lower back region, either just before or during menstruation. There may be pain with sexual activity or with bowel movements. Additionally, some women can develop lesions and scar tissue in the pelvic area or on the ovaries.

Does it Affect Fertility?
Endometriosis can make it harder to become pregnant, depending on the severity of the condition. Out of all women diagnosed with endometriosis, only around 25 percent experience problems with fertility. However, women with moderate to severe endometriosis may develop complications like distorted pelvic anatomy, altered egg quality, and scarring that prevents an egg from entering the fallopian tube. These women may need advanced fertility treatment to improve their chances of pregnancy success.

Are There Treatment Options?
The good news is endometriosis can be treated, and an obstetrician/gynecologist (OB/GYN) can tailor treatment to each patient. "A treatment plan for endometriosis typically begins with hormonal therapy," says Gregory Sacher, MD, a board-certified OB/GYN with St. Joseph Health Medical Group in Sonoma County. "The hormone estrogen exacerbates the symptoms of endometriosis, so there are several kinds of estrogen-suppressing medication that are used to shrink the lining of the uterus and any lesions that have formed on that lining."

Medications used to treat endometriosis include:

  • Nonsteroidal anti-inflammatory medications, such as ibuprofen, for general pain relief.
  • Oral contraceptives or similar methods such as a vaginal ring or birth control patch, to deliver hormones to the body. For many years the oral contraceptive pill was the main hormonal drug used to treat endometriosis. The low doses of estrogen-related hormones delivered in the pill relieve the pain of endometriosis by tempering the menstrual cycle and slowing the growth of endometrial implants. Many women tolerate the pill better than other hormonal drug treatments and can safely take it for many years.
  • Progesterone (a female hormone) or progestins (drugs that mimic the behavior of progesterone). Both progesterone and progestins come in different forms, including pill, injection, implant and IUD. Like other hormonal treatments, these drugs relieve symptoms while, at the dosages usually prescribed, causing menstruation to stop during the course of treatment. After stopping treatment, menstruation usually resumes within 4-6 weeks, depending on the dosage and the rate at which the woman's metabolism removes the drug from the body.
  • GnRH (gonadotropin-releasing hormone) agonist. This is typically the most effective nonsurgical treatment, putting the body into temporary menopause. A GnRH agonist is a drug that helps control the menstrual cycle by stopping the production of estrogen. Without estrogen, the endometrial implants become inactive and start to degenerate. GnRH agonists are given via injection or nasal spray, and many OB/GYNs use them in combination with other medications to reduce common side effects such as hot flashes or night sweats. Like progesterone and progestins, these drugs cause the body to stop menstruating during treatment. Menstruation usually returns within 6-10 weeks of the last injection, or 4-6 weeks of the last spray, as the body needs time to work the drug out of its system.

Some women may, after trying medication, opt for surgery to diagnose, treat and remove the implants caused by endometriosis. Medications are almost always tried first because any surgery--even the minimally-invasive procedure used to diagnosis and treat endometriosis--involves some level of risk that complications may develop during or after the procedure. On the other hand, surgery is the only way to determine for sure whether endometriosis is present; there is no x-ray, ultrasound, or CT scan that can show endometriosis. And some women may need relief from unpleasant and difficult-to-live-with side effects that can accompany long-term hormonal therapy, such as bleeding, bloating, lethargy and nausea.

Surgery begins with an exploratory laparoscopy, considered the most reliable method for diagnosing endometriosis. It involves placing a tiny camera into a small incision in the abdomen so that pelvic anatomy can be seen. The gynecological surgeon looks for endometriosis and, if found, an operative laparoscopy is performed at the at the same time to remove or burn away lesions, implants, and scar tissue. Laparoscopy is considered safe and effective, and most complications, if any (such as difficulty urinating or vaginal discharge) are minor and go away rapidly. In more serious cases, a full hysterectomy (removal of uterus and ovaries) may be needed. This is permanent and will cause a woman to start menopause.

Dr. Sacher says that women seeking treatment for endometriosis should start by consulting with their doctor to discuss their symptoms, make sure they understand their options, and provide the doctor the information needed to come up with a plan that's right for them. "Endometriosis is a process that, generally speaking, requires a lifelong management plan that maximizes medical therapy and avoids repeat surgical intervention," he says. "The treatment plan is individualized to take into account the clinical presentation, symptom severity, disease extent and location, reproductive desires, patient age, medication side effects, surgical complication rates, and cost.”

If you are experiencing pelvic symptoms that don’t seem normal, speak with your OB/GYN. If you don't have one click here to find an experienced OB/GYN affiliated with one of the 16 St. Joseph Health hospitals located throughout Northern California, Southern California and Texas.

Sources:

http://endometriosis.org/resources/articles/facts-about-endometriosis/

http://www.stjoesonoma.org/Health-Library/Article.aspx?CT=3&C=82202

http://www.stjoesonoma.org/Health-Library/Article.aspx?CT=3&C=82212

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