Written by: Somer Baburek, CEO & Co-Founder of Hera Biotech developing the first non-surgical, direct pathology test for diagnosis and staging of endometriosis.
Written on 2/15/21
Updated 6/7/21
Endometriosis is a painful disorder where tissue similar to the tissue in your uterine lining grows outside of your uterus.
What is endometriosis?
The Mayo Clinic defines endometriosis as, “An often-painful disorder in which tissue similar to the tissue that normally lines the inside of your uterus – the endometrium – grows outside of your uterus.”
Endometriosis, sometimes called “endo,” is one of the most common yet poorly understood gynecological diseases. Endo impacts women of any socioeconomic class, age, or race, and can affect nearly every aspect of their lives.
Symptoms of endometriosis
According to the National Institute of Health, while the primary symptoms of endo are pain and infertility it can also cause any one or combination of the following symptoms:
- Painful or even debilitating menstrual cramps, which may get worse over time
- Pain during or after sex
- Pain in the intestine or lower abdomen
- Painful bowel movements or painful urination during menstrual periods
- Heavy menstrual periods
- Premenstrual spotting or bleeding between periods
- Problems getting pregnant
- Painful bladder syndrome
- Digestive or gastrointestinal symptoms
- Fatigue or lack of energy
Prevalence and diagnosis
It is estimated that between 10-20% of women of childbearing age have endometriosis; 7-13 million in the United States alone. These numbers are often considered to be conservative estimates given difficulty of diagnosis.
In the U.S., the average woman with endometriosis will go 7-12 years and attend 10+ doctor visits, with 68% receiving a misdiagnosis, before receiving a correct diagnosis of endo (1).
In an interview with Good Morning America, Dr. Tamer Seckin, a co-founder of the Endometriosis Foundation of America, said a lack of knowledge among doctors, a social stigma around periods and the fact that there is no single diagnostic test all contribute to the often-long road to diagnosis.
The absence of a single diagnostic test, leaving surgery as the only way to diagnose endo, is arguably the largest contributing factor to the length of time it takes to receive a diagnosis. This particular issue is why I founded Hera Biotech, after discovering endometriosis-specific biomarkers, are developing a diagnostic test that can be done right in your doctor’s office.
The absence of a single diagnostic test, leaving surgery as the only way to diagnose end, is arguably the largest contributing factor to the length of time it takes to receive a diagnosis.
What causes endometriosis?
Unfortunately, the cause of endometriosis is unknown. While there are a number of hypotheses about its cause, all of them require substantial research to be validated. You can learn more about the more popular theories here.
How does endometriosis impact fertility?
Up to 30-50% of women with endometriosis may experience infertility. The correlation between endometriosis and infertility is well-documented but despite that, how endometriosis disrupts fertility function is not as well understood (2).
It’s possible that the endometrial growths may cause fertility issues such as:
- Blocking the fallopian tubes when growths involve the ovaries
- The inflammation caused by endo can make implantation difficult
- Growths can form scar tissue and adhesions that may bind organs together
Finally, trying to conceive can be further complicated by the effect that the pain associated with endometriosis can have on lifestyle, mental health, and intercourse.
How does endometriosis impact progesterone levels?
Studies show that women with low progesterone and endometriosis may experience a delay in adequate progesterone secretion. While these women may seem to have a normal length luteal phase, their “functional luteal phase” can be significantly shortened. This refers to the part of the luteal phase where a woman produces sufficient progesterone (2). In addition to the functionality of the luteal phase, progesterone is critical to reducing inflammation in the endometrium, meaning that having less progesterone than normal can increase inflammation (3).
These common insufficient or low progesterone levels found in patients with endometriosis make sense, given that research has shown that estrogen seems to promote endo growth. Biopsies of endometrial lesions reveal that the lesions contain estrogen receptors and the expression patterns of both estrogen and progesterone receptors in the growths are different from those in the lining of the uterus (4).
These studies would suggest that, when it comes to taking control of your fertility, simply tracking BBT and LH is not optimal (2). Ideally, when trying to conceive, confirming “successful” ovulation — meaning progesterone levels remained elevated for long enough post-ovulation — via PdG tracking is a better way to ensure a healthy luteal phase.
Ideally, when trying to conceive, confirming “successful” ovulation — meaning progesterone levels remained elevated for long enough post-ovulation — via PdG tracking is a better way to ensure a healthy luteal phase.
How is endometriosis treated?
Presently there is no cure for endometriosis and treatment for the disease is based on symptom control. However, there has been groundbreaking research surrounding excision surgery that is promising for women with endometriosis.
Pain
Pain is one of the primary symptoms of endo, with approximately one-third of patients requiring opioids to control their pain (5). An alternative to opioids is a medication by the name of Orilissa, now being marketed specifically for the treatment of endometriosis pain. Other treatment options for controlling pain include:
- Pain relievers
- Birth control pills and estrogen suppressing therapies
In instances of severe pain, surgical treatments can be used. These treatments include procedures aimed at removing the endometrial growths either by excision or ablation, or in the most severe cases, hysterectomy. Many of the pain controlling treatments are not suitable for patients trying to conceive.
Infertility
For patients struggling with fertility due to endometriosis, a physician may prescribe a gonadotropin-releasing hormone (GnRH) agonist. This medication will stop the body from making any of the hormones responsible for ovulation, your menstrual cycle and, in turn, help control the growth of endometrial lesions. However, this may cause a temporary menopause but once the medication is discontinued, your menstrual cycle will return and it’s possible you will be more likely to get pregnant. For women choosing to have children later in life, this may not be ideal.
In cases where the GnRH agonist is not suitable or effective, surgical treatments to remove the endometrial patched can also be used. Studies have shown that early detection followed by surgical treatment of endometriosis resulted in an improvement in pregnancy rate. The largest of these studies showed a significantly higher pregnancy rate in patients treated with laparoscopic excision or ablation compared with diagnostic laparoscopy (30% vs 17%).
Finally, as with all cases of unexplained infertility, when other treatments are unsuccessful fertility interventions can be administered to increase chances of pregnancy. It’s important to note that if the underlying endometriosis is left unresolved, meaning has not been treated by reducing inflammation or surgical removal of the lesions, IVF cycles have a lower probability of success.
Natural progesterone treatment
Sometimes, but not often, endometriosis can be treated with bioidentical progesterone. This however is not a common practice in the U.S. In some naturopathic clinics, doctors may use natural progesterone treatment via creams or suppositories. If you have questions about progesterone and endometriosis, we recommend consulting your doctor.
Knowing both your endometriosis status and your progesterone levels are critical components to fertility success! If you have concerns about endometriosis or progesterone, we recommend consulting your doctor.
(1) Mettler L, Schollmeyer T, Lehmann-Willenbrock E, et al. Accuracy of laparoscopic diagnosis of endometriosis. JSLS. 2003;7(1):15–18
(2) Cheesman, Kerry L., et al. “Alterations in Progesterone Metabolism and Luteal Function in Infertile Women with Endometriosis”**Presented in Part at the Annual Meeting of the Society for Gynecologic Investigation, March 18 to 20, 1983, Washington, D.C. Fertility and Sterility, vol. 40, no. 5, Nov. 1983, pp. 590–595., doi:10.1016/s0015-0282(16)47414-5.
(3) Patel, Bansari G., et al. “Progesterone Resistance in Endometriosis: Origins, Consequences and Interventions.” Acta Obstetricia Et Gynecologica Scandinavica, vol. 96, no. 6, 2017, pp. 623–632., doi:10.1111/aogs.13156.
(4) Kitawaki, J, et al. “Endometriosis: the Pathophysiology as an Estrogen-Dependent Disease.” The Journal of Steroid Biochemistry and Molecular Biology, vol. 83, no. 1-5, Dec. 2002, pp. 149–155., doi:10.1016/s0960-0760(02)00260-1.
(5) Lopes, Jose M. “Large Economic Burden of Opioid Use in US Women with Endometriosis.” PharmacoEconomics & Outcomes News, vol. 854, no. 1, 9 July 2019, pp. 25–25., doi:10.1007/s40274-020-6855-9.
