Can Endometriosis really be that dangerous?

I am Dr. Ulas Bozdogan, and I’m passionate about my specialty, particularly endometriosis and the unfair toll it takes on women. In a previous article (7 Reasons Why Endometriosis is a True Emergency) I explained why I think endometriosis is an emergency. That is, it’s a dire emergency because of what’s at stake: your fertility and your quality of life. To many—and I agree—a threat to a woman’s quality of life is as much as a threat as an infected appendix; and a threat to her fertility is as much a threat to the function of her heart when taking inventory on what’s important in life. Admittedly, this is a somewhat philosophical distinction from an actual life-threatening emergency such as a heart attack, stroke, burst appendix, or severe car accident. There are scenarios, however, in which this condition can render a full-fledged “official” emergency, even by emergency room standards.

Can it really be that dangerous?

Endometriosis is the presence of the gland-like tissue of the innermost lining of your uterus (womb) anywhere else but in your uterus. This tissue, cyclically stimulated and then atrophied, every month, is meant to be discarded on a tampon or pad. When this type of tissue, however, is trapped in your abdomen, it remains; it is stimulated to grow, then deteriorates, creating inflammation that sets your body’s anti-inflammatory processes into action. An inflammatory state causes other organs in your abdomen to migrate toward the inflamed site and stick to it to wall it off. This causes both the mechanical obstructions seen in infertility (sperm cannot meet egg for fertilization) and biochemical irritations that interfere with ovarian ovulation, normal egg transport down the fallopian tube, and probably even implantation of a fertilized egg in early pregnancy.  Also, the bloody consistency of this hormonally affected tissue is as irritating to your abdomen as any blood is.

Peritonitis

The bloody elements which remain to accumulate in your abdomen can get your entire abdominal cavity into an inflammatory uproar. When there is enough tissue amassed, and/or it is deeply infiltrating, this “mass” is called an endometrioma. Like any runaway structure without bounds, at some point it can outgrow its own blood supply or even its cyst-like capsule, rupturing its contents into your pelvis and abdomen. The response of the lining of your abdomen, called the peritoneum, is no different than its response from the spilling of any other extremely irritating substance, be it blood from an ovarian cyst, pus from an abscess, or even fecal material from an appendix. In fact, in a woman the variety of conditions that can cause peritonitis is more than in men, because added to the usual suspects are ruptured endometrioma, ruptured ovarian chocolate cyst (endometrial cyst in the ovary), and ruptured ectopic pregnancy. These things expand the list of possibilities of peritonitis—all added to the usual rogues’ gallery of appendicitis, cholecystitis (gallbladder disease), diverticulitis, and inflammatory bowel diseases (Crohn’s and ulcerative colitis).

Peritonitis is a surgical emergency, because it indicates severe dysfunction in otherwise peaceful abdominal cavity, where your bladder, reproductive organs, bowel and colon, and their unique processes mind their own business and do their jobs. Because all of your organs are covered with peritoneum lining, an inflammatory disaster anywhere will affect all of the other organs, from mild dysfunction to outright cessation of activity. In the abdomen and pelvis, bad news travels fast!

Bowel obstruction.

One condition in particular is likely to get anyone’s attention quickly because of the extreme colicky, sharp volleys of pain it produces. It involves your bowel and what happens if endometriosis complications cause peritonitis: bowel obstruction.

There are two types of bowel obstruction.

1. Functional Obstruction: the bowels are very sensitive to any irritations. Any inflammatory process can get them to slow down their peristalsis (moving contents down the line) until an obstruction can occur from fecal material that is stopped or bottlenecked. This type of accumulation then distends the peritoneum covering the bowel conduit which makes for additional inflammatory pain, from mild colic to severely debilitating agony. If the situation worsens, there can even be rupture, which then rises to a whole new level of peritonitis and “emergency.”
   
2. Mechanical Obstruction: besides generalized inflammation, there is the mechanical migration of bowel and bowel fat to the site of your endometrioma, ruptured endometrial chocolate cyst, or deeply infiltrating endometriosis to wall it off, which then can create a mechanical (as opposed to a functional, as above) obstruction when the passageway become kinked. The bowels are meant to be internally free-flowing with their contents, and if there develop kinks or hairpin turns by their anchoring to spots of inflammation, this free flow can become impeded, as with the functional obstruction above; this, however, is an absolute obstruction. The risk of rupture is there, but it’s a much more likely complication. As you may suspect, “rupture” of anything is not pretty. It implies destruction and the chaos that ensues. When it occurs in the bowel, its emergency is no different from a ruptured appendix or internal hemorrhage.

Another obstruction is characteristic of a severe presentation of endometriosis called “frozen pelvis.” With this condition, the peritoneum has obliterated the free space around your uterus and rectum, which can cause very painful bowel movements. Rupture is not likely, but rectal fecal impactions will put you in the emergency room just because of the pain—it is completely intolerable.

Not life-threatening, but fertility-threatening (which is life-threatening to your future children!) is when this process causes the open ends of your fallopian tubes to become blocked.

Urinary tract obstruction.

Urine gets to your bladder from your kidneys via bilateral tubes called your ureters. These tubes are well protected from the usual mayhem that can occur from endometriosis’ abdominal inflammation, because they are below the floor of the abdomen, under the bottom peritoneal covering. However, a deeply infiltrating endometriosis can overlie the floor of the peritoneal cavity under which your ureters run. And like any invader, this can impact the usual free flow of urine through them. Like the bowel, an obstruction of a ureter will back up its contents, possibly all the way up to the kidney, putting it at risk. Any condition that threatens your kidney(s) is officially an emergency, because your kidneys do so much more than make urine: they are the gatekeepers for all of your electrolytes, directors for blood pressure control, and they even make hormones. True, you have two of them, but if the pain doesn’t make this an emergency, knowing you might have only one left creates a different worry altogether.

The weird stuff.

Endometriosis is thought to represent menstrual tissue that goes the wrong way—up and out of your tubes to drip into your abdomen, instead of out onto a tampon or sanitary napkin. Yet, this doesn’t explain the presence of endometriosis in unexpected locations, like the lung or brain. Yet, this happens, and because this tissue waxes and wanes based on your monthly cycle, “periodic” presentations of coughing up blood, nosebleeds, and even repetitive headaches and strokes are known to occur. While these presentations don’t offer the luxury of simply removing them surgically, they do necessitate an emergency response based on the sensitive locations affected.

From the philosophical to the actual.

Whether endometriosis is considered a philosophical emergency because of its endangerment to your fertility, sex life, and quality of life; or if it’s a true emergency due to complications that directly threaten the organs of your abdominal cavity, one thing is clear: you’ll have the actual emergency if you ignore the philosophical emergency. This is why I recommend an aggressive approach to most endometriosis, including the use of the da Vinci robot for robotic excision—and the sooner the better, because besides making the extent and severity of endometriosis worse, waiting also can put you at risk for the actual emergencies that can be life-threatening.