What is endometriosis

Endometriosis is a disease in which the kind of tissue (the endometrium) that normally grows inside the uterus grows outside the uterus ¹. Endometriosis can grow (often called implants) in the cul-de-sac (the space behind the uterus), outer surfaces of the uterus, on the ovaries, fallopian (uterine) tubes, intestines and rectum, ureters or bladder. Rarely, it grows in other parts of the body.

With endometriosis, displaced endometrial tissue continues to act as it normally would — it thickens, breaks down and bleeds with each menstrual cycle. Because this displaced tissue has no way to exit your body, it becomes trapped. When endometriosis involves the ovaries, cysts called endometriomas may form. Surrounding tissue can become irritated, eventually developing scar tissue and adhesions — abnormal bands of fibrous tissue that can cause pelvic tissues and organs to stick to each other.

Endometriosis can cause pelvic pain — sometimes severe — especially during your period. Fertility problems also may develop. Fortunately, effective treatments are available.

Endometriosis may affect more than 11% of American women between 15 and 44 ². It is especially common among women in their 30s and 40s and may make it harder to get pregnant.

Complications of endometriosis

Infertility

The main complication of endometriosis is impaired fertility. Approximately one-third to one-half of women with endometriosis have difficulty getting pregnant.

For pregnancy to occur, an egg must be released from an ovary, travel through the neighboring fallopian tube, become fertilized by a sperm cell and attach itself to the uterine wall to begin development. Endometriosis may obstruct the tube and keep the egg and sperm from uniting. But the condition also seems to affect fertility in less-direct ways, such as damage to the sperm or egg.

Even so, many women with mild to moderate endometriosis can still conceive and carry a pregnancy to term. Doctors sometimes advise women with endometriosis not to delay having children because the condition may worsen with time.

Ovarian cancer

Ovarian cancer does occur at higher than expected rates in women with endometriosis. But the overall lifetime risk of ovarian cancer is low to begin with. Some studies suggest that endometriosis increases that risk, but it’s still relatively low. Although rare, another type of cancer — endometriosis-associated adenocarcinoma — can develop later in life in women who have had endometriosis.

Endometriosis pain

How does endometriosis cause problems ?

Endometriosis implants respond to changes in estrogen, a female hormone. The implants may grow and bleed like the uterine lining does during the menstrual cycle. Surrounding tissue can become irritated, inflamed, and swollen. The breakdown and bleeding of this tissue each month also can cause scar tissue, called adhesions, to form. Sometimes adhesions can cause organs to stick together. The bleeding, inflammation, and scarring can cause pain, especially before and during menstruation.

Endometriosis diet

Women with endometriosis are frequently misdiagnosed with irritable bowel syndrome (IBS) for some time before a correct diagnosis is made. A study ³ found women with concurrent endometriosis and IBS report a unique symptom phenotype. The low FODMAP diet appears effective in women with gut symptoms and endometriosis.

For more information of FODMAP diet go here: Fodmap diet

The literature on dietary factors and the risk of developing endometriosis is limited. The few studies conducted in this area are contradictory.

The current scientific evidence suggests that the diet and lifestyle may influence the presence of inflammation in the body, estrogen activity, menstrual cycle, and prostaglandin metabolism. As such, diet and lifestyle can also impact the risk of developing endometriosis ⁴, ⁵.

One of the possible pathogenic factors affecting both endometriosis and dysmenorrhea is prostaglandin levels. Omega-6 fatty acids derived from the diet are the precursors of the proinflammatory prostaglandins PGE2 and PGF2α that probably increase uterine cramps and cause the painful symptoms. However, PGE3 and PGE3α derived from the Omega-3 fatty acids were linked to reduced inflammation and thus, lesser pain ⁶.

High levels of estrogen may be another risk factor for developing endometriosis. Research has demonstrated a connection between diet and the incidence of the  estrogen-dependent diseases (e.g. breast and endometrial cancer). We can therefore assume that dietary impact blood estrogen levels may also play a role in the etiology of endometriosis ⁷, ⁸.

Food may also contain chemical compounds from contaminated environments, especially chlorinated hydrocarbons including polychlorinated biphenyls (PCBs). Such compounds tend to bioaccumulate in lipids contained particularly in meat, liver, and dairy products. Similarly, pesticides can be consumed together with contaminated fruits and vegetables. The above compounds can also be counted among the risk factors for endometriosis ⁹, ¹⁰.

On the basis of the data presented in this study ¹¹, it can be suggested that the increased consumption of vegetables, fruits ¹², Omega-3 fatty acids ⁵, ¹³, Omega-6 fatty acids ¹³, fats ¹⁴, soy and phytoestrogens ¹⁵ as well as dairy products rich in calcium and vitamin D ¹⁶ decreases the risk of developing endometriosis. Conversely, factors identified to increase the risk for endometriosis include fruits ¹⁷, dietary fiber ¹⁸, fats in general ¹⁹ [including vegetable fats, monounsaturated fats, polyunsaturated fats  ¹⁹, and trans-unsaturated fatty acids ⁵], pork and beef ¹², ham ¹², and alcohol ¹⁶.

It appears that in developing endometriosis antioxidants, vitamins A, C, and E, and B-group vitamins as well as folic acid also play an important role. Consumption of these vitamins and antioxidants decreases the risk of developing endometriosis, potentially by influencing oxidative stress and steroid hormone metabolism in the body. From 1991 to 2005 a cohort study was conducted on a group of 70,617 women by Darling et al. ²⁰. The experimental group (n = 1.383) consisted of women with the endometriosis confirmed by laparoscopy and the control group (n = 69.234) consisted of the healthy women. On the basis of a questionnaire concerning consumption of products and usage of vitamin supplements, the relationship between vitamins C and E as well as B-group vitamins and endometriosis risk was examined. It has been found that consumption of products rich in vitamins such as folic acid, vitamin C, and vitamin E is inversely proportional to the risk of developing endometriosis. However, supplying these vitamins via dietary supplement had no influence on the occurrence of endometriosis ²⁰. This may suggest that other factors present in food
may modify the risk of endometriosis ²⁰. A similar study was conducted in 2008 by Mier-Cabrera et al. ²¹ on a group  of women suffering from endometriosis (n = 83) compared to a control group of healthy women (n = 80). Disorders in blood serum were defined on the basis of a questionnaire assessing frequency of product consumption and serum testing to assess oxidant-antioxidant balance. The findings of the study showed lower consumption of vitamins A, C, and E, and microelements zinc and copper in the group of women with diagnosed endometriosis ²¹.

A high fat diet in which more than 45% of daily calorie requirements come from fat can also increase oxidative stress and inflammation in the body, thereby increasing the risk of developing endometriosis. This finding comes from a 2016 study by Heard et al. ²² conducted in mice in which  the experimental group was on the diet of 45% of fat and the control group was on a diet of 17% of fat. Another study performed on animals in 2013 by Herington
et al. ²³ seems to confirm the positive influence of fish oils on decreasing the risk of developing endometriosis, demonstrating that supplementation with fish oil  reduced the development of postoperative adhesions connected with endometriosis.

CONCLUSIONS

Dietary factors that may decrease the risk of endometriosis include consumption of vegetables, antioxidant vitamins, B-group vitamins, dairy products rich in  calcium and vitamin D, fish oils, and Omega-3 fatty acids.

The dietary factors that may potentially increase the risk of developing endometriosis include consumption of trans unsaturated fatty acids, red meat and ham, as well as alcohol.

Currently there are no clear connections between the diet and the risk of endometriosis. Further research is needed in order to explain the relationship between consumed foods and development of this disease.

Figure 1. Uterus anatomy

Figure 2. Endometrium of the uterus and its blood supply

Figure 3. Endometriosis

What is the link between infertility and endometriosis ?

This is one of the most perplexing aspects of the disease, confronting researchers and patients alike. Almost 40% of women with infertility have endometriosis. Not only do some of these women have difficulty conceiving and carrying a live birth to term, they are less likely to conceive following assisted reproduction, such as fertility medication, artificial insemination, and in vitro fertilization. Studies to address the link between endometriosis and infertility have just begun. These studies suggest that women with endometriosis may have implantation defects (abnormalities of the environment that make it difficult for the embryo to attach and survive) and/or low quality eggs. These conditions, in turn, could be related to an abnormal immune environment that some suspect exist in women with endometriosis. Furthermore, inflammation from endometriosis may damage the sperm or egg or interfere with their movement through the fallopian tubes and uterus. In severe cases of endometriosis, the fallopian tubes may be blocked by adhesions or scar tissue.

What are the symptoms of endometriosis ?

The most common symptom of endometriosis is chronic (long-term) pelvic pain, especially just before and during the menstrual period. Although many women experience cramping during their menstrual period, women with endometriosis typically describe menstrual pain that’s far worse than usual. They also tend to report that the pain increases over time.

Pelvic pain also may occur during sex. If endometriosis is present on the bowel, pain during bowel movements can occur. If it affects the bladder, pain may be felt during urination. Heavy menstrual bleeding is another symptom of endometriosis. Many women with endometriosis have no symptoms at all. Having trouble getting pregnant may be the first sign.

Common signs and symptoms of endometriosis may include:

• Painful periods (dysmenorrhea). Pelvic pain and cramping may begin before your period and extend several days into your period. You may also have lower back and abdominal pain.
• Pain with intercourse. Pain during or after sex is common with endometriosis.
• Pain with bowel movements or urination. You’re most likely to experience these symptoms during your period.
• 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 infertility.
• Other symptoms. You may also experience fatigue, diarrhea, constipation, bloating or nausea, especially during menstrual periods.

The severity of your pain isn’t necessarily a reliable indicator of the extent of the condition. Some women with mild endometriosis have intense pain, while others with advanced endometriosis may have little pain or even no pain at all.

Endometriosis is sometimes mistaken for other conditions that can cause pelvic pain, such as pelvic inflammatory disease (PID) or ovarian cysts. It may be confused with irritable bowel syndrome (IBS), a condition that causes bouts of diarrhea, constipation and abdominal cramping. IBS can accompany endometriosis, which can complicate the diagnosis.

When to see a doctor

See your doctor if you have signs and symptoms that may indicate endometriosis.

Endometriosis can be a challenging condition to manage. An early diagnosis, a multidisciplinary medical team and an understanding of your diagnosis may result in better management of your symptoms.

Causes of endometriosis

Although the exact cause of endometriosis is not certain, possible explanations include:

• Retrograde menstruation. In retrograde menstruation, menstrual blood containing endometrial cells flows back through the fallopian tubes and into the pelvic cavity instead of out of the body. These displaced endometrial cells stick to the pelvic walls and surfaces of pelvic organs, where they grow and continue to thicken and bleed over the course of each menstrual cycle.
• Transformation of peritoneal cells. In what’s known as the “induction theory,” experts propose that hormones or immune factors promote transformation of peritoneal cells — cells that line the inner side of your abdomen — into endometrial cells.
• Embryonic cell transformation. Hormones such as estrogen may transform embryonic cells — cells in the earliest stages of development — into endometrial cell implants during puberty.
• Surgical scar implantation. After a surgery, such as a hysterectomy or C-section, endometrial cells may attach to a surgical incision.
• Endometrial cells transport. The blood vessels or tissue fluid (lymphatic) system may transport endometrial cells to other parts of the body.
• Immune system disorder. It’s possible that a problem with the immune system may make the body unable to recognize and destroy endometrial tissue that’s growing outside the uterus.

Risk factors for developing endometriosis

Several factors place you at greater risk of developing endometriosis, such as:

• Never giving birth
• Mother, sister, or daughter had endometriosis (raises the risk about six times)
• Starting your period at an early age (before age 11)
• Going through menopause at an older age
• Short menstrual cycles — for instance, less than 27 days
• Menstrual cycles are heavy and last more than 7 days
• Having higher levels of estrogen in your body or a greater lifetime exposure to estrogen your body produces
• Low body mass index
• Alcohol consumption
• One or more relatives (mother, aunt or sister) with endometriosis
• Any medical condition that prevents the normal passage of menstrual flow out of the body
• Uterine abnormalities

Endometriosis usually develops several years after the onset of menstruation (menarche). Signs and symptoms of endometriosis end temporarily with pregnancy and end permanently with menopause, unless you’re taking estrogen.

Endometriosis Diagnosis

To diagnose endometriosis and other conditions that can cause pelvic pain, your doctor will ask you to describe your symptoms, including the location of your pain and when it occurs.

Tests to check for physical clues of endometriosis include:

• Pelvic exam. During a pelvic exam, your doctor manually feels (palpates) areas in your pelvis for abnormalities, such as cysts on your reproductive organs or scars behind your uterus. Often it’s not possible to feel small areas of endometriosis, unless they’ve caused a cyst to form.
• Ultrasound. This test uses high-frequency sound waves to create images of the inside of your body. To capture the images, a device called a transducer is either pressed against your abdomen or inserted into your vagina (transvaginal ultrasound). Both types of ultrasound may be done to get the best view of your reproductive organs. Ultrasound imaging won’t definitively tell your doctor whether you have endometriosis, but it can identify cysts associated with endometriosis (endometriomas).

Laparoscopy. Medical management is usually tried first. But to be certain you have endometriosis, your doctor may refer you to a surgeon to look inside your abdomen for signs of endometriosis using a surgical procedure called laparoscopy.

While you’re under general anesthesia, your surgeon makes a tiny incision near your navel and inserts a slender viewing instrument (laparoscope), looking for endometrial tissue outside the uterus. He or she may take samples of tissue (biopsy). Laparoscopy can provide information about the location, extent and size of the endometrial implants to help determine the best treatment options.

Treatment for Endometriosis

Treatment for endometriosis is usually with medications or surgery. The approach you and your doctor choose will depend on the severity of your signs and symptoms and whether you hope to become pregnant.

Generally, doctors recommend trying conservative treatment approaches first, opting for surgery as a last resort.

Pain medications

Your doctor may recommend that you take an over-the-counter pain reliever, such as the nonsteroidal anti-inflammatory drugs (NSAIDs) ibuprofen (Advil, Motrin IB, others) or naproxen (Aleve, others), to help ease painful menstrual cramps.

If you find that taking the maximum dose of these medications doesn’t provide full relief, you may need to try another approach to manage your signs and symptoms.

Home remedies for endometriosis

If your pain persists or if finding a treatment that works takes some time, you can try measures at home to relieve your discomfort.

• Apply a hot water bottle or heating pad to your lower stomach. This can get blood flowing and relax your muscles. Warm baths also may help relieve pain.
• Lie down and rest. Place a pillow under your knees when lying on your back. If you prefer to lie on your side, pull your knees up toward your chest. These positions help take the pressure off your back.
• Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil, Motrin IB, others) or naproxen (Aleve, others), can help ease painful menstrual cramps. If the pain is worse during your periods, try starting these medicines 1 to 2 days before your period begins.
• Regular exercise may help improve symptoms. Exercise helps improve blood flow. It also triggers your body’s natural painkillers, called endorphins.
• Eat a balanced, healthy diet. Maintaining a healthy weight will help improve your overall health. Eating plenty of fiber can help keep you regular so you don’t have to strain during bowel movements.

Techniques that also offer ways to relax and may help relieve pain include:

• Muscle relaxation
• Deep breathing
• Visualization
• Biofeedback
• Yoga

Some women find that acupuncture helps ease painful periods. Some studies show it also helps with chronic pain.

Hormone therapy

Supplemental hormones are sometimes effective in reducing or eliminating the pain of endometriosis. The rise and fall of hormones during the menstrual cycle causes endometrial implants to thicken, break down and bleed. Hormone medication may slow endometrial tissue growth and prevent new implants of endometrial tissue.

Hormone therapy isn’t a permanent fix for endometriosis. You could experience a return of your symptoms after stopping treatment.

Therapies used to treat endometriosis include:

• Hormonal contraceptives. Birth control pills, patches and vaginal rings help control the hormones responsible for the buildup of endometrial tissue each month. Most women have lighter and shorter menstrual flow when they’re using a hormonal contraceptive. Using hormonal contraceptives — especially continuous cycle regimens — may reduce or eliminate the pain of mild to moderate endometriosis.
• Gonadotropin-releasing hormone (Gn-RH) agonists and antagonists. These drugs block the production of ovarian-stimulating hormones, lowering estrogen levels and preventing menstruation. This causes endometrial tissue to shrink. Because these drugs create an artificial menopause, taking a low dose of estrogen or progestin along with Gn-RH agonists and antagonists may decrease menopausal side effects, such as hot flashes, vaginal dryness and bone loss. Your periods and the ability to get pregnant return when you stop taking the medication.
• Progestin therapy. A progestin-only contraceptive, such as an intrauterine device (Mirena), contraceptive implant or contraceptive injection (Depo-Provera), can halt menstrual periods and the growth of endometrial implants, which may relieve endometriosis signs and symptoms.
• Danazol. This drug suppresses the growth of the endometrium by blocking the production of ovarian-stimulating hormones, preventing menstruation and the symptoms of endometriosis. However, danazol may not be the first choice because it can cause serious side effects and can be harmful to the baby if you become pregnant while taking this medication.
• Researchers are exploring the use of other hormones for treating endometriosis and the pain related to it. One example is gestrinone, which has been used in Europe but is not available in the United States. Drugs that lower the amount of estrogen in the body, called aromatase inhibitors, are also being studied. Some research shows that they can be effective in reducing endometriosis pain, but they are still considered experimental in the United States. They are not approved by the Food and Drug Administration for treatment of endometriosis ²⁴.

Oral contraceptives, or birth control pills

These help make your period lighter, more regular, and shorter. Women prescribed contraceptives also report relief from pain ²⁴.

• In general, the therapy contains two hormones-estrogen and progestin, a progesterone-like hormone. Women who can’t take estrogen because of cardiovascular disease or a high risk of blood clots can use progestin-only pills to reduce menstrual flow.
• Typically, a woman takes the pill for 21 days and then takes sugar pills for 7 days to mimic the natural menstrual cycle. Some women take birth control pills continuously, without using the sugar pills that signal the body to go through menstruation. Taken without the sugar pills, birth control pills may stop the menstrual period altogether, which can reduce or eliminate the pain. There are also birth control pills available that provide only a couple days of sugar pills every 3 months; these also help reduce or eliminate pain.
• Pain relief usually lasts only while taking the pills, while the endometriosis is suppressed. When treatment stops, the symptoms of endometriosis may return (along with the ability to get pregnant). Many women continue treatment indefinitely. Occasionally, some women have no pain for several years after stopping treatment.
• There are some mild side effects from these hormones, such as weight gain, bloating, and bleeding between periods (especially when women first start to take the pills continuously).

Progesterone and progestin

Progesterone and progestin, taken as a pill, by injection, or through an intrauterine device (IUD), improve symptoms by reducing a woman’s period or stopping it completely. This also prevents pregnancy.

• As a pill taken daily, these hormones reduce menstrual flow without causing the uterus lining to grow. As soon as a woman stops taking the progestin pill, symptoms may return and pregnancy is possible.
• An IUD containing progestin, such as Mirena®, may be effective in reducing endometriosis-associated pain. It reduces the size of lesions and reduces menstrual flow (one third of women no longer get their period after a year of use).6
• As an injection taken every 3 months, these hormones usually stop menstrual flow. However, one-third of women bleed several times in the first year of injection use. During these times of bleeding, pain may occur. Additionally, it may take a few months for a period to return after stopping the injections. When menstruation starts again, the ability to get pregnant returns.
• Women taking these hormones may gain weight, feel depressed, or have irregular vaginal bleeding.

Gonadotropin-releasing hormone (GnRH) agonists

Gonadotropin-releasing hormone (GnRH) agonists stop the production of certain hormones to prevent ovulation, menstruation, and the growth of endometriosis. This treatment sends the body into a “menopausal” state.

• GnRH agonists come in a nose spray taken daily, as an injection given once a month, or as an injection given every 3 months.
• Most health care providers recommend staying on GnRH agonists for only about 6 months at a time, with several months between treatments if they are repeated. The risk for heart complications and bone loss can rise when taking them longer.2 After stopping the GnRH agonist, the body comes out of the menopausal state, menstruation begins, and pregnancy is possible.7
• As with all hormonal treatments, endometriosis symptoms return after women stop taking GnRH agonists.
• These medications also have side effects, including hot flashes, tiredness, problems sleeping, headache, depression, joint and muscle stiffness, bone loss, and vaginal dryness.

Danazol

Danazol (also called Danocrine®) treatment stops the release of hormones that are involved in the menstrual cycle. While taking this drug, women will have a period only now and then or sometimes not at all.

• Common side effects include oily skin, pimples or acne, weight gain, muscle cramps, tiredness, smaller breasts, and sore breasts. Headaches, dizziness, weakness, hot flashes, or a deepening of the voice may also occur while on this treatment. Danazol’s side effects are more severe than those from other hormone treatment options ²⁵.
• Danazol can harm a developing fetus. Therefore, it is important to prevent pregnancy while on this medication. Hormonal birth control methods are not recommended while on danazol. Instead, health care providers recommend using barrier methods of birth control, such as condoms or a diaphragm.

Conservative surgery

If you have endometriosis and are trying to become pregnant, surgery to remove as much endometriosis as possible while preserving your uterus and ovaries (conservative surgery) may increase your chances of success. If you have severe pain from endometriosis, you may also benefit from surgery. After surgery, most women have relief from pain. However, about 40–80% of women have pain again within 2 years of surgery. The more severe the disease, the more likely it is to return. Taking birth control pills or other medications after having surgery may help extend the pain-free period.

In some cases, hormone therapy is used before or after surgery to reduce pain and/or continue treatment. Current evidence supports the use of an intrauterine device (IUD) containing progestin after surgery to reduce pain.6 Currently, the only such device approved by the FDA is Mirena®.

Your doctor may do this procedure laparoscopically or through traditional abdominal surgery in more extensive cases. In laparoscopic surgery, your surgeon inserts a slender viewing instrument (laparoscope) through a small incision near your navel and inserts instruments to remove endometrial tissue through another small incision.

Laparoscopy

The surgeon uses an instrument to inflate the abdomen slightly with a harmless gas and then inserts a small viewing instrument with a light, called a laparoscope, into the abdomen through a small cut to see the growths.

To remove the endometriosis, the surgeon makes at least two more small cuts in the abdomen and inserts lasers or other surgical instruments to:

• Remove the lesions, which is a process called excising.
• Destroy the lesions with intense heat and seal the blood vessels without stitches, a process called cauterizing or vaporizing.
• Some surgeons also will remove scar tissue at this time because it may be contributing to endometriosis-associated pain.
• The goal is to treat the endometriosis without harming the healthy tissue around it.
• Although most women have relief from pain with surgery in the short term, pain often returns ²⁵. The excision of deep lesions seems to be associated with long-term pain relief.
• Some evidence shows that surgical treatment for endometriosis-related pain is actually more effective in women who have moderate endometriosis rather than minimal endometriosis. The reason is that women with minimal endometriosis may have changes in their pain perception that persist after the lesions are removed ²⁶.

Laparotomy

In this major abdominal surgery procedure, the surgeon may remove the endometriosis patches. Sometimes, the endometriosis lesions are too small to see in a laparotomy.

• During this procedure, the surgeon may also remove the uterus. Removing the uterus is called hysterectomy.
• If the ovaries have endometriosis on them or if damage is severe, the surgeon may remove the ovaries and fallopian tubes along with the uterus. This process is called total hysterectomy and bilateral (meaning “on both sides”) salpingo-oophorectomy.
• When possible, health care providers will try to leave the ovaries in place because of the important role ovaries play in overall health.
• Health care providers recommend major surgery as a last resort for endometriosis treatment.
• Having a hysterectomy or salpingo-oophorectomy does not guarantee that the lesions will not return or that the pain will go away. Endometriosis symptoms and lesions may come back in as many as 15% of women who have a total hysterectomy with bilateral salpingo-oophorectomy ²⁵.

Hysterectomy

In severe cases of endometriosis, surgery to remove the uterus and cervix (total hysterectomy) as well as both ovaries may be the best treatment. A hysterectomy alone is not effective — the estrogen your ovaries produce can stimulate any remaining endometriosis and cause pain to persist. There is a small chance that pain will come back even if your uterus and ovaries are removed. This may be due to endometriosis that was not visible or could not be removed at the time of surgery.

A hysterectomy is typically considered a last resort, especially for women still in their reproductive years. You can’t get pregnant after a hysterectomy.

Finding a doctor with whom you feel comfortable is crucial in managing and treating endometriosis. You may also want to get a second opinion before starting any treatment to be sure you know all of your options and the possible outcomes.

Surgery to sever pelvic nerves

If the pain is located in the center of the abdomen, health care providers may recommend cutting nerves in the pelvis to lessen the pain. This can be done during either laparoscopy or laparotomy ²⁵.

Two procedures are used to sever different nerves in the pelvis.

1. Presacral neurectomy. This procedure severs the nerves connected to the uterus. Research shows that this procedure can be useful in relieving pain along the center of the abdomen ²⁷.
2. Laparoscopic uterine nerve ablation (LUNA). This procedure involves severing nerves in the ligaments that secure the uterus. However, studies have shown that LUNA did not relieve pain any better than laparoscopy alone. For this reason, it is generally not recommended for treatment of endometriosis-associated pain ²⁴.
   The American College of Obstetricians and Gynecologists (ACOG) reports several clinical trials that showed these procedures to be ineffective at relieving pain from endometriosis. These procedures are not currently included in the ACOG recommendations for management of endometriosis ²⁵.

Treatments for Infertility Related to Endometriosis

In most cases, health care providers will recommend laparoscopy to remove or vaporize the growths as a way to also improve fertility in women who have mild or minimal endometriosis.6 Although studies show improved pregnancy rates following this type of surgery, the success rate is not clear.

If pregnancy does not occur after laparoscopic treatment, in vitro fertilization (IVF) may be the best option to improve fertility. Taking any other hormonal therapy usually used for endometriosis-associated pain will only suppress ovulation and delay pregnancy. Performing another laparoscopy is not the preferred approach to improving fertility unless symptoms of pain prevent undergoing IVF. Multiple surgeries, especially those that remove cysts from the ovaries, may reduce ovarian function and hamper the success of IVF ²⁷.

IVF makes it possible to combine sperm and eggs in a laboratory to make an embryo. Then the resulting embryos are placed into the woman’s uterus. IVF is one type of assisted reproductive technology that may be an option for women and families affected by infertility related to endometriosis.

In general, the process of IVF involves the following steps. First, a woman takes hormones to cause “superovulation,” which triggers her body to produce many eggs at one time. Once mature, the eggs are collected from the woman, using a probe inserted into the vagina and guided by ultrasound. The collected eggs are placed in a dish for fertilization with a man’s sperm. The fertilized cells are then placed in an incubator, a machine that keeps them warm and allows them to develop into embryos. After 3 to 5 days, the embryos are transferred to the woman’s uterus. It takes about 2 weeks to know if the process is successful.

Even though the use of hormones in IVF is successful in treating infertility related to endometriosis, other forms of hormone therapy are not as successful. For instance, ACOG does not recommend using oral contraceptive pills or GnRH agonists to treat endometriosis-related infertility. The use of these hormonal agents prevents ovulation and delays pregnancy ²⁸.

In addition, the hormones used during IVF do not cure the endometriosis lesions, which means that pain may recur after pregnancy and that not all women with endometriosis are able to become pregnant with IVF. Researchers are still looking for hormone treatments for infertility due to endometriosis.

1. Endometriosis. Medline Plus. https://medlineplus.gov/endometriosis.html[↩]
2. Buck, L.G.M., Hediger, M.L., Peterson, C.M., Croughan, M., Sundaram, R., Stanford, J., Chen, Z., et al. (2011). Incidence of endometriosis by study population and diagnostic method: the ENDO study. Fertility and Sterility; 96(2): 360-5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3143230/[↩]
3. Endometriosis in patients with irritable bowel syndrome: Specific symptomatic and demographic profile, and response to the low FODMAP diet. Aust N Z J Obstet Gynaecol. 2017 Apr;57(2):201-205. doi: 10.1111/ajo.12594. Epub 2017 Mar 17. http://onlinelibrary.wiley.com/doi/10.1111/ajo.12594/full[↩]
4. Darling AM, Chavarro JE, Malspeis S, et al. A prospective cohort study of Vitamins B, C, E, and multivitamin intake and endometriosis. J Endometr. 2013; 5(1): 17–26, doi: 10.5301/je.5000151 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2873173/[↩]
5. Missmer SA, Chavarro JE, Malspeis S, et al. A prospective study of dietary fat consumption and endometriosis risk. Hum Reprod. 2010; 25(6): 1528–1535, doi: 10.1093/humrep/deq044 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2873173/[↩][↩][↩]
6. Fjerbaek A, Knudsen UB. Endometriosis, dysmenorrhea and diet–what is the evidence? Eur J Obstet Gynecol Reprod Biol. 2007; 132(2): 140–147, doi: 10.1016/j.ejogrb.2006.12.006 https://www.ncbi.nlm.nih.gov/pubmed/17210218[↩]
7. Tsubura A, Uehara N, Kiyozuka Y, et al. Dietary factors modifying breast cancer risk and relation to time of intake. J Mammary Gland Biol Neoplasia. 2005; 10(1): 87–100, doi: 10.1007/s10911-005-2543-4, https://www.ncbi.nlm.nih.gov/pubmed/15886889[↩]
8. Littman AJ, Beresford SA, White E. The association of dietary fat and plant foods with endometrial cancer (United States). Cancer Causes Control. 2001; 12(8): 691–702, https://www.ncbi.nlm.nih.gov/pubmed/11562109[↩]
9. La Rocca C, Mantovani A. From environment to food: the case of PCB. Ann Ist Super Sanita. 2006; 42(4): 410–416. http://www.iss.it/publ/anna/2006/4/424410.pdf[↩]
10. Grassi P, Fattore E, Generoso C, et al. Polychlorobiphenyls (PCBs), polychlorinated dibenzo-p-dioxins (PCDDs) and dibenzofurans (PCDFs) in fruit and vegetables from an industrial area in northern Italy. Chemosphere. 2010; 79(3): 292–298, doi: 10.1016/j.chemosphere.2010.01.028 https://www.ncbi.nlm.nih.gov/pubmed/20153014[↩]
11. Influence of diet on the risk of developing endometriosis. https://journals.viamedica.pl/ginekologia_polska/article/view/GP.a2017.0017/37603[↩]
12. Parazzini F, Chiaffarino F, Surace M, et al. Selected food intake and risk of endometriosis. Hum Reprod. 2004; 19(8): 1755–1759, doi: 10.1093/humrep/deh395, https://www.ncbi.nlm.nih.gov/pubmed/15254009[↩][↩][↩]
13. Khanaki K, Nouri M, Ardekani AM, et al. Evaluation of the relationship between endometriosis and omega-3 and omega-6 polyunsaturated fatty acids. Iran Biomed J. 2012; 16(1): 38–43. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3614254/[↩][↩]
14. Sesti F, Capozzolo T, Pietropolli A, et al. Recurrence rate of endometrioma after laparoscopic cystectomy: a comparative randomized trial between post-operative hormonal suppression treatment or dietary therapy vs. placebo. Eur J Obstet Gynecol Reprod Biol. 2009; 147(1): 72–77, doi:10.1016/j.ejogrb.2009.07.003 https://www.ncbi.nlm.nih.gov/pubmed/19665279[↩]
15. Tsuchiya M, Miura T, Hanaoka T, et al. Effect of soy isoflavones on endometriosis: interaction with estrogen receptor 2 gene polymorphism. Epidemiology. 2007; 18(3): 402–408. https://www.ncbi.nlm.nih.gov/pubmed/17474167[↩]
16. Matalliotakis IM, Cakmak H, Fragouli YG, et al. Epidemiological characteristics in women with and without endometriosis in the Yale series. Arch Gynecol Obstet. 2008; 277(5): 389–393, doi: 10.1007/s00404-007-0479-1, https://www.ncbi.nlm.nih.gov/pubmed/17922285[↩][↩]
17. Trabert B, Peters U, De Roos AJ, et al. Diet and risk of endometriosis in a population-based case-control study. Br J Nutr. 2011; 105(3): 459–467, doi: 10.1017/S0007114510003661 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3374872/[↩]
18. Savaris AL, do Amaral VF. Nutrient intake, anthropometric data and correlations with the systemic antioxidant capacity of women with pelvic endometriosis. Eur J Obstet Gynecol Reprod Biol. 2011; 158(2): 314–318,doi: 10.1016/j.ejogrb.2011.05.014 https://www.ncbi.nlm.nih.gov/pubmed/21700380[↩]
19. Britton JA, Westhoff C, Howe GR, et al. Diet and benign ovarian tumors (United States). Cancer Causes Control. 2000; 11(5): 389–401, https://www.ncbi.nlm.nih.gov/pubmed/10877332[↩][↩]
20. Darling AM, Chavarro JE, Malspeis S, et al. A prospective cohort study of Vitamins B, C, E, and multivitamin intake and endometriosis. J Endometr. 2013; 5(1): 17–26, doi: 10.5301/je.5000151 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3916184/[↩][↩][↩]
21. Mier-Cabrera J, Aburto-Soto T, Burrola-Méndez S, et al. Women with endometriosis improved their peripheral antioxidant markers after the application of a high antioxidant diet. Reprod Biol Endocrinol. 2009; 7: 54, doi: 10.1186/1477-7827-7-54 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2693127/[↩][↩]
22. Heard ME, Melnyk SB, Simmen FA, et al. High-Fat Diet Promotion of Endometriosis in an Immunocompetent Mouse Model is Associated With Altered Peripheral and Ectopic Lesion Redox and Inflammatory Status. Endocrinology. 2016; 157(7): 2870–2882, doi: 10.1210/en.2016-1092, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4929556/[↩]
23. Herington JL, Glore DR, Lucas JA, et al. Dietary fish oil supplementation inhibits formation of endometriosis-associated adhesions in a chimeric mouse model. Fertil Steril. 2013; 99(2): 543–550, doi: 10.1016/j.fertnstert. 2012.10.007 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3582352/[↩]
24. Practice Committee of the American Society for Reproductive Medicine. (2008). Treatment of pelvic pain associated with endometriosis. Fertility and Sterility, 90(Suppl. 3), S260-S269.[↩][↩][↩]
25. American College of Obstetricians and Gynecologists. (2010). Management of endometriosis (Practice Bulletin No. 114). Obstetrics & Gynecology, 116(1), 223-236.[↩][↩][↩][↩][↩]
26. Stratton, P., & Berkley, K. J. (2011). Chronic pelvic pain and endometriosis: Translational evidence of the relationship and implications. Human Reproduction Update, 17(3), 327-346.[↩]
27. Yeung, P. P., Jr., Shwayder, J., & Pasic, R. P. (2009). Laparoscopic management of endometriosis: Comprehensive review of best evidence. Journal of Minimally Invasive Gynecology, 16(3), 269-281.[↩][↩]
28. Hughes, E., Brown, J., Collins, J. J., Farguhar, C., Fedorkow, D. M., & Vandekerckhove, P. (2007). Ovulation suppression for endometriosis. Cochrane Database of Systematic Reviews, (3), Art. No. CD000155.[↩]