Endometriosis

ENDOMETRIOSIS

In endometriosis, a benign lesion or lesions with cells similar to those lining the uterus grow aberrantly in the pelvic cavity out-side the uterus. Often, extensive endometriosis causes few symp-toms, whereas an isolated lesion may produce severe symptoms. Between 7% and 10% of women in the United States are affected by this disorder (Olive & Pritts, 2001). It is a major cause of chronic pelvic pain and infertility. In order of frequency, pelvic endometriosis involves the ovary, uterosacral ligaments, cul-de-sac, rectovaginal septum, uterovesical peritoneum, cervix, outer sur-face of the uterus, umbilicus, laparotomy scar tissue, hernial sacs, and appendix.

Endometriosis has been diagnosed more frequently as a result of the increased use of laparoscopy. Before laparoscopy, major surgery was necessary before a diagnosis could be made. There is a high incidence among patients who bear children late and among those who have fewer children. In countries where tradi-tion favors early marriage and early childbearing, endometriosis is rare. There also appears to be a familial predisposition to en-dometriosis; it is more common in women whose close female relatives are affected. Other factors that may suggest increased risk include a shorter menstrual cycle (less than every 27 days), flow longer than 7 days, outflow obstruction, and younger age at menarche. Characteristically, endometriosis is found in young, nulliparous women between the ages of 25 and 35 years. It is also found in teens, particularly those with dysmenorrhea that does not respond to NSAIDs or oral contraceptives.

Pathophysiology

Misplaced endometrial tissue responds to and depends on ovar-ian hormonal stimulation. During menstruation, this ectopic tis-sue bleeds, mostly into areas having no outlet, which causes pain and adhesions. The lesions are typically small and puckered, with a blue/brown/gray powder-burn appearance and brown or blue-black appearance, indicating concealed bleeding. They may also have an atypical appearance as red, white, petechial, and reddish-brown implants.

Endometrial tissue contained within an ovarian cyst has no outlet for the bleeding; this formation is referred to as a pseudocyst or chocolate cyst. Adhesions, cysts, and scar tissue may result, causing pain and infertility.

Currently the best-accepted theory regarding the origin of en-dometrial lesions is the transplantation theory, which suggests that a backflow of menses (retrograde menstruation) transports endometrial tissue to ectopic sites through the fallopian tubes. Transplantation of tissue can also occur during surgery if en-dometrial tissue is transferred inadvertently by way of surgical in-struments. Retrograde menstruation has been found to occur in many women, not just those with endometriosis. Why some women develop this condition and others do not is unknown. Endometrial tissue can also be spread by lymphatic or venous channels.

Clinical Manifestations

Symptoms vary but include dysmenorrhea, dyspareunia, and pelvic discomfort or pain. Dyschezia (pain with bowel move-ments) and radiation of pain to the back or leg may occur. De-pression, loss of work due to pain, and relationship difficulties may result. Infertility may occur because of fibrosis and adhesions or because of a variety of substances (prostaglandins, cytokines, other factors) produced by the implants (Olive & Pritts, 2001).

Assessment and Diagnostic Findings

A health history, including an account of the menstrual pattern, is necessary to elicit specific symptoms. On bimanual pelvic ex-amination, fixed tender nodules are sometimes palpated and uter-ine mobility may be limited, indicating adhesions. Laparoscopic examination confirms the diagnosis and helps to stage the disease. In stage 1, the patient has superficial or minimal lesions; stage 2, mild involvement; stage 3, moderate involvement; and stage 4, deep involvement and dense adhesions, with obliteration of the cul-de-sac.

Medical Management

Treatment depends on the symptoms, the patient’s desire for pregnancy, and the extent of the disease. If the woman does not have symptoms, routine examination may be all that is required. Other therapy for varying degrees of symptoms may be NSAIDs, oral contraceptives, GnRH agonists, or surgery. Pregnancy often alleviates symptoms because neither ovulation nor menstruation occurs.

PHARMACOLOGIC THERAPY

Palliative measures include use of medications, such as analgesic agents and prostaglandin inhibitors, for pain. Hormonal therapy is effective in suppressing endometriosis and relieving dysmenor-rhea (menstrual pain). Oral contraceptives are used frequently. Side effects that may occur with oral contraceptives include fluid retention, weight gain, or nausea. These can usually be managed by changing brands or formulations. Depo-Provera or Lunelle, injectable contraceptive agents, may also be used.

Several types of hormonal therapy are also available in addi-tion to the oral contraceptives. A synthetic androgen, danazol (Danocrine), causes atrophy of the endometrium and subsequent amenorrhea. The medication inhibits the release of gonadotropin with minimal overt sex hormone stimulation. The drawbacks of this medication are that it is expensive and may cause trouble-some side effects such as fatigue, depression, weight gain, oily skin, decreased breast size, mild acne, hot flashes, and vaginal atrophy. GnRH agonists decrease estrogen production and cause subsequent amenorrhea. Side effects are related to low estrogen levels (eg, hot flashes and vaginal dryness). Loss of bone density is often offset by concurrent use of estrogen. Leuprolide, another medication, is injected monthly to suppress hormones, induce an artificial menopause, and thereby avoid menstrual effects and re-lieve endometriosis. Some clinicians prescribe a combination of therapies. Most women continue treatment despite side effects, and symptoms diminish for 80% to 90% of women with mild to moderate endometriosis.

Assisted reproductive techniques may be warranted and effec-tive in women with infertility secondary to endometriosis (Olive Pritts, 2002). Hormonal medications are not used, however, in patients with a history of abnormal vaginal bleeding or liver, heart, or kidney disease. Bone density is followed carefully because of the risk of bone loss; hormone therapy is usually short-term.

SURGICAL MANAGEMENT

If conservative measures are not helpful, surgery may be necessary to relieve pain and enhance the possibility of pregnancy. Surgery may be combined with use of medical therapy. The procedure se-lected depends on the patient. Laparoscopy may be used to ful-gurate (cut with high-frequency current) endometrial implants and to release adhesions. Laser surgery is another option made possible by laparoscopy. Laser therapy vaporizes or coagulates the endometrial implants, thereby destroying this tissue. Other sur-gical options include endocoagulation and electrocoagulation, laparotomy, abdominal hysterectomy, oophorectomy, bilateral salpingo-oophorectomy, and appendectomy. For women olderthan 35 or those willing to sacrifice reproductive capability, total hysterectomy is an option. Endometriosis recurs in many women.

Nursing Management

The health history and physical examination focus on specific symptoms (eg, pain) and when and how long they have been both-ersome, the effect of prescribed medications, and the woman’s reproductive plans. This information helps in determining the treatment plan. Explaining the various diagnostic procedures may help to alleviate the patient’s anxiety. Patient goals include relief of pain, dysmenorrhea, dyspareunia, and avoidance of infertility.

As the treatment progresses, the woman with endometriosis and her partner may find that pregnancy is not easily possible, and the psychosocial impact of this realization must be recognized and addressed. Alternatives, such as in vitro fertilization or adoption, may be discussed at an appropriate time and referrals offered.

The nurse’s role in patient education is to dispel myths and encourage the patient to seek care if dysmenorrhea or dyspareu-nia occurs. The Endometriosis Association is a helpful resource for patients seeking further in-formation and support for this condition, which can cause dis-abling pain and severe emotional distress.