Do you have a younger female family member with episodes of intense pain in various locations in the abdomen or pelvis, even the back and hips areas usually preceding their monthly cycle but not necessarily so and sometimes accompanied by diarrhea or paradoxically, the opposite with severe bloating and constipation? Has this young woman ever required an emergency room visit for a presumed acute surgical abdomen such as appendicitis only to have the symptoms reverse? The diagnosis may be ENDOMETRIOSIS. There may be as many as quarter to half million young Canadian women with this disorder and data analysis suggests they are afflicted for an average of six to eight years before the diagnosis is recognized and proven.
To understand the complexities of making the diagnosis, its first necessary to understand the normal female physiology. Cyclically, a woman produces a hormone surge preparing the uterine lining for implantation of a fertilized egg. When that process is not completed, this lining, called endometrium, is discarded and exits the female in what is colloquially called “the period”. However, when that lining material is located internally, it cannot exit the body in the normal manner and becomes a source of irritation wherever it is attached. In a single episode, the pain can be incapacitating but over time scar tissue is formed and other abdominal organs form adhesions. There are four stages to this disorder scaling from single lesion to multiple organ attachments. The degree of pain is quite variable and NOT correlate with the staging. Obviously the location of the lesion(s) determines the clinical presentation. On the right side, it can mime appendicitis or ruptured ovarian cyst. Centrally, and with diarrhea it will mimic irritable bowel syndrome (a very common alternative diagnosis). If present in the lower pelvis, it can interfere with bowel function causing constipation and intense bloating with cramping. Its effect on normal cycles is to intensify the cramps, produce heavier and more protracted blood flow, sometimes cycle irregularity. It can result in pain internally during bowel movements or even while urinating. Its associated with marked mood swings, sometimes a family history and, at minimum, a 30% risk of infertility.
The origin of this disease is also perplexing. Old school thinking attributed the problem to “aggressive” physical activity forcing the sloughing endometrium internally rather than being expelled but this probably represents only a fraction of cases as the disease can be found any time after menarche and in younger females with no sexual history. The more likely cause is retrograde flow of endometrial cells in to the pelvic cavity. This would explain the random localizing of the lesions. We see a similar migration process with cancer cells drifting away from the primary tumour site. Another explanation is metaplasia in which the lining of other pelvic organs contain cells capable of evolving along endometrial lines. Diagnosis is difficulty because the disease is the great imitator. Pelvic exam and transvaginal ultrasound offer clues but definitively, an MRI followed by LAPAROSCOPY for biopsy is usually a necessity. Treatment is a gamut from analgesics and anti-inflammatories with their inherent dependency risks, to hormone suppression and infertility side effect to laparoscopic surgery for isolated lesions, even hysterectomy for more severe cases, steps never taken easily in reproductive age women. Diagnosis depends on a high degree of suspicion. No young woman with that intense discomfort should ever hear the words “it’s in your head”. All young women are averse to discussing their cycles except peer to peer. I rarely found intense pelvic pain a ploy for school absentee behaviour. If you have a family member with this degree of distress, they deserve the benefit of the doubt and a thorough diagnostic evaluation.
Dr. David Carll