Many females, from teenage years through their fifth, sixth, or even seventh decade of life, claim that they suffer monthly during the menstrual phase of their uterine cycle, the painful menses being labeled as dysmenorrhea. There are naysayers who claim that menstrual cramps are all in their heads, or that some women are just using their cramps as an excuse to skip a day of work or school. There are some who believe in the existence of menstrual cramps but who have never endured the excruciating pain that these sufferers claim to be experiencing. There are some who say that all women have menstrual cramps and that the level of pain varies only because individual pain tolerances vary. While it may be difficult to objectively quantify pain, it is relatively easy to measure menstrual flow, fertility, and a number of other factors related to a woman’s reproductive health to determine the cause of her physical suffering.
Before discussing possible causes and treatments for any clinical symptoms, it is important to have a clear understanding of the terminology that will be used in the discussion, as well as the anatomy involved in the female reproductive system. The normal amount of fluid lost during a normal menstrual cycle is eighty to one hundred milliliters; therefore, a heavy menstrual flow, or menorrhagia, would be classified as have above one hundred milliliters of fluid loss. Infertility is defined as the inability of a woman to become pregnant despite frequent, unprotected sexual intercourse for at least one year. While estimates vary, it has been stated that approximately one of every six couples is affected by fertility issues.
Because a thorough discussion of the female reproductive system is beyond the scope of this essay, we will focus on the membranous lining of the uterine wall. This specific area has been chosen as the focus of attention as it is the endometrial layer of the uterus that is sloughed off during each menstrual cycle in the absence of a fertilized egg, or that would host the zygote were fertilization to occur. Deep to the outer perimetrium and the muscular myometrium lays the mucosal endometrium of the uterus. Composed of two layers, the endometrium undergoes cyclic changes that are related to the reproductive cycle in the female body. The thinner, deep layer is called the stratum basalis and is largely unresponsive to hormonal stimuli, and functions primarily to regrow new tissue every twenty-eight days. The luminal layer is called the stratum functionalis, and is highly responsive to ovarian hormones. As the blood levels of estrogen and progesterone rise and fall, the stratum functionalis thickens as it prepares for zygote implantation and then sloughs off if fertilization and implantation do not occur. It is the repeated vasoconstriction of the spiral arteries in the stratum functionalis that cause tissue ischemia of the endometrium, and the following vasodilations that cause an inrushing of blood to split the dead and dying tissue cells from the underlying stratum basalis.
In Debbye’s case, a number of imbalances, disorders, and diseases can be eliminated as the cause of her complaint as we know that “the tests all turn up negative.” Although they have been eliminated, it may be nice for Debbye to know that she does have many processes going on right in her body. First, low levels of ovarian hormones could have been related to her infertility, as it is the estrogen and progesterone from the developing follicle and corpus luteum that stimulate the endometrial lining to grow into a suitable environment for the fertilized zygote to implant itself. While the inflammation of gonorrhea could have accounted for pelvic pain and sterility, and while Chlamydia could have accounted for her pelvic pain and may have caused some irregularity in her menstrual bleeding, we know Debbye has tested negative for both of these sexually transmitted diseases. We can assume that Debbye’s infertility is not caused by Turner’s syndrome, in which a single X chromosome with no second sex chromosome present would have caused her to not develop ovaries, as this lack would have been discovered during the palpation portion of her gynecological exam. In addition, there is no mention in Debbye’s introduction of any mental impairment that could have indicated that she has four or more X chromosomes, which would have in turn caused her to have underdeveloped ovaries and would also have decreased her chances of bearing a child. A lack of vaginal discharge and painful or difficult urination rules out the diagnosis of pelvic inflammatory disease for Debbye, as does the negative test of her vaginal discharge and cervical culture. Debbye can rest assured that her problems are not caused by ovarian cysts, which also could have caused her to experience painful bowel movements and painful intercourse, as the cysts would have been felt by the doctor during her pelvic exam. Although Debbye’s heavy menstrual bleeding could have been caused by uterine fibroids, she is not complaining of constipation and none were noted to have been palpated during the pelvic exam.
With the knowledge that all other tests have been negative, Debbye’s doctor may next hypothesize that Debbye has endometriosis. A clinical definition of endometriosis could be as follows: the endometrial tissues that are typical contained within the uterine walls migrate to other locations within the female’s body, such as the uterine tubes or the peritoneum surrounding the infindibulum of the uterine tubes and ovaries. Being endometrial in nature, the tissue remains responsive to the ovarian hormones estrogen and progesterone, and so will also increase in vascularity and slough some of its cells in conjunction with the uterine cycle. Because it increases the amount of tissue that is undergoing growth and ischemia every twenty-eight days, endometriosis causes an increase in the menstrual flow of the affected woman. In addition, because the tissue is abnormally placed, it can lead to scarring which may restrict the uterine tube lumen or may infill the peritoneal cavity surrounding the ovary so that the ovulated follicle is not able to be swept into the uterine tube by the fimbria.
While the cause remains uncertain and there is no oral history questionnaire that can lead to a definitive conclusion that a woman has endometriosis, there is a relatively simple out-patient procedure that can be performed to not only determine the existence of endometriosis but which can simultaneously help to eliminate or at least greatly reduce the extra tissue growths. A woman who believes that she may have endometriosis can choose to have a laparoscopy performed under general anesthesia. During this procedure, her doctor will fill the patient’s abdominal cavity with a gas, usually carbon dioxide, through a small incision just inferior to her naval. The doctor will then thread a laparoscope with its fiber-optic capability into the patient’s pelvic cavity. Using illumination from the laparoscope, the doctor will then be able to clearly view any tissue growths or scarring that would indicate that the patient has endometriosis. If so agreed upon prior to the procedure, the doctor may at this time cauterize the problematic tissue growths. In addition, it may be possible during the laparoscopy for the doctor to dilate the uterine tube if it has been blocked by scarring, although it should be noted that this is typically more effective if the blocked portion of the uterine tube is closer to the ovary than to the uterus.
Some women may be apprehensive about undergoing laparoscopy, and some women may wisely continue to ask questions prior to agreeing with their doctor’s first suggestions. A second option of a blood test for cancer antigen 125 may be offered at this point. Although primarily used to detect tumor markers, this blood test can also detect specific proteins in the blood of women with endometriosis. While this may at first glance appear to be a better option than a surgery done under general anesthesia, it should be noted that the blood test will only reveal the protein if it is in elevated levels of women with advanced endometriosis and so will give a false negative for women with mild or moderate endometriosis. There are also a number of hormonal treatments that may be offered to women who suffer from, or are believed to suffer from, endometriosis. As with any hormone treatment, the side effects of the hormones must be taken into account when doing a risk-benefit analysis prior to beginning treatment. The use of hormonal contraceptives that limit the amount of endometrial growth each cycle could decrease the amount of menstrual flow and residual scarring of reproductive tissues. A variety of hormone treatments are available that cause a cessation of menstruation for a period of three to six months, with the hope that the outlying endometrial tissue clumps will completely die due to the absence of estrogen and progesterone. In the most severe cases of endometriosis, a total hysterectomy and removal of the ovaries may be the treatment of choice due to the amount of bleeding, pain, and scarring.
If Debbye does have endometriosis, as the numerous negative tests combined with her ongoing symptoms suggest, then she may be comforted to know that she is not alone in her suffering, nor is her pain all in her head. Endometriosis is not a disease that must be endured for a lifetime, but is a dis-ease that can be managed through the use of over-the-counter pain medications or a number of viable treatment options.