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Endometriosis is a condition in which the tissue that behaves like the cells lining the uterus (endometrium)

grows in other areas of the body, causing pain, irregular bleeding, and possible infertility.


Pain is the main symptom for women with endometriosis. This can include:

• Painful periods
• Pain in the lower abdomen or pelvic cramps that can be felt for a week or two before menstruation
• Pain in the lower abdomen felt during menstruation (the pain and cramps may be steady and dull or
• Pain during or following sexual intercourse
• Pain with bowel movements
• Pelvic or low back pain that may occur at any time during the menstrual cycle

Affected Area

Q. What are the most common sites of endometriosis in the pelvic area?
A. If we accept the theory of retrograde menstruation as the main cause for the initiation
of endometriosis, the ovaries are the most frequently involved organ (in 75 percent of
cases) because of the unique characteristics of their site. The next most common areas are
the posterior cul-de-sac (70 percent of cases), the area between the uterus and the bowel,
and the anterior fold of the uterus between the uterus and the bladder (35 percent of
cases). Presumably, this is due to the effects of gravity. The next most common area is
the posterior aspect of the pelvic wall and the uterosacral ligaments (35 percent) which
are attached behind the uterus. The ureters are the most commonly affected pelvic organs
also due to their site, which is again sitting close to the ovarian bed or opening of the tube
to the pelvis. The next most common sites are the uterus (10 percent), the tubes, the
sigmoid colon and the appendix. Due to high motility and active peristalsis, the small
bowel is the least frequent organ involved in endometriosis (less than one percent).

Endometriosis is most often found in the ovaries, on the fallopian tubes, and the ligaments
supporting the uterus, in the internal area between the vagina and rectum, on the outer surface of
the uterus, and on the lining of the pelvic cavity. Infrequently, endometrial growths are found on
the intestines or in the rectum, on the bladder, vagina cervix, and vulva (external genitals), or in
abdominal surgery scars, Very rarely, endometrial growths have been found outside the
abdomen, in the thigh, arm, or lung.


What is the Cause of Endometriosis?

The cause of endometriosis is still unknown. One theory is that during menstruation some of the
menstrual tissue backs up through the fallopian tubes into the abdomen, where it implants and
grows. Another theory suggests that endometriosis may be a genetic process or that certain
families may have predisposing factors to endometriosis. In the latter view, endometriosis is seen
as the tissue development process gone awry.
According to the theory of traditional chinese medicine, endometriosis is a disease which is
caused by the stagnation of blood. Blood stagnation may occur due to one or more abortions or
lower abdominal or pelvic surgeries.

Additionally, engaging in sexual intercourse during menstruation may very likely over time cause
blood stagnation. Emotional trauma, severe stress, physical or emotional abuse can all lead to
the stagnation of blood.

Medical Management: Medical management can be relatively effective for moderate

endometriosis, particularly for women with superficial rather than deep peritoneal
implants. When endometriosis involves the ovaries, the response to medication is usually
not as good.

Major Surgery: For severe cases of endometriosis, major surgery used to be the mainstay
to remove thick adhesions and excise endometriomas (endometriotic cysts of the ovary).
However, an experienced laser laparoscopist can perform the majority of these
procedures without a major surgical incision.

Endometriosis and Infertility: treatment

The treatment of endometriosis for improvement of fertility is controversial. Well
controlled good quality studies have not demonstrated an improvement in fertility
following any of the medical (drug) management protocols. Therefore, I usually
restrict my use of medical management for endometriosis to the treatment of
endometriosis associated pain. Surgical treatment for endometriosis has been shown
to improve fertility in advanced stages of endometriosis. Modern surgical techniques
such as those using ultrapulse lasers are just now being shown to be of value in the
treatment of less extensive stages of endometriosis.

The surgical approach to a patient with endometriosis currently leans strongly

toward "minimally invasive procedures." In the hands of an experienced
laparoscopic surgeon, virtually any endometriosis associated problem that can be
treated by laparotomy can now be dealt with via laparoscopy. The performance of
more conservative procedures primarily via the laparoscope has benefited women in
many ways. The difference in the approach includes:

(1) laparotomy

1. opening the abdomen to perform the surgery directly through a large open
2. cosmetically considered "disfiguring" to many younger women
3. requires a stay (usually several days) in the hospital
4. postoperative recovery may be several weeks with significant time out from

(2) laparoscopy
1. minimally invasive same day surgical approach
2. a telescope is entered through an incision about 1 cm long near the umbilicus
and one to three smaller incisions are also usually made in the lower
abdomen for the entry of additional instruments

3. postoperative recovery usually only a few days with little time out from

There are several treatment options for women with endometriosis:

• Nonsteroidal antiinflammatory drug

• Hormonal birth control
• Other forms of hormone treatment (gonadotropin releasing hormone
• Surgery

The best treatment depends on your future plans to become pregnant and what
symptoms are most bothersome.

Nonsteroidal antiinflammatory drugs —

Surgery — Surgery might be an option to treat endometriosis if you:

• Have severe pain or bleeding

• Have tried medicines but still have bothersome pain or bleeding
• Have a growth or mass in the pelvic area. Surgery is the best way to remove
the mass and figure out if endometriosis, or another problem, is the cause.
• Are having trouble getting pregnant and endometriosis might be the cause.

The goal of surgery is to remove endometriosis implants and scar tissue. More than
80 percent of women who have surgery have less pain for several months after
surgery. However, there is a good chance that the pain will come back unless you
take some form of treatment after surgery (like hormonal birth control).

Laparoscopy — Laparoscopy is one way to perform surgery, and is commonly used

to diagnose and treat endometriosis. During laparoscopy, a doctor makes several
small incisions to insert instruments inside the abdomen and pelvis. One of these
instruments has a light and camera, which allows the doctor to see the organs on a
Treatment of an endometrioma — Medicines are unlikely to make an
endometrioma go away. Surgery to remove the endometrioma is usually
recommended because surgery can confirm the diagnosis, prevent complications
(such as rupture of the endometrioma), and treat any symptoms, such as pain. (See
"Diagnosis and management of ovarian endometriomas".)

Removal of the uterus or ovaries — Your doctor might recommend surgery to

remove your uterus or ovaries or both if:

• You have tried other treatments but continue to have severe symptoms
• You do not want to become pregnant in the future
• You want a permanent treatment

• Surgery to remove the uterus is called hysterectomy. (See "Patient

information: Abdominal hysterectomy".)
• Surgery to remove the ovaries and fallopian tubes is called salpingo-
oophorectomy. It is not always necessary to remove the ovaries to treat
endometriosis; this decision will depend on your age and your preferences.

Hormone therapy after surgery — If your ovaries are removed, your doctor or
nurse might recommend hormone therapy (estrogen) after surgery. This is especially
true for women under age 50 who are not yet menopausal. Estrogen can help to
minimize menopausal symptoms like hot flashes, night sweats, vaginal dryness, and
weakening of the bones. (See "Patient information: Postmenopausal hormone

What is an endometrioma?

An endometrioma is a mass of tissue (noncancerous cyst or tumor) that contains shreds of endometrial
tissue. Endometriomas most frequently occur in the ovary, in a part of the peritoneum (sac around the
internal organs) between the rectum and uterus, the wall (septum) between the rectum and vagina, and the
outside of the uterus.

……………….Surgical intervention is the most aggressive treatment for endometriosis. Surgery may be done if you:

• Do not respond to other treatment

• Are older and feel you need to become pregnant more quickly
• Have severe physical changes due to the disease

The two main surgical procedures used are:

• Laparoscopy
• Hysterectomy with or without bilateral salpingo-oophorectomy (removal of the tubes
and ovaries)


• Identify the location, type, duration, and history
of the pain.
• Recommend analgesics and heat therapy.
• Provide information on biofeedback, relaxation, and imagery
to lessen pain.
• Discuss with Mr. and Mrs. Hall the causes of endometriosis and
its manifestations.
• Encourage the Halls to discuss their feelings about the effect
of the disease on their sex life, lifestyle, and fertility.
• Refer the couple to the local mental health center if appropriate

The most common symptoms of Endometriosis are:

• Pain before and during periods

• Pain with intercourse
• General, chronic pelvic pain throughout the month
• Low back pain
• Heavy and/or irregular periods
• Painful bowel movements, especially during menstruation
• Painful urination during menstruation
• Fatigue
• Infertility
• Diarrhoea or constipation

Other symptoms which are common with Endometriosis include:

• Headaches
• Low grade fevers
• Depression
• Hypoglycaemia (low blood sugar)
• Anxiety
• Susceptibility to infections, allergies

Late symptoms:
Painful periods (dysmenorrhea). Pelvic pain and cramping may begin before and
extend several days into your period and may include lower back and abdominal pain.
Severity of pain isn't necessarily a reliable indicator of the extent of the condition. Some
women with mild endometriosis have intense pain, while others with more severe
scarring may have little pain or even no pain at all.
Pelvic pain at other times. You may experience pelvic pain during ovulation, a sharp pain
deep in the pelvis during intercourse, or pain during bowel movements or urination.
Excessive bleeding. You may experience occasional heavy periods (menorrhagia) or
bleeding between periods (menometrorrhagia).
Infertility. Endometriosis is first diagnosed in some women who are seeking treatment for
Endometriosis Symptoms
The symptoms of Endometriosis vary from one woman to another but the
most common symptom is pelvic pain.

One of the biggest problems regarding Endometriosis is that the signs of this disease
in the early stages, appear to be the ‘normal’ bodily changes that take place with the
menstrual cycle.

It is only as time goes by that a woman begins to suspect that what is happening,
and the symptoms she feels, are not normal. The pain of her menstrual cycle
gradually and steadily becomes worse and worse as the months go by. This is only
the beginning of what will become a gradual decline in a woman’s general health, as
well as the health of her reproductive system.

Definitive risk factors for endometriosis remain unknown due to the lack of knowledge
concerning the pathogenesis of the condition, and little research has evaluated
within the adolescent population. The purpose of this cross-sectional descriptive study
was to
compare the exercise habits, cigarette smoking, alcohol consumption, and caffeine intake
between adolescent girls with and without endometriosis. Health behaviors were assessed
using a
researcher-developed mailed questionnaire. A convenience sample of girls between 13
and 21
years of age consisted of 24 girls without endometriosis and 15 girls with endometriosis.
with endometriosis were significantly less likely to perform aerobic and strength-training
exercises than girls without endometriosis. There were only three current smokers in the
all three had endometriosis, and more girls with endometriosis had tried smoking. More
with endometriosis currently drink alcoholic beverages compared to girls without
No differences were found between the groups regarding caffeine intake, but all of the
girls with
endometriosis who had quit drinking caffeine did so for health-related reasons. The
suggest that lack of aerobic exercise and strength-training activities is associated with
endometriosis, although whether it is the cause or effect is unknown. Further research is
to determine whether or not there is an association of alcohol and cigarette smoking with
endometriosis, but the findings from this study suggest that girls with endometriosis are
likely to drink alcoholic beverages and smoke cigarettes. Additional research is also
needed to
evaluate caffeine consumption and the influence of ceasing caffeine intake related to
Thesis 3
Comparison of Health Behaviors in Adolescents
with and without Endometriosis
The adolescent years for young women are an exciting and eventful time of life, but
unfortunately some adolescent girls do not experience the optimum quality of life
because they
are victims of the symptoms associated with endometriosis. Dysmenorrhea is one of the
common symptoms, and 50% of teenagers with intractable dysmenorrhea have been
with endometriosis (Cramer & Missmer, 2002). This suggests that adolescents who
bedrest and analgesics for their painful menstruation have an increased possibility of
endometriosis and require additional effort for early detection or prevention (Cramer &
The pathology of endometriosis is not well understood, making the facilitating factors
unknown (Murphy, 2002). Current research has associated family history with an
increased risk
of developing the disease. In particular, an adolescent with a first-degree relative with
endometriosis has a 6.9% risk compared to the 1% risk for the general adolescent
without an affected relative (Emans & Goldstein, 1990). Other non-modifiable risk
factors of
adult-aged women who have been studied include history of autoimmune diseases and
characteristics such as length of cycle, age at menarche, and heaviness of menstrual flow
(Murphy, 2002). The association of health behaviors such as exercise habits, cigarette
alcohol consumption, and caffeine intake to endometriosis has also been studied, but
research is indicated since results have been inconsistent in these areas.
The purpose of this cross sectional descriptive study was to compare the health behaviors
of exercise, cigarette smoking, alcohol consumption, and caffeine use between
adolescents who
have been diagnosed with endometriosis and those who have not. The results of this
study will
Thesis 4
supply further data regarding modifiable lifestyle factors, and will provide a new
perspective of
these risk factors concerning the adolescent population. Also, further knowledge of the
facilitating factors associated with endometriosis will allow health care providers to
and educate adolescents about possible preventative strategies.