Hugh Taylor, MD: Hello. Welcome to this Contemporary OB/GYNÒ Clinical consultation entitled “Updates in the management of endometriosis”. I am Dr. Hugh Taylor, Professor and Chair of the Department of Obstetrics, Gynecology, and Reproductive Sciences at Yale School of Medicine, and Chief of Obstetrics and Gynecology at Yale New Haven Hospital. [New Haven, Connecticut]. Our discussion today will focus on endometriosis and the various factors that shape our approaches to treating the disease. We’ll look at diagnostic tools for endometriosis, treatment options, and gaps in care.
It is important to differentiate endometriosis from other disorders that can cause pelvic pain. Endometriosis is by far the most common cause of pelvic pain in women of childbearing age. It is therefore very likely that a woman with pelvic pain has endometriosis, but other etiologies must be excluded, which can be cysts, adenomyosis, infectious etiologies, tumors, musculoskeletal problems. There are a host of other things. Our job, when someone presents with pelvic pain, is to start thinking about the signs and symptoms that might make them more likely to have endometriosis and to rule out other potential causes of pelvic pain.
In general, endometriosis usually initially presents as dysmenorrhea. Often menarche will occur, someone will have time with periods that are not extremely painful. These will progress to dysmenorrhea and the pain may, over time, go beyond the dysmenorrhea. There may be pelvic pain outside the time of menstruation. There may be pelvic pain that is not specifically menstrual uterine cramping. We have to assume that some of these other pains may very well be due to endometriosis. Endometriosis usually begins with cyclic pelvic pain, usually dysmenorrhea. Endometriosis is also often a progressive disease. It may start with dysmenorrhea that gets worse over time, then gradually move past menstruation, gradually occur in other areas of the pelvis or abdomen, and begin to affect other organ systems. Most women with progressive cyclic pain suffer from endometriosis. I think that’s the hallmark of the disease, that it’s cyclical. If the pain is not cyclical, does not initially occur with menstruation, occurs randomly throughout the menstrual cycle, or is continuous, it is probably not endometriosis and start looking for other causes pain. If someone has periods that are extremely painful after their first period, and they don’t progress or get worse, it may not be endometriosis. So I’m looking for cyclical progressive pain, most of these women will have endometriosis.
Risk factors associated with endometriosis are generally those that would increase menstrual flow and exposure to menstrual flow. Remember that endometriosis is caused primarily by retrograde menstruation. Menstrual flow travels up the fallopian tubes and into the peritoneal cavity where some of these cells implant and continue to grow. Everyone has a bit of retrograde menstruation, and we don’t know why in some circumstances it continues to persist as endometriosis, but we do know that the more retrograde periods a person has, the more likely they are to have of endometriosis. Particularly with heavy periods, in addition to the antegrade flow, the normal period, there is probably also more retrograde flow. Early menarche, more exposure to more periods, is also a risk factor. Things like using birth control pills that reduce menstrual flow are protective. So not using contraceptives, not being pregnant, the more and heavier periods you have in your lifetime, tend to be risk factors for endometriosis. One of the other most important risk factors, however, is family history. There is a genetic component, and probably about half of the risk of endometriosis is due to this genetic component. There is definitely an environmental component and other etiologies to endometriosis, but there is definitely a genetic component. A family history of endometriosis is a very important risk factor.
Transcript edited for clarity