Endometriosis

Anne had never had problems with her periods the way some of her friends did. But over time her periods started getting so painful that she dreaded their arrival. Every month for a few days she would curl up on the couch with a heating pad and take a pain reliever. But the cramps eventually became so bad that she was missing school a couple of days a month, and the pain even started happening between periods.

Anne's doctor thought Anne might have endometriosis. So she referred her to a specialist in treating this condition. It turned out Anne's doctor was right.

What Is Endometriosis?
Endometriosis (pronounced: en-doe-mee-tree-o-sus) takes its name from the endometrium, the tissue that lines the uterus. When a woman has endometriosis, tissue that looks and acts like the endometrium starts growing outside the uterus. The most common locations for these growths - called endometrial implants - are the outside surface of the uterus, the ovaries, the fallopian tubes, the ligaments that support the uterus, the internal area between the vagina and rectum, and the lining of the pelvic cavity.

Endometriosis affects more than 5 million American women, including teen girls. It's not always diagnosed right away in teens because at first they or their doctors assume that their painful periods are a normal part of menstruating. But continuing, excessive pain that limits activity isn't normal and should always be taken seriously. Because severe endometriosis can make it complicated for a girl to have children in the future, it's a good idea to get medical help for endometriosis and not wait too long.

To understand why endometriosis causes problems, it helps to have a basic understanding of how the monthly menstrual cycle works: During the course of each cycle, the lining of a woman's uterus builds up with blood vessels and tissue. This happens because the uterus is getting ready to receive the egg that will be released from one of the ovaries. If the egg isn't fertilized by sperm, though, the uterus sheds the tissue and blood near the end of the cycle, preparing for the next cycle. The tissue that is shed is the menstrual period. This entire process is controlled by the female sex hormones and usually takes about 28 to 30 days.

Because the abnormal growths associated with endometriosis are made up of the same kind of tissue and blood vessels found in the uterine lining, any endometrial implants will act just like the endometrium in the uterus. That means they respond in the same way to the hormonal changes of the menstrual cycle. However, in the uterus, if the egg isn't fertilized, the extra tissue and blood leave a girl's body in the form of menstrual fluid. With endometriosis, though, there's nowhere for the accumulating blood and tissue to go once the implants start to break down. For this reason, the implants usually become somewhat larger with each cycle, and the symptoms of endometriosis tend to become more painful over time.

What Causes Endometriosis?
Doctors aren't sure what causes endometriosis. They do know that it is slightly more common in teens and women who have a family member who has been diagnosed with endometriosis.

There are several theories about how the endometrial tissue actually gets outside the uterus in the first place. One theory suggests that the menstrual blood flow somehow "backs up" into the fallopian tubes, carrying some tissue from the uterine lining with it. In effect, the tissue gets transplanted and starts growing outside the uterus. Another theory is that endometrial tissue cells travel out of the uterus through blood or lymph vessels, and then start growing in the new locations where they're deposited. Yet another theory suggests that some girls are born with "misplaced" cells that can turn into endometrial implants later in life. Scientists continue to research the condition to help doctors fully understand and treat it.

What Are the Signs and Symptoms?
The most common sign of endometriosis is severe pelvic (lower abdominal) pain. It may occur occasionally or constantly, and it may be associated with a girl's period. Although slight cramps for a couple of days before or during a menstrual period are normal, lasting or intense pain that disrupts a person's day is not. With endometriosis, the pain is usually so bad that it causes a girl to miss school, sports, and social activities.

Other possible symptoms include:

• pelvic pain that gets worse during exercise, after sex, or after a pelvic exam
• a very heavy period
• lower back pain
• constipation, diarrhea, or feeling pain or seeing blood when going to the bathroom (endometrial implants can press on some of the organs involved in getting waste out of the body, such as the bladder, intestines, and rectum)

If a girl notices these symptoms, it doesn't necessarily mean that she has endometriosis. Lots of other things - like an infection - may cause similar symptoms. But it's important to see a doctor right away if you notice these symptoms. If you haven't been examined by a gynecologist for the first time yet, this is a good time.

How Is It Diagnosed?
Diagnosing endometriosis isn't always easy. Lots of things can cause pelvic pain, so even if a girl's symptoms point to endometriosis, a doctor may want to rule out other possibilities.

In addition to doing a physical examination, the doctor will ask you about any concerns and symptoms you have, your past health, your family's health, any medications you're taking, any allergies you may have, and other issues. This is called the medical history. Depending on your symptoms, a doctor may also ask you to keep a pain diary. This may involve recording the following information every time you experience pain:

• type of pain (Is it sharp? dull? aching? crampy?)
• location (Where is it?)
• duration (How long does it last?)
• intensity (On a scale of 1 to 10, how bad is the pain?)
• treatment (Did you try anything to make the pain go away? Did it help?)

The only way to know for certain whether a girl has endometriosis is to perform a minor surgical procedure called laparoscopy (pronounced: la-puh-ras-kuh-pee). This allows the doctor to know for certain whether a girl has endometrial implants and, if so, how extensive they are.

While a girl is under anesthesia, the doctor makes a small cut near her belly button and inserts a thin, lighted tube (known as a laparoscope) that acts as a tiny video camera so that the doctor can view the pelvic organs. During the procedure, the abdomen is filled with a gas to help the doctor see the organs better. The doctor may also do a biopsy, which means removing small pieces of the growths for examination under a microscope.

Even if a girl's symptoms point to endometriosis, a doctor may not want to perform a laparoscopy right away. He or she may first order scanning tests that can create images of the pelvic region, such as ultrasound or magnetic resonance imaging (MRI). This helps to rule out other possible causes of the symptoms. Doctors may also start by telling a girl to take acetaminophen or ibuprofen. Some doctors will prescribe birth control pills, not as a method of contraception but because they have been proven to reduce painful periods, especially those associated with endometriosis.

If these approaches don't work, and the doctor thinks a girl has endometriosis, then he or she will probably order the laparoscopy.

What Do Doctors Do?
Endometriosis can't be cured, but its symptoms can usually be controlled. Surgery is often helpful. A doctor can remove the growths by directing an intense light beam (laser) onto them with the help of a laparoscope. After this treatment, many girls find relief from their symptoms, but some may experience pain again if the growths return over time. Laparoscopic treatment is the typical type of surgical treatment for endometriosis, although in rare cases more extensive surgery may be needed.

Doctors often prescribe birth control pills after surgery because they limit the body's release of the hormone gonadotropin (pronounced: go-nah-duh-tro-pun), which normally triggers ovulation (the monthly release of an egg from an ovary). If a girl doesn't ovulate, then the endometrial implants won't build up as much, and this can make endometriosis less painful.

Other medications used to treat endometriosis work in the same way as birth control pills to modify the hormone-driven buildup and breakdown of endometrial tissue. Doctors typically don't recommend these treatments for teens until well after puberty is completed, though.

Doctors often suggest lifestyle changes for teens who have endometriosis, too. A healthy diet, moderate exercise, rest, and even relaxation techniques such as yoga and meditation can help.

What's It Like to Have Endometriosis?
Apart from the pain, there are other things that can make living with endometriosis a challenge for some girls. It may feel difficult explaining to friends and teachers why you miss school, sports, or other activities, for example. If you feel embarrassed, ask your doctor to write a note you can give to teachers and coaches so you don't have to explain yourself. You can then work with them to be sure you don't miss out on key assignments - or fun. And you don't have to go into detail about your condition to friends or classmates unless you want to. If you think someone won't understand, just tell that person you're not feeling well. You have no obligation to provide them with a detailed explanation.

These days, more and more doctors recognize and understand endometriosis. Many girls find that medication limits the extent of their endometriosis. It also controls any pain so they can take part in the activities they enjoy.