Internal Medicine / Endocrinology, Metabolism and Lipid Research: Endocrine and

Metabolic Disorders
Endocrine Disorders
Endocrine disorders involve an abnormality of one of the body's endocrine glands. Among the endocrine disorders, thyroid
problems are the most common.
Thyroid underactivity/overactivity: Of the endocrine disorders, thyroid diseases are the most common. Effective
treatment of thyroid over-activity (hyperthyroidism) and under-activity (hypothyroidism) is important in both the short term
and long term. Although treating underactive thyroid is a bit more complex, either condition can be treated effectively.
Thyroid growths: Most thyroid growths do not have serious consequences. A technique called "fine-needle aspiration"
can be used to identify the minority of thyroid growths that are cancerous. The technique involves insertion of a small
needle into the thyroid growth and withdrawing a small amount of fluid much like drawing a blood sample from a vein.
Cells in that fluid are then examined under a microscope.
Other endocrine disorders: Disorders of the other endocrine glands are less common. The expertise of an
endocrinologist often is needed to select the most efficient diagnostic approach, assess the need for treatment, select the
best treatment approach, and assure a favorable outcome.
Metabolic Disorders
Diabetes mellitus: Diabetes mellitus is the most common endocrine/metabolic disorder. It affects 6.5% of the U.S.
population. It is more common as we age and is more prevalent in African Americans, Latinos and Native Americans.
Although the disease is potentially devastating, it is now well established that comprehensive treatment makes a
difference in the health of diabetics in the short-term and the long term. It prevents or delays complications that can lead
to blindness, kidney failure or amputations, as well as the nonspecific complications such as heart attack or stroke that
often occur in people with diabetes.
Endocrinologists' goal is to prevent complications or, failing that, to recognize complications early when they can be
treated effectively. This includes controlling blood sugar, blood cholesterol and blood pressure, as well as detecting early
damage to the eyes, kidneys and nerves.
Hyperlipidemia: It is now well established that lowering high cholesterol levels reduces the risk of death from a heart
attack, which is the single most common cause of death in our society.
Osteoporosis: Thin bones can lead to debilitating bone fractures. Osteoporosis can be largely prevented. Even
established osteoporosis can now be treated.
Prevalence
The prevalence of uterine malformation is estimated to be 6.7% in the general population, slightly higher (7.3%) in the
infertility population, and significantly higher in a population of women with a history of recurrent miscarriages (16%). [1]
Types

The American Fertility Society (now American Society of Reproductive Medicine) Classification distinguishes:

Class I: Mllerian agenesis (absent uterus).

Uterus is not present, vagina only rudimentary or absent. The condition is also called Mayer-RokitanskyKuster-Hauser syndrome. The patient with MRKH syndrome will have primary amenorrhea.

Class II: Unicornuate uterus (a one-sided uterus).

Only one side of the Mllerian duct forms. The uterus has a typical "penis shape" on imaging systems.

Class III: Uterus didelphys, also uterus didelphis (double uterus).

Both Mllerian ducts develop but fail to fuse, thus the patient has a "double uterus". This may be a
condition with a double cervix and a vaginal partition (v.i.), or the lower Mllerian system fused into its unpaired
condition. See Triplet-birth with Uterus didelphys for a case of a woman having spontaneous birth in both wombs
with twins.
Class IV: Bicornuate uterus (uterus with two horns).

Only the upper part of that part of the Mllerian system that forms the uterus fails to fuse, thus the caudal
part of the uterus is normal, the cranial part is bifurcated. The uterus is "heart-shaped".
Class V: Septated uterus (uterine septum or partition).

The two Mllerian ducts have fused, but the partition between them is still present, splitting the system
into two parts. With a complete septum the vagina, cervix and the uterus can be partitioned. Usually the septum
affects only the cranial part of the uterus. A uterine septum is the most common uterine malformation and a cause
for miscarriages. It is diagnosed by medical image techniques, i.e. ultrasound or an MRI. MRI is considered the
preferred modality due to its multiplanar capabilities as well as its ability to evaluate the uterine contour, junctional
zone, and other pelvic anatomy. A hysterosalpingogram is not considered as useful due to the inability of the
technique to evaluate the exterior contour of the uterus and distinguish between a bicornuate and septate uterus.

A uterine septum can be corrected by hysteroscopic surgery.

Hysterosalpingography of a T shaped uterus

Class VI: DES uterus.

The uterine cavity has a "T-shape" as a result of fetal exposure to diethylstilbestrol.

An additional variation is the arcuate uterus where there is a concave dimple in the uterine fundus within the cavity.

A rudimentary uterus is a uterine remnant not connected to cervix and vagina and may be found on the other side of an
unicornuate uterus.

Patients with uterine abnormalities may have associated renal abnormalities including unilateral renal agenesis. [2]
"Double vagina"
Main article: Vaginal septum

As the vagina is largely derived from the Mllerian ducts, lack of fusion of the two ducts can lead to the formation of a
vaginal duplication and lack of absorption of the wall between the two ducts will leave a residual septum, leading to a
"double vagina". This condition may be associated with a uterus didelphys or a uterine septum.[3][4][5] Since the condition is
internal and usually asymptomatic, a person may not be aware of having a "double vagina." If necessary, the partition can
be surgically corrected, however, there is no valid medical reason for such a procedure.
Diagnosis

Uterine and ovarian abnormalities

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Abnormalities of the female reproductive organs can cause infertility, miscarriage,premature birth (before
37 weeks of pregnancy) and other pregnancy complications. Reproductive tract abnormalities can be
congenital (present at birth) or acquired (develop later in life).
Many women with reproductive tract abnormalities have no symptoms and do not know they have an
abnormality. Some women with reproductive tract abnormalities are able to become pregnant and have
normal, full-term pregnancies. Others may learn that they have a reproductive tract abnormality if they
have difficulty becoming pregnant or develop pregnancy complications. In some cases, treatment can
improve the chances for a healthy pregnancy.
What are congenital uterine abnormalities?
The uterus is a hollow muscular organ shaped like an upside-down pear. The narrow, lower end of the
uterus is called the cervix. About 3 in 100 women are born with an abnormality in the size, shape or
structure of the uterus (1). In the female embryo, the uterus is formed from two small tubes called
Mullerian ducts. At about 10 weeks gestation, these two tubes come together and fuse, forming a single
uterine cavity. When the Mullerian ducts do not fuse at all or fuse incompletely, a uterine abnormality can
result.
Some women with a congenital uterine abnormality have normal, full-term pregnancies. However, these
abnormalities can increase the risk of a number of reproductive problems, including:

Miscarriage (pregnancy loss that occurs before 20 weeks of pregnancy)

Premature birth

Poor fetal growth

Abnormal presentation, such as breech position (the baby is in a position other than head down)

Cesarean birth

The risk may be different for each one of these problems, depending on the specific uterine abnormality.
Congenital uterine abnormalities include:

Septate uterus. This is the most common congenital uterine abnormality and is most commonly
associated with adverse pregnancy outcomes, especially miscarriage (1, 2). In a septate uterus, the
uterus is divided into two sections by a band of muscle or tissue. This tissue is the remainder of the
joined Mullerian tubes, which the body did not break down and absorb as it should have.
Bicornate uterus. In this condition, the uterus has two partially or completely joined cavities,
instead of one large cavity. This abnormality is caused by incomplete fusion of the Mullerian tubes.
Didelphic uterus (double uterus). The Mullerian tubes fail to join, resulting in two separate
uterine cavities and two cervices. Each uterine cavity may be smaller than normal.
Unicornate uterus. One Mullerian duct fails to form, resulting in absence of half of the uterus.

How are congenital uterine abnormalities diagnosed?

Congenital uterine abnormalities usually are diagnosed using imaging tests. Sometimes more than one of
these tests is needed to distinguish between uterine abnormalities. It is important to make the correct
diagnosis because certain uterine abnormalities (such as septate and bicornate uterus) appear similar on
some imaging tests but are treated differently. Imaging tests include (1, 3):
Vaginal ultrasound. A tampon-sized probe is placed in the vagina. The probe uses sound waves
to show pictures of the uterus and other pelvic organs. A new form of ultrasound, called threedimensional ultrasound, is highly accurate in diagnosing uterine abnormalities.
Sonohysterogram. The health care provider inserts salt water into the uterus through the cervix
and then performs a vaginal ultrasound. The salt water allows a clearer picture of the uterine cavity.
Hysterosalpingogram. The health care provider inserts a dye into the cervix and then follows the
path of the dye with a uterine x-ray. This exam shows the condition of the cervix, the uterine cavity
and fallopian tubes. This test uses radiation and cannot distinguish between septate and bicornate
uterus.
Magnetic resonance imaging (MRI). This test uses strong magnets and a computer to create
detailed images of organs. It provides a clear picture of the uterine cavity and is highly accurate in
diagnosing most uterine abnormalities, including septate and bicornate uterus.
How are congenital uterine abnormalities treated?
Some congenital uterine abnormalities can be corrected with surgery. The provider may recommend
surgery for a woman who has a congenital uterine abnormality and a history of miscarriage or premature
birth. Surgery usually is not recommended if the woman has no history of pregnancy problems because
some women with uterine abnormalities have normal, full-term pregnancies.
Studies suggest that more than 80 percent of women with septate uterus have successful pregnancies
after surgical removal of the septum (1). Surgery for this abnormality generally can be done during
hysteroscopy. In a hysteroscopy, the provider inserts a thin, telescope-like instrument through the vagina
and cervix into the uterus to see inside the uterine cavity. The provider inserts a small instrument through
the hysteroscope to remove the septum. Surgery to correct bicornate uterus and other congenital uterine
abnormalities involves more extensive surgery through an incision (cut) in the abdomen.
What are acquired uterine abnormalities?
Acquired uterine abnormalities are those that develop later in life. Acquired uterine abnormalities that
affect pregnancy include:
Fibroids

Uterine adhesions (scars)

Cervical insufficiency and short cervix

What are fibroids?

Fibroids are benign (non-cancerous) growths made up of muscle tissue. They range from pea-size to 5 to
6 inches across. About 20 to 40 percent of women develop fibroids during their reproductive years, most
frequently in their 30s and 40s (4). Many women with fibroids have no symptoms, while others have
symptoms such as (5):
Heavy menstrual bleeding

Anemia (resulting from heavy menstrual bleeding)

Abdominal or back pain

Pain during sex

Difficulty urinating or frequent urination

The health care provider may first detect fibroids during a routine pelvic exam. The diagnosis can be
confirmed with one or more imaging tests.
Do fibroids cause pregnancy complications?
Small fibroids usually do not cause problems during pregnancy and usually require no treatment. However,
fibroids occasionally break down during pregnancy, resulting in abdominal pain and low-grade fever.
Treatment includes bedrest and pain medication. Multiple or large fibroids may need to be surgically
removed, generally before pregnancy, to avoid potential complications associated with pregnancy. Due to
pregnancy hormones, fibroids sometimes grow larger during pregnancy. Rarely, large fibroids may block
the uterine opening, making a cesarean birth necessary.
Most women with fibroids have healthy pregnancies. However, fibroids can increase the risk of certain
pregnancy complications, including (2, 5):

Infertility

Miscarriage

Preterm labor
Abnormal presentation (such as breech position)

Cesarean birth (usually due to breech position)

Placental abruption (separation of the placenta from the wall of the uterus before birth)
Heavy bleeding after birth

If the health care provider determines that a womans infertility or repeated pregnancy losses are probably
caused by fibroids, he may recommend surgery to remove the fibroids. This surgery is called a
myomectomy. In some cases, myomectomy can be done during hysteroscopy.
What are uterine adhesions?
Uterine adhesions, sometimes called Asherman syndrome, are scar tissue that can damage the uterine
lining (endometrium). The damage may range from mild to severe. Causes of uterine adhesions can
include (2, 6):
D&C (dilation and curettage), which may be done after a miscarriage (this is a surgical procedure, in
which the cervix is dilated and the uterus is emptied with suction or with an instrument called a
curette)

Other uterine surgery

Severe infection of the uterine lining (endometritis)

Some women have no symptoms, while others may have light or infrequent menstrual periods. Adhesions
can contribute to infertility, repeat miscarriage and premature birth (2, 6). Imaging tests and

hysteroscopy can diagnose adhesions. Adhesions can be removed during hysteroscopy, improving the
chances of a normal pregnancy (2).
What are cervical insufficiency and short cervix?
Cervical insufficiency (sometimes called incompetent cervix) refers to a cervix that opens too early during
pregnancy, usually without pain and contractions. This usually occurs in the second or early third trimester
of pregnancy, resulting in late miscarriage or premature birth. A woman may be diagnosed with cervical
insufficiency based largely on this history. There is no specific diagnostic test.
Medical experts do not always know why cervical insufficiency occurs. Factors that may contribute include

Uterine defects. Women with certain uterine defects, such as bicornate uterus, are more likely to
have cervical insufficiency than women without these defects (1, 2).
History of surgical procedures involving the cervix. These include LEEP (loop electrosurgical
excision procedure), which is used to diagnose and treat abnormal cells found during a Pap test.
Injuries during a previous birth
Short cervix. The shorter the cervix, the more likely the woman is to have cervical insufficiency. In
some cases, a short cervix can be congenital.

Miscarriage and premature birth due to cervical insufficiency frequently happens again in another
pregnancy. These problems can sometimes be prevented with a procedure called cerclage, in which the
provider places a stitch in the cervix to keep it from opening too early. The provider removes the stitch
when the woman is ready to give birth.
It is not always clear which women will benefit from cerclage. This is because there is no specific test for
cervical insufficiency, and many women who have had a late miscarriage or early premature birth go on to
have normal pregnancies without treatment. Some studies suggest that cerclage is most likely to be
beneficial in women who have had three or more late miscarriages or premature births (7). In some
cases, providers may monitor a woman suspected of having cervical insufficiency with repeated vaginal
ultrasounds to see if her cervix is shortening or showing other signs that she may give birth soon. The
provider may recommend cerclage if these changes occur.
Some women learn that they have a short cervix during a routine ultrasound. Most of these women do not
end up having a premature birth. However, short cervix, especially a very short cervix (less than 15
millimeters), does increase her risk of premature birth (8, 9). Studies suggest that treatment with the
hormone progesterone may help reduce the risk of premature birth in women with a very short cervix (8,
9). According to the American College of Obstetricians and Gynecologists (ACOG), progesterone treatment
may be considered for these women (8). However, ACOG does not recommend routine cervical-length
screening for low-risk women.
Does a retroverted (tipped) uterus pose pregnancy risks?
Almost never. About 20 percent of women have a uterus that tips slightly backward (10). This is
considered a normal variant of uterine positioning in most women, though some women may develop a
retroverted uterus due to fibroids or scar tissue in the pelvis. Generally, the uterus straightens by early in
the second trimester and does not contribute to pregnancy complications.
At about 12 weeks of pregnancy, the top of the uterus normally extends past the pelvic cavity. Rarely, a
retroverted uterus may become trapped in the pelvis. This is called uterine incarceration and can cause
pain and difficulty passing urine (10). An ultrasound can diagnose retroverted uterus in women with these
symptoms. Simple treatments, including bladder drainage, positioning exercises the woman can do at
home, or gentle manipulation by the health care provider, usually can restore the uterus to its normal
position. Occasionally, an untreated incarcerated uterus may contribute to second-trimester miscarriage.
What is polycystic ovary syndrome?
Polycystic ovary syndrome (PCOS) is a condition that affects a womans hormones and ovaries. PCOS

affects up to 7 percent of women of childbearing age and is the leading cause of female infertility (12).
Some women learn they have PCOS when they have problems becoming pregnant.
Women with PCOS have high levels of male hormones (androgens), which may interfere with normal
ovarian function. Affected women often do not ovulate regularly. PCOS also affects other bodily systems,
increasing a womans risk for diabetes and heart disease (11, 12). Signs and symptoms of PCOS include
(11, 12):

Irregular or absent menstrual periods

Ovaries containing many small cysts (fluid-filled sacs)

Increased facial hair

Acne

Weight gain or obesity

Male-pattern baldness

Abnormal blood sugar levels or diabetes

High blood pressure

How is PCOS diagnosed?

There is no specific diagnostic test for PCOS. Diagnosis is usually based on:
Signs and symptoms, including menstrual irregularities

Physical examination

Blood tests to check androgen and blood sugar levels

Ultrasound of the ovaries

How is PCOS treated?

Women with PCOS who are overweight or obese should attempt to lose weight. Women who lose even 10
percent of their body weight can improve menstrual irregularities, lower androgen levels and reduce the
risk of diabetes (11, 12). Weight loss also can improve fertility (11).
Women who do not wish to become pregnant right away can be treated with birth control pills. This
treatment often helps regulate menstrual cycles and reduce androgen levels. In some cases, the woman
may be treated with an oral diabetes drug called metformin (Glucophage), instead of or in addition to birth
control pills. Metformin also helps reduce androgen levels and may help with weight loss.
Women who are having difficulty conceiving can be treated with medications that stimulate ovulation,
usually starting with clomiphene citrate (Clomid, Serophene). If clomiphene treatment is not successful,
the woman can be treated with injected fertility drugs (gonadotropins) or in vitro fertilization (IVF). In IVF,
eggs are combined with sperm in the laboratory to create embryos which are transferred into the womans
uterus. All fertility treatments increase the risk of multiple gestation (twins, etc.), which increases the risk
for premature birth and other complications.
Does PCOS increase the risk of pregnancy complications?
Studies suggest that women with PCOS are at increased risk of gestational diabetes, preeclampsia (a
pregnancy-related form of high blood pressure) and premature birth (11, 12, 13). Obesity also can
increase the risk of these complications, so women with PCOS may be able to reduce their risk by reaching
a healthy weight before they become pregnant. Women with PCOS should see their health care
provider before pregnancy to make sure any health problems, such as diabetes, are under control, and
that any medications they take are safe in pregnancy. When they become pregnant, they should go to all

their prenatal appointments so that any complications can be diagnosed and managed before they become
serious.
Does the March of Dimes support research on uterine and ovarian abnormalities and
pregnancy?
The March of Dimes supports a number of grants on uterine and ovarian abnormalities and the pregnancy
complications they may cause. One grantee is seeking to identify cell-to-cell signaling pathways that may
help trigger shortening of the cervix before labor, in order to develop new treatments aimed at preventing
premature birth. Another is studying the role of androgens in normal ovarian growth and fertility, in order
to develop improved fertility treatments for PCOS.

References
1. Rackow, B.W. & Arici, A. (2007). Reproductive Performance of Women with Mullerian Anomalies.
Current Opinion in Obstetrics and Gynecology, 19, 229-337.
2. Wold, A.S.D., Pham, N. & Arici, A. (2006). Anatomic Factors in Recurrent Pregnancy Loss.
Seminars in Reproductive Medicine, 24 (1), 25-32.
3. Syed, I., Hussain, H.K., Weadock, W. & Ellis, J. (2008). Uterus, Mullerian Duct Abnormalities.
EMedicine. Retrieved October 14, 2009.
4. Klatsky, P.C., Tran, N.D., Caughey, A.B. & Fujimoto, V.Y. (2008). Fibroids and Reproductive
Outcomes: A Systematic Literature Review from Conception to Delivery. American Journal of
Obstetrics and Gynecology, 198 (4), 357-366.
5. American College of Obstetricians and Gynecologists (ACOG). (2009). Uterine Fibroids. Retrieved
October 14, 2009.
6. American Society for Reproductive Medicine. (2005). Patients Fact Sheet: Intrauterine Adhesions.
Retrieved October 14, 2009.
7. American College of Obstetricians and Gynecologists (ACOG). (2003). Clinical Management
Guidelines for Obstetrician-Gynecologists, Number 48: Cervical Insufficiency. Obstetrics and
Gynecology, 102 (5), 1091-1099.
8. American College of Obstetricians and Gynecologists (ACOG). (2008). ACOG Committee Opinion,
Number 419: Use of Progesterone to Reduce Preterm Birth. Obstetrics and Gynecology, 112 (4),
963-965.
9. Da Fonseco, E.B., Damiao, R. & Nicholaides, K. (2009). Prevention of Preterm Birth Based on Short
Cervix: Progesterone. Seminars in Perinatology, 33 (5), 334-337.
10. OGrady, J.P. (2008). Malposition of the Uterus. EMedicine. Retrieved November 9, 2009.
11. American College of Obstetricians and Gynecologists (ACOG). (2009). Clinical Management
Guidelines for Obstetrician-Gynecologists, Number 108: Polycystic Ovary Syndrome. Obstetrics
and Gynecology, 114 (4), 936-949.
12. U.S. Department of Health and Human Services. (2007). Polycystic Ovary Syndrome. Retrieved
October 13, 2009.
13. Boomsma, C.M., Eijkemans, M.J.C., Hughes, E.G., Visser, G.H.A., Fauser, B.C.J.M., et al. (2006). A
Meta-Analysis of Pregnancy Outcomes in Women with Polycystic Ovary Syndrome. Human
Reproduction Update, 12 (6), 673-683.
March 2010
Endometriosis can cause painful periods, persistent pain in the pelvic area, infertility, and other symptoms. The symptoms
can range from mild to severe. Treatment options include painkillers, hormone treatments, and surgery.

What is endometriosis?
The endometrium is the tissue that lines the inside of the womb (uterus).
Endometriosis is a condition where endometrial tissue is found outside the uterus. It is 'trapped' in the pelvic area and
lower tummy (abdomen) and, rarely, in other areas in the body.

Related discussions

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Who gets endometriosis?
The exact number of women who develop endometriosis is not known. This is because many women have endometriosis
without symptoms, or with mild symptoms, and are never diagnosed.
Investigations to diagnose endometriosis are only done if symptoms become troublesome and are not eased by initial
treatments (see below). Estimates vary so that from about 1 in 10 to as many as 5 in 10 of all women develop some
degree of endometriosis.
If symptoms develop they typically begin between the ages of 25-40. Sometimes symptoms begin in the teenage years.
Endometriosis can affect any woman. However:

Sometimes it runs in families. Therefore, endometriosis is more common in close blood relatives of affected
women.

Endometriosis is rare in women past the menopause, as to develop endometriosis you need oestrogen, the
female hormone. Oestrogen levels fall after the menopause.

The combined oral contraceptive pill (often called 'the pill') reduces the risk of developing endometriosis. This
protective effect may persist for up to a year after stopping 'the pill'.

What causes endometriosis?

The exact cause is not known. It is thought that some cells from the womb (uterus) lining (the endometrium) get outside
the uterus into the pelvic area. They get there by spilling backwards along the Fallopian tubes when you have a period.
The 'spilt' endometrial cells then continue to survive next to the uterus, ovary, bladder, bowel, or Fallopian tube. The cells
respond to the female hormone oestrogen, just like the lining of the uterus does each month. Throughout each month the
cells multiply and swell, and then break down as if ready to be shed at the time of your period. However, because they are
trapped inside the pelvic area, they cannot escape. They form patches of tissue called endometriosis.
Patches of endometriosis tend to be 'sticky' and may join organs to each other. The medical term for this is adhesions. For
example, the bladder or bowel may 'stick' to the uterus. Large patches of endometriosis may form into cysts which bleed
each month when you have a period. The cysts can fill with dark blood; this is known as 'chocolate cysts'.
What are the symptoms of endometriosis?
Patches of endometriosis can vary in size from the size of a pinhead to large clumps. Many women with endometriosis
have no symptoms. If symptoms develop they can vary, and include those listed below.
In general, the bigger the patches of endometriosis, the worse the symptoms. However, this is not always the case. Some
women have large patches of endometriosis with no symptoms. Some women have just a few spots of endometriosis, but
have bad symptoms.

Painful periods. The pain typically begins a few days before the period and usually lasts the whole of the period.
It is different to normal period pain which is usually not as severe, and doesn't last as long.

Painful sex. The pain is typically felt deep inside, and may last a few hours after sex.

Pain in the lower abdomen and pelvic area. Sometimes the pain is constant, but is usually worse on the days
just before and during a period.

Other menstrual symptoms may occur. For example, bleeding in between periods.

Difficulty becoming pregnant (reduced fertility). This may be due to clumps of endometriosis blocking the
passage of the egg from an ovary to the Fallopian tube. Sometimes, the reason for reduced fertility is not clear.

Uncommon symptoms include pain on passing poo (faeces), pain in the lower tummy (abdomen) when you
pass urine, and, very rarely, blood in the urine or faeces. Very rarely, patches of endometriosis occur in other sites of
the body. This can cause unusual pains in parts of the body that occur at the same time as period pains.

Dr. Sarah Jarvis

Q

Endometriosis - sometimes it's hard to be a woman

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How is the diagnosis of endometriosis confirmed?
The symptoms caused by endometriosis can be caused by other conditions. Therefore, if any of the above symptoms
become persistent then tests are usually advised to find the cause of the symptoms. Endometriosis is usually confirmed
by a laparoscopy. This is a small operation that involves making a small cut, under anaesthetic, in the tummy (abdominal)
wall below the tummy button (umbilicus). A thin telescope-like instrument (a laparoscope) is pushed through the skin to
look inside. Patches of endometriosis can be seen by the doctor.
A small pilot research study published in 2009 (cited at the end) showed that the diagnosis may be able to be confirmed
by a new test. In the study, a small sample (biopsy) was taken from the inner lining of the womb (uterus) the endometrium - of women with endometriosis. The sample was looked at in the laboratory for some specific 'markers'
of endometriosis. The results were that, in most cases, this new test was able to confirm the presence of endometriosis.
So, if these results are confirmed by further studies, it may mean that in the future the diagnosis can be confirmed without
the need for a laparoscopy (which involves a small operation).
How does endometriosis progress?
If endometriosis is left untreated, it becomes worse in about 4 in 10 cases. It gets better without treatment in about 3 in 10
cases. For the rest it stays about the same. Endometriosis is not a cancerous condition.

Complications sometimes occur in women with severe untreated endometriosis. For example, large patches of
endometriosis can sometimes cause a blockage (obstruction) of the bowel or of the tube from the kidney to the bladder
(the ureter).
What are the aims of treatment?
The main aims of treatment are to improve symptoms such as pain and heavy periods, and to improve fertility if this is
affected. There are various treatment options which are discussed below.

Not treating as an option

If symptoms are mild and fertility is not an issue for you then you may not want any treatment. In about 3 in 10 cases,
endometriosis clears and symptoms go without any treatment. You can always change your mind and opt for treatment if
symptoms do not go, or become worse.
Painkillers for endometriosis

Paracetamol taken during periods may be all that you need if symptoms are mild.

Anti-inflammatory painkillers such as ibuprofen, diclofenac, naproxen, may be better than paracetamol.
However, some people have side-effects with these.

Codeine alone, or combined with paracetamol, is a more powerful painkiller. It may be an option if antiinflammatories don't suit. Constipation is a common side-effect.

To ease pain during periods, it is best to take painkillers regularly over the time of your period rather than 'now and then'.
You can take painkillers in addition to other treatments.
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Heavy Periods (Menorrhagia)

Hormone treatments for endometriosis
Understanding oestrogen and how hormone treatments work
Oestrogen is a hormone that is made in the ovaries. The cells that line the inside of the womb (uterus) - the endometrial
cells - need oestrogen to grow and survive. The endometrial cells outside the uterus that cause endometriosis also need
oestrogen. Hormone treatment works by reducing the amount of oestrogen that you make, or by blocking the effect of
oestrogen on the endometrial cells. The endometrial cells are then starved of oestrogen which they need to survive.
Therefore, patches of endometriosis gradually shrink, and may clear away.
It may help to understand how oestrogen is made. Hormones called gonadotrophins are made in the pituitary gland, which
is a gland next to the brain. Gonadotrophin hormones are released into the bloodstream and stimulate the ovaries to
make oestrogen which is also released into the bloodstream. The stimulus to release gonadotrophins into the bloodstream
comes from a hormone called gonadotrophin-releasing hormone (GnRH). This is made in the brain and travels to the
pituitary gland. Therefore:

GnRH (brain) >> Gonadotrophins (pituitary) >> Oestrogen (ovaries) >> Endometrial cells.
The different hormone treatments work by affecting different parts of this process. However, the end result of all of them is
to reduce the amount of oestrogen that is made or to block the action of oestrogen on endometrial cells.
Types of hormone treatments
There are several options. They all have similar success rates at easing pain. However, they do not improve fertility.
(Surgical treatments may improve fertility - discussed later.)
The combined oral contraceptive pill ('the pill'). The pill is not licensed for the treatment of endometriosis. However, many
women report improved symptoms when they are on the pill. The pill stops ovulation which reduces the amount of
oestrogen made by the ovaries. Periods are also lighter and less painful. Other symptoms such as painful sex, and pain in
the pelvic area may also improve.
The intrauterine system (IUS). The IUS is a small device made from plastic and contains a progestogen hormone called
levonorgestrel. It is also called the levonorgestrel intrauterine system (LNG-IUS). The progestogen in the IUS makes the
lining of the uterus thinner. It probably also has some effect on the ovary, and ovulation may not occur (the release of the
egg each month). The IUS is put into a woman's uterus by a doctor or nurse. It is a popular type of contraceptive.
However, it can also reduce endometriosis-associated pain. It also greatly reduces or even abolishes bleeding of periods.
Once put in place, it can remain effective (for contraception and to ease pain) for up to five years.
GnRH (gonadotrophin releasing hormone) analogues. These medicines block the pituitary from releasing gonadotrophins.
This greatly reduces the amount of oestrogen that you make in the ovaries. There are several GnRH analogue
preparations which includebuserelin, goserelin, nafarelin, leuprorelin, and triptorelin. Some preparations are taken as a
nasal spray, some are given by injection. A six-month course is usual. Side-effects may occur due to the very low levels of
oestrogen that this treatment causes. For example, hot flushes, dry vagina, reduced sex drive, headaches, and difficulties
with sleeping. Periods usually stop too. An option is to take a small dose of oestrogen and progestogen as hormone
replacement therapy (HRT) to stop these side-effects. This 'add-back' HRT does not affect the effectiveness of the
treatment.
Progestogen hormone tablets. These reduce the effect of oestrogen on the endometrial cells which causes the cells to
'shrink'. Progestogens also prevent ovulation, which lowers the oestrogen level. Progestogen hormone tablets
include norethisterone, dydrogesterone and medroxyprogesterone. Side-effects that may occur include: irregular
menstrual bleeding, weight gain, mood changes, and bloating. Progestogen hormone tablets are less commonly used
these days, as other treatments tend to be used.
Danazol. This works mainly by reducing the amount of gonadotrophins that you make. This has a 'knock-on' effect of
reducing the amount of oestrogen that you make. Side-effects commonly occur including: weight gain, hair growth, acne,

and mood changes. Rarely, they cause a deepening of the voice, which may be irreversible. They usually stop periods
too. Danazol is not often used now, as it often causes unacceptable side-effects.
Note: you should use contraception with condoms if you have sex whilst taking hormone treatments (apart from 'the pill'
and the LNG-IUS, which are contraceptives). This is because there is a risk that hormone treatments may affect a
developing baby.
Surgery for endometri
Endometriosis: Causes, Symptoms & Treatments
Amanda Chan, MyHealthNewsDaily Staff Writer | May 27, 2013 07:20pm ET
Reddit
Endometriosis is a women's medical condition that occurs when the lining of the uterus, called the endometrium,

grows in other places, such as the fallopian tubes, ovaries or along the pelvis. When that lining breaks down, like the
regular lining in the uterus that produces the menstruation, it has nowhere to go. This causes cysts, heavy periods, severe
cramps and even infertility. More than 5 million women in the United States are affected by this condition, according to the
National Institute of Child Health and Human Development.
Credit: Piotr Marcinski |Shutterstock

Causes & Symptoms

The cause of endometriosis is unknown, but researchers have several theories. One theory is that during menstruation,
blood with endometrial cells flows back into the fallopian tubes, according to the Mayo Clinic. The cells are rooted there
and grow a new lining. Another theory is that the bloodstream carries endometrial cells throughout the body, while it's also
theorized that endometriosis is a genetic condition. Yet another theory, according to the Mayo Clinic, is that abdominal
cells that were present since a woman's embryonic state retain their ability to become endometrial cells.
The most common symptom of endometriosis is extreme cramping during menstruation. This is due to internal bleeding
from the lining being shed inside the body, and can also lead to scar tissue formation and bowel problems, according to
the Endometriosis Association.
Women with the condition may also experience pain while having sex, fatigue, painful urination or bowel movements
during menstruation and gastrointestinal upset according to the Endometriosis Association.

However, some women don't experience any symptoms at all, but realize they have the condition when they are unable to
get pregnant, according to the National Institutes of Health.
Diagnosis & Tests
The only way for endometriosis to be diagnosed for certain is through laparoscopy, which is a minor surgical procedure
that involves your doctor putting a thin scope into your abdomen to view your pelvic organs, according to the American
Congress of Obstetricians and Gynecologists. If the doctor sees the extra endometrial tissue during the laparoscopy, he or
she can also remove it right there to treat the condition.
A basic pelvic exam, where the doctor manually feels for abnormalities, is another way of testing for endometriosis. If all
other causes of pelvic pain can be ruled out, the doctor can choose to treat the condition surgically or with medicine,
according to the American Congress of Obstetricians and Gynecologists.
Vaginal or abdominal ultrasound can't test for endometriosis, but it can test for ulcers that may be caused by the condition,
according to the Mayo Clinic.

Risks & Complications

There are several risk factors for endometriosis, according to the Mayo Clinic, none of which can really be helped. They
include: never having given birth, having a mother with endometriosis, having menstrual cycles that are shorter than 27
days and bleeding that lasts longer than eight days, being white or Asian, having a medical condition that makes the
passage of menstrual flow irregular, and having previous damage to cells that line the pelvis.
The biggest complication with endometriosis, the Mayo Clinic said, is fertility problems. The clinic estimates that a third to
a half of women with endometriosis have difficulties getting pregnant. Infertility can occur because the condition can
create adhesions that trap the egg near the ovary, making it difficult for it to travel down the fallopian tube to be fertilized
by sperm.
However, that doesn't mean all women with endometriosis can't get pregnant it just might take them a little longer, the
Mayo Clinic said. However, the longer you go without having had a child, the worse endometriosis gets. Thirty to 40

percent of women with endometriosis are infertile, according to the National Institute of Child Health and Human
Development.
Treatments & Medications
Treatment for endometriosis is usually limited to pain medication (for the severe cramping), hormone therapy to slow
growth of the endometrial tissue and surgery to remove the tissue, according to the National Institute of Child Health and
Human Development.
Some common hormones prescribed include oral contraceptives, or birth control pills, a gonadotropin-releasing hormone,
which essentially turn off the ovaries to lower estrogen levels, or the progestin hormone, which shrinks the endometrial
tissue, according to the American College of Obstetricians and Gynecologists. However, some of these hormones come
with side effects.
Laparoscopy and laparotomy are common forms of surgery used to treat endometriosis that require going in through the
abdominal region to remove the endometrial tissue. However, if symptoms keep coming back after these surgical
procedures, a hysterectomy, or total removal of the uterus, could be an option, according to the American College of
Obstetricians and Gynecologists. Often, medications and surgery are used together to treat women with endometriosis.

Topic Overview
Is this topic for you?

This topic contains information about loss of ovarian function before age 40. If you want information about the normal loss
of ovarian function around age 50 or about symptoms in the few years before it, see the topic

Menopause and Perimenopause.

What is primary ovarian insufficiency?

Primary ovarian insufficiency (sometimes called premature ovarian failure) occurs when your ovarieswhich store and
release eggsstop working before age 40. You may have no or few eggs. Depending on the cause, primary ovarian
insufficiency may develop as early as the teen years, or the problem may have been present from birth.

A woman who has primary ovarian insufficiency is very likely to have irregular or no periods, infertility problems,
and menopause-like symptoms. It is difficult, though not impossible, for women who have primary ovarian insufficiency to
become pregnant.
What causes primary ovarian insufficiency?

Although the exact cause of primary ovarian insufficiency may be unknown, a genetic factor or a problem with the
body's immune systemmay play a role in some women. In an immune system disorder, the body may attack its own
tissuesin this case, the ovaries.

Primary ovarian insufficiency may develop after a hysterectomy or other pelvic surgery or
from radiation or chemotherapy treatment forcancer. In some of these cases, the condition may be temporary, with the
ovaries starting to work again some years later.
What are the symptoms?

The symptoms of primary ovarian insufficiency are similar to those ofmenopause. Your menstrual periods may become
irregularyou have a period one month but not the nextor they may stop. You also may have some or all of
the symptoms of menopause, such as hot flashes,night sweats, irritability, vaginal dryness, low sex drive, or trouble
sleeping.
How is primary ovarian insufficiency diagnosed?

If your periods become irregular or stop, your doctor will give you a physical exam and ask you questions about your
general health and whether you have other symptoms of primary ovarian insufficiency. You will also have a pregnancy
test. And your blood will be tested for other possible causes of irregular periods.
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Further Reading:
What Causes Female Infertility?

Causes of Failure to Ovulate

Ovulatory disorders are one of the most common reasons why women are unable to conceive, and account for 30% of women's
infertility. Fortunately, approximately 70% of these cases can be successfully treated by the use of drugs such as Clomiphene and
Menogan/Repronex. The causes of failed ovulation can be categorized as follows:
(1) Hormonal Problems
These are the most common causes of anovulation. The process of ovulation depends upon a complex balance of
hormones and their interactions to be successful, and any disruption in this process can hinder ovulation. There are three
main sources causing this problem:

Failure to produce mature eggs

In approximately 50% of the cases of anovulation, the ovaries do not produce normal follicles inwhich the eggs can mature.
Ovulation is rare if the eggs are immature and the chance of fertilization becomes almost nonexistent. Polycystic ovary
syndrome, the most common disorder responsible for this problem, includes symptoms such as amenorrhoea, hirsutism,
anovulation and infertility. This syndrome is characterized by a reduced production of FSH, and normal or increased levels
of LH, oestrogen and testosterone. The current hypothesis is that the suppression of FSH associated with this condition
causes only partial development of ovarian follicles, and follicular cysts can be detected in an ultrasound scan. The affected
ovary often becomes surrounded with a smooth white capsule and is double its normal size. The increased level of oestrogen
raises the risk of breast cancer.

Malfunction of the hypothalamus

The hypothalamus is the portion of the brain responsible for sending signals to the pituitary gland, which, in turn, sends
hormonal stimuli to the ovaries in the form of FSH and LH to initiate egg maturation. If the hypothalamus fails to trigger and
control this process, immature eggs will result. This is the cause of ovarian failure in 20% of cases.

Malfunction of the pituitary gland

The pituitary's responsibility lies in producing and secreting FSH and LH. The ovaries will be unable to ovulate properly if
either too much or too little of these substances is produced. This can occur due to physical injury, a tumor or if there is a
chemical imbalance in the pituitary.
(2) Scarred Ovaries
Physical damage to the ovaries may result in failed ovulation. For example, extensive, invasive, or multiple surgeries, for
repeated ovarian cysts may cause the capsule of the ovary to become damaged or scarred, such that follicles cannot mature
properly and ovulation does not occur. Infection may also have this impact.
(3) Premature Menopause
This presents a rare and as of yet unexplainable cause of anovulation. Some women cease menstruation and begin
menopause before normal age. It is hypothesized that their natural supply of eggs has been depleted or that the majority
of cases occur in extremely athletic women with a long history of low body weight and extensive exercise. There is also
a genetic possibility for this condition.
(4) Follicle Problems
Although currently unexplained, "unruptured follicle syndrome" occurs in women who produce a normal follicle, with an egg
inside of it, every month yet the follicle fails to rupture. The egg, therefore, remains inside the ovary and proper ovulation
does not occur.
Causes of Poorly Functioning Fallopian Tubes
Tubal disease affects approximately 25% of infertile couples and varies widely, ranging from mild adhesions to complete tubal
blockage. Treatment for tubal disease is most commonly surgery and, owing to the advances in microsurgery and lasers, success rates
(defined as the number of women who become pregnant within one year of surgery) are as high as 30% overall,
with certain procedures having success rates up to 65%. The main causes of tubal damage include:

(1) Infection
Caused by both bacteria and viruses and usually transmitted sexually, these infections commonly cause inflammation
resulting in scarring and damage. A specific example is Hydrosalpnix, a condition in which the fallopian tube is occluded at
both ends and fluid collects in the tube.
(2) Abdominal Diseases
The most common of these are appendicitis and colitis, causing inflammation of the abdominal cavity which can affect the
fallopian tubes and lead to scarring and blockage.
(3) Previous Surgeries
This is an important cause of tubal disease and damage. Pelvic or abdominal surgery can result in adhesions that alter the
tubes in such a way that eggs cannot travel through them.
(4) Ectopic Pregnancy
This is a pregnancy that occurs in the tube itself and, even if carefully and successfully overcome, may cause tubal damage
and is a potentially life-threatening condition.
(5) Congenital Defects
In rare cases, women may be born with tubal abnormalities, usually associated with uterus irregularities.

Endometriosis
Approximately 10% of infertile couples are affected by endometriosis. Endometriosis affects five million US women, 6-7% of all
females. In fact, 30-40% of patients with endometriosis are infertile. This is two to three times the rate of infertility in the general
population. For women with endometriosis, the monthly fecundity (chance of getting pregnant) diminishes by 12 to 36%. This
condition is characterized by excessive growth of the lining of the uterus, called the endometrium. Growth occurs not only in the
uterus but also elsewhere in the abdomen, such as in the fallopian tubes, ovaries and the pelvic peritoneum. A positive diagnosis can
only be made by diagnostic laparoscopy, a test that allows the physician to view the uterus, fallopian tubes, and pelvic cavity directly.
The symptoms often associated with endometriosis include heavy, painful and long menstrual periods, urinary urgency, rectal bleeding
and premenstrual spotting. Sometimes, however, there are no symptoms at all, owing to the fact that there is no correlation between
the extent of the disease and the severity of the symptoms. The long term cumulative pregnancy rates are normal in patients with
minimal endometriosis and normal anatomy. Current studies demonstrate that pregnancy rates are not improved by treating minimal
endometriosis.
Additional Factors
(1) Other variables that may cause infertility in women:

At least 10% of all cases of female infertility are caused by an abnormal uterus. Conditions such as fibroid, polyps,
and adenomyosis may lead to obstruction of the uterus and Fallopian tubes.
Congenital abnormalities, such as septate uterus, may lead to recurrent miscarriages or the inability to conceive.
Approximately 3% of couples face infertility due to problems with the females cervical mucus. The mucus needs to be
of a certain consistency and available in adequate amounts for sperm to swim easily within it. The most common
reason for abnormal cervical mucus is a hormone imbalance, namely too little estrogen or too much progesterone.

(2) Behavioral Factors:

It is well-known that certain personal habits and lifestyle factors impact health; many of these same factors may limit a
couple's ability to conceive. Fortunately, however, many of these variables can be regulated to increase not only the
chances of conceiving but also one's overall health.

Diet and Exercise

Optimal reproductive functioning requires both proper diet and appropriate levels of exercise. Women who are significantly
overweight or underweight may have difficulty becoming pregnant.

Smoking
Cigarette smoking has been shown to lower sperm counts in men and increases the risk of miscarriage, premature birth, and
low-birth-weight babies for women. Smoking by either partner reduces the chance of conceiving with each cycle, either
naturally or by IVF, by one-third.

Alcohol Alcohol intake greatly increases the risk of birth defects for women and, if in high enough levels in the mothers
blood, may cause Fetal Alcohol Syndrome. Alcohol also affects sperm counts in men.

Drugs
Drugs, such as marijuana and anabolic steroids, may impact sperm counts in men. Cocaine use in pregnant women may
cause severe retardations and kidney problems in the baby and is perhaps the worst possible drug to abuse while pregnant.
Recreational drug use should be avoided, both when trying to conceive and when pregnant.

(3) Environmental and Occupational Factors:

The ability to conceive may be affected by exposure to various toxins or chemicals in the workplace or the surrounding
environment. Substances that can cause mutations, birth defects, abortions, infertility or sterility are called reproductive
toxins. Disorders of infertility, reproduction, spontaneous abortion, and teratogenesis are among the top ten work-related
diseases and injuries in the U.S. today. Despite the fact that considerable controversy exists regarding the impacts of
toxins on fertility, four chemicals are now being regulated based on their documented infringements on conception.

Lead
Exposure to lead sources has been proven to negatively impact fertility in humans. Lead can produce teratospermias
(abnormal sperm) and is thought to be an abortifacient, or substance that causes artificial abortion.

Medical Treatments and Materials

Repeated exposure to radiation, ranging from simple x-rays to chemotherapy, has been shown to alter sperm production, as
well as contribute to a wide array of ovarian problems.

Ethylene Oxide
A chemical used both in the sterilization of surgical instruments and in the manufacturing of certain pesticides, ethylene oxide
may cause birth defects in early pregnancy and has the potential to provoke early miscarriage.

Dibromochloropropane (DBCP)
Handling the chemicals found in pesticides, such as DBCP, can cause ovarian problems, leading to a variety of health
conditions, like early menopause, that may directly impact fertility.
[H

Ovulatory Dysfunction Infertility

IHR has extensive experience in treating women with all forms of ovulatory dysfunction.

Ovulation, which is the release of an egg from the ovary, must happen in order to achieve pregnancy. If ovulation is
irregular, but not completely absent, this is called oligovulation. Anovulation means lack of ovulation, or absent
ovulation. Both anovulation and oligovulation are kinds of ovulatory dysfunction. The IHR experts work closely with
couples undergoing the many different types of assisted fertility treatments available. We are renowned for our
specialized knowledge and high infertility success rates even in difficult cases. IHR's expertise in ovulatory dysfunction
lies in our willingness and ability to individualize our approach to best suit each and every one of our patients. If you
have any questions as you review the material on ovulatory dysfunction, please contact us for a FREE Ovulatory
Dysfunction E-Mail Consultation.
Ovulatory Dysfunction is the single-most frequent cause of female infertility and denotes a problem with the monthly
release of an egg (ovulation). When a woman is anovulatory, she can't get pregnant because there is no egg to be
fertilized. If a woman has irregular ovulation, she has fewer chances to conceive, since she ovulates less frequently.
Plus, it seems that late ovulation doesn't produce the best quality eggs, which may also make fertilization less likely.
Also, it's important to remember that irregular ovulation means the hormones in the woman's body aren't quite right.
These hormonal irregularities can sometimes lead to other issues, like lack of fertile cervical mucus, thinner or over
thickening of the endometrium (where the fertilized egg needs to implant), abnormally low levels of progesterone, and
a shorter luteal phase.
Anovulation and ovulatory dysfunction can be caused by a number of factors. The most common cause of ovulatory
dysfunction is polycystic ovarian syndrome, PCOS. Other potential causes of irregular or absent ovulation is obesity, too
low body weight, extreme exercise, hyperprolactinemia, premature ovarian failure, advanced maternal age, thyroid
dysfunction, stress.
IHR has extensive experience in testing for ovulatory issues. We will reach a specific diagnosis of your condition after
learning more about you by carrying out a physical examination and conducting a careful review of your medical
records. To ensure we gather as much information as is necessary, other tests may sometimes be helpful, including: FSH
Blood Level, Progesterone Blood Level, Ultrasound, Endometrial Biopsy.
If you are not ovulating, your infertility specialist may prescribe a medication to stimulate your ovulation. If the
treatment plan is to take medication to ovulate, your infertility specialist will want to monitor you carefully to see if
and when you are ovulating. Monitoring usually involves: Ultrasound and Blood Tests.
IHR Ovulatory Dysfunction Treatment will depend on the cause of the anovulation. Some cases of anovulation can be
treated by lifestyle change or diet. If low body weight or extreme exercise is the cause of anovulation, gaining weight
or lessening your exercise routine may be enough to restart ovulation. If you are overweight, losing even 10% of your
current weight may be enough to restart ovulation.
The most common treatment for anovulation is fertility drugs. Usually, Clomid is the first fertility drug tried. Clomid
can trigger ovulation in 80% of anovulatory women, and help about 45% get pregnant within six months of treatment. If
Clomid doesn't work, there are many other drugs worth trying.
For women with PCOS, insulin sensitizing drugs like Metformin may help a woman start ovulating again. Usually, six

months of treatment is required before you'll know if the Metformin will work. If Metformin alone doesn't help, using
fertility drugs in combination has been shown to increase the chance of success in women who didn't ovulate on
fertility drugs alone.
If the cause of anovulation is premature ovarian failure, or low ovarian reserves, then we have specific treatment
programs which we will suggest including our advanced age program, egg donor program, and embryo adoption
program.