This condition can cause intense menstrual pain, cramping, irregular periods, and heavy flow during menstrual cycles. You will learn diagnostic and treatment options to seek out if you feel you may be suffering from endometriosis.

What is Endometriosis?

Endometriosis is a condition in which endometrial tissue is present in abnormal locations in the pelvic cavity and abdominal region. Generally, endometriosis is thought to result from endometrial cells passing from the uterus through the uterine tubes into the pelvic cavity. Endometrial cells then invade the peritoneum of the pelvic cavity.

Periodic inflammation of areas where the endometrial cells have invaded occurs because the endometrium (the lining of the uterus) is sensitive to estrogen and progesterone. Endometriosis is often the cause of abdominal pain associated with menstruation since blood cannot leave through the normal exit. Because of this, it irritates nearby tissues causing pain and, in severe cases, scarring.

Almost any organ in the pelvic cavity can be affected by endometriosis, from the ovaries to the large intestine and abdominal region. Roughly one in ten women of childbearing age are affected by endometriosis. It can cause debilitating pain, heavy menstrual periods, and fertility problems. Up to 20% of women with endometriosis have concurrent chronic pain conditions including irritable bowel syndrome, interstitial cystitis/painful bladder syndrome, fibromyalgia, and migraines.

How Is Endometriosis Diagnosed?

There are several diagnostic tools doctors, nurse practitioners, and physician assistants can use to find endometrial cells in abnormal areas. These include MRIs, cystoscopy (for bladder endometriosis), sigmoidoscopy or colonoscopy (for transmural bowel lesions) and ultrasound-guided fine needle aspiration (for endometriosis in the rectosigmoid, rectovaginal septum, or in abdominal scars).

Let’s take a closer look at both invasive and non-invasive techniques for diagnosing endometriosis:

Laparoscopy

Laparoscopy is a minor surgical procedure that requires the surgeon to make a small surgical cut in or near the belly button, and then fill the pelvic region with harmless gas. A laparoscope (a small lighted viewing instrument) is inserted in the incision area. With the laparoscope inside, endometriosis can be visualized as peritoneal implants, peritoneal windows, endometriomas, and deep infiltrating nodules of endometriosis, which may be associated with adhesions. All of these are pathologies of the pelvic cavity. The color, size, and morphology of endometriotic lesions are highly variable from person to person.

In several studies, only about 54-67% of suspected endometriotic lesions are confirmed histologically (by viewing tissues with a microscope) and about 18% of patients clinically suspected to have it had no evidence of endometriosis on pathology. So, laparoscopy is still very useful for the diagnosis of endometriosis and is just a minor surgery.

Imaging

Imaging has limited utility in the diagnosis of endometriosis, as it lacks adequate resolution to identify adhesions. Ultrasound is a cheaper and easier method, but is user-dependent. MRIs are more accurate, but more expensive to use. MRI may help guide surgical approaches for patients with suspected endometriosis, especially for deep infiltrating endometriosis and other unusual sites.

Endometrial Nerve Fibers

Endometrial biopsies are still being explored because there is a lack of information about pain symptoms in the research, as they seem to vary from person to person. There is some limitation to this type of diagnostic tool, but recent studies do suggest an increased number of nerve fibers in the endometrium of women with endometriosis compared to women without.

Already Been Diagnosed? Your Treatment Options: Complementary Alternative Medicine (CAM)

CAM therapies include several treatments such as herbal prescriptions, acupuncture, microwave physiotherapy or physical therapy, and Chinese herbal enema. It is suggested that CAM therapies can be effective at relieving pain and promoting pregnancy with less unpleasant side effects. This form of treatment is still undergoing research and testing.

Hormone Therapy

Hormone therapy is used to treat endometriosis by means of pill, injection, or nasal spray. There are several therapies in this sub-group of treatment.

• Oral Contraceptives (birth control pills): Lighten periods and help regulate cycles.
• Progesterone and Progestin: Improve symptoms by reducing a woman’s period or stopping it completely.
• Gonadotropin-Releasing Hormone Agonists: Stops the production of certain hormones, which puts the body in a menopausal state, usually for a period of six months.
• Danazol: Stops the release of hormones that are involved in the menstrual cycle. Women on this medication will have a menstrual cycle only a few times a year or sometimes not at all.

Already Been Diagnosed? Your Treatment Options: Surgical

There are a few surgical procedures that can be done to help with endometriosis. Some surgical procedures are more invasive than others, so we will go over each of these treatment options:

If you suspect you may be suffering with endometriosis, don’t be afraid to talk to your healthcare provider about the problem. These diagnostic and treatment options are just a few examples of what is available to you, but always listen to your primary care physician on the best treatment and diagnostic options that will fit your needs.

This series is to help women with ailments they may face, teach women how to catch things, and educate them on what treatment options are available. This will be a four-part series going over different challenges women face today – not just in the gym, but also in life.

References:

1. Parker, S. The Human Body Book (New York: DK Publishing, 2007), 226

2. Tate, P. Seely’s Principles of Anatomy and Physiology (New York: McGraw Hill Companies, 2012), 785

3. Hughes, B. et. al. “What are The Treatments For Endometriosis,” Eunice Kennedy Shriver National Institute of Child Health and Human Development. (2013): efirst, accessed April 14, 2014. www.nichd.nih.gov

4. Stratton, Pamela et. al. “Invasive and Non-Invasive Methods for the diagnosis of endometriosis,” Clinical Obstetrics and Gynecology. (2011): 413-419, accessed April 14, 2014. DOI 10.1097/GRF.0b013e3181db7ce8

5. Kong, S et. al. “The Complementary and Alternative Medicine for Endometriosis: A Review of Utilization and Mechanism,” Evidence Based Complementary Alternative Medicine. (2014): Epub, accessed April 14, 2014.

Photo 1 by BruceBlaus (Own work) [CC-BY-3.0], via Wikimedia Commons.

Photos 2 & 3 courtesy of Shutterstock.

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The female menstrual cycle has been considered as a contributing factor as well. Not only does it represent an obvious biological difference between male and female athletes, but the hormones involved in the cycle – estrogen, progesterone, and relaxin, among others – are known to play a role in muscle tone and joint laxity.

Still, exactly what role these hormones might play and what the implications are for injury avoidance remain controversial. A recent literature review by researchers at the Canadian Memorial Chiropractic College doesn’t offer much additional guidance.² Though it analyzed thirteen different studies of the menstrual cycle’s effect on joint laxity and ACL injuries, the results were inconclusive.

While eight of the studies found a correlation between the menstrual cycle and ACL injury susceptibility, five did not. Moreover, those studies that reported increased ACL laxity did not agree about the phase of the menstrual cycle when it occurred, with some correlating laxity with the ovulatory phase and some with the pre-ovulatory phase.

As the researchers pointed out, most of the studies they considered – and indeed most studies of the role of the menstrual cycle in athletic performance – excluded women with irregular cycles, women using hormone-based contraceptives, or both. Disruption of menstrual cycles due to low body fat levels (amenorrhea) is not unusual in female athletes, and well over half of all sexually active women use hormone-based contraceptives at some point.³ It seems likely, then, that studies that exclude these groups may not be representative of all female athletes.

Most studies also relied on self-reporting to monitor menstrual cycles and did not actually measure hormone levels. More research is needed to determine whether the observed effects are due to absolute hormone levels or to the fluctuations in hormone levels in different phases of the cycle, and to identify the underlying biological mechanisms involved. In the absence of such studies, the researchers were only able to offer vague suggestions to athletes and coaches to “be aware” of potential hormone-related variations in joint stability.

Somewhat more usefully, an earlier review did find evidence that disproportionate quadriceps activation, relative to the hamstrings, can reduce the stability of the knee joint.⁴ Hormone-based contraceptive use – which tends to reduce cyclical fluctuations in hormone levels – appears to reduce this instability. While the reasons why are unclear, the correlation between quadriceps-hamstring ratio and knee stability suggests that training programs designed to balance the two may help reduce knee injuries.

References:

1. T. Hewett, B. Zazulak, and G. Myer, “Effects of the menstrual cycle on anterior cruciate ligament injury risk: a systematic review,” Am J Sports Med. 35(4): 659-668 (2007).

2. Lesley Belanger, et. al., “Anterior cruciate ligament laxity related to the menstrual cycle: an updated systematic review of the literature,” J Can Chiropr Assoc 57(1), 76-86 (2013).

3. William D. Mosher, et. al., “Use of Contraception and Use of Family Planning Services in the United States: 1982–2002,” Adv. Data from Vital and Health Stats., 350, December 10, 2004.

4. T. Hewett, G. Myer, and K. Ford, “Anterior cruciate ligament injuries in female athletes: Part 1, mechanisms and risk factors,” Am J Sports Med. 34(2), 299-311 (2006).

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The purpose of the study was to investigate whether different endurance performance and training parameters are affected by the hormonal fluctuations and symptoms from the normal menstrual cycle, and the synthetic menstrual cycle of those who used an oral contraceptive. There were 24 female rowers who took part in the study and all of them had reported a normal menstrual cycle during the last six months. The women taking oral contraceptives in the study had been using an oral contraceptive for a minimum three months before the tests.²

Those rowers who were not taking an oral contraceptive completed two experimental testing sessions during days 7-11 of the menstrual cycle, and 18-22 days from the onset of menstruation. For the women who used oral contraceptives, two experimental testing sessions were done during days 7-11 and days 22-24 of the oral contraceptive pill cycle. The testing sessions for each group was identical, and the first session included an incremental rowing ergometer test, followed by body composition measurements. An hour endurance rowing ergometer session was performed on the day after the incremental rowing ergometer test.³

The results of the study showed that rowers taking an oral contraceptive had no significant advantage in the measured endurance parameters compared to those who did not take an oral contraceptive. The results indicated that sport-specific endurance was not influenced by the phase of the normal menstrual cycle. Based on this study, female athletes should not have to worry about the timing of their menstrual cycle in regards to optimal performance.⁴

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