Being pregnant once does not guarantee that conceiving a second time will be easy. In fact, approximately 11% of couples face secondary infertility, often due to undiagnosed endometriosis. It’s possible to have a successful first pregnancy despite endometriosis, only to encounter challenges in becoming or remaining pregnant subsequently.
Pregnancy and childbirth are transformative experiences that significantly alter a woman’s body and hormonal equilibrium. Those acquainted with endometriosis, marked by the growth of endometrial-like tissue outside the uterus, might wonder about its connection to childbirth. Can endometriosis emerge after having a baby? This blog post explores the intricacies of endometriosis during the postpartum phase.
To gain a deeper understanding, we consulted a fertility specialist who provided answers to all your questions regarding endometriosis following pregnancy.
Key facts:
- Globally, endometriosis impacts about 10% (190 million) of women and girls of reproductive age.
- This chronic condition is linked to severe pain that significantly affects life quality, manifesting during menstruation, sexual intercourse, bowel movements, and urination. It also involves chronic pelvic pain, abdominal bloating, nausea, fatigue, and can sometimes lead to depression, anxiety, and infertility.
- Currently, there is no known cure for endometriosis, and treatments typically focus on symptom management.
- Early diagnosis and effective treatment for endometriosis are crucial, yet access is often restricted in various environments, particularly in low- and middle-income nations.
Overview
Endometriosis is a condition where tissue resembling the lining of the uterus develops outside of it. This can lead to significant pelvic pain and may complicate pregnancy.
Endometriosis may begin with a person’s first menstrual cycle and persist until menopause.
Endometriosis is a condition where tissue resembling the uterine lining grows outside the uterus, causing inflammation and the formation of scar tissue in the pelvic area and occasionally in other parts of the body.
The exact cause of endometriosis remains a mystery, and prevention methods are not yet known. While there is no definitive cure, the symptoms of endometriosis can be managed with medication or, in certain instances, surgical intervention.
Endometriosis can lead to a chronic inflammatory response, potentially causing scar tissue formation, such as adhesions and fibrosis, in the pelvis and other body areas. Various types of lesions have been identified:
- Superficial endometriosis, primarily on the pelvic peritoneum
- Cystic ovarian endometriosis, also known as endometrioma, within the ovaries
- Deep endometriosis affecting the recto-vaginal septum, bladder, and bowel
- In rare instances, endometriosis may also occur outside the pelvic region.
But first, What Is Endometriosis? Understanding Endometriosis
Endometriosis is a persistent condition characterized by pelvic pain, irregular menstrual cycles, and potential infertility. It arises when tissue resembling the uterine lining grows outside the uterus, affecting areas like the ovaries, fallopian tubes, and the lining of the pelvis. This abnormal growth can cause inflammation, significant discomfort, and scarring.
Endometriosis is a condition where tissue resembling the lining inside the uterus grows outside of it, often in the pelvic area. This tissue can cause inflammation and lesions, which may significantly hinder an embryo’s ability to implant and attach to the uterine lining, resulting in infertility in 30-50% of cases.
This condition, affecting up to 10% of women and an even higher percentage among those undergoing IVF, presents a complex diagnostic challenge. On average, it takes 7-10 years to diagnose in women of childbearing age. This delay is partly because symptoms like pelvic pain are common to other conditions, and partly because many women do not exhibit symptoms, a phenomenon referred to as “silent” endometriosis.
Studies indicate that 20 to 25% of endometriosis cases are classified as silent endometriosis, where the individual may not exhibit any significant symptoms except for infertility.
Pregnancy and Endometriosis
For some women, pregnancy may provide temporary respite from the symptoms of endometriosis. This is because the body generates increased amounts of progesterone during pregnancy, which can inhibit the growth of endometrial-like tissue. Moreover, since menstrual periods do not occur during pregnancy, the symptoms typically linked to menstruation, like pelvic pain and significant bleeding, tend to lessen.
Developing Endometriosis Postpartum
While pregnancy may temporarily alleviate endometriosis symptoms, it does not serve as a cure. Symptoms may recur after childbirth when menstrual cycles return. The formation of new endometriosis lesions postpartum is not well understood.
Limited research exists on the emergence of endometriosis following childbirth. The medical community is investigating how hormonal and physiological changes during and after pregnancy might affect the condition. Theoretically, hormonal shifts and bodily changes after giving birth could lead to the development of endometriosis in women who have not been previously diagnosed, although such instances are rare. Further research is essential to fully comprehend this potential link.
Secondary infertility and endometriosis: What’s the connection?
Jessica Ryniec, MD, a Boston-based OB/GYN and reproductive endocrinologist & infertility specialist who is double board-certified, states that receiving an endometriosis diagnosis postpartum is not uncommon.
“Someone could have had endometriosis without knowing it, and then it started causing symptoms, or they might have developed endometriosis later on,” Dr. Ryniec explains. According to her, there may not be a significant change in symptoms whether endometriosis is diagnosed after or before pregnancy. It’s possible that infertility issues post-first pregnancy bring the condition to attention.
How to know if you have “silent” endometriosis
If you’re concerned that endometriosis might be affecting your fertility, it’s crucial to consult with your OB/GYN or a fertility specialist. While the definitive diagnosis of endometriosis requires laparoscopic surgery, the ReceptivaDx test is a less invasive alternative. This test detects BCL6, a biomarker indicative of uterine lining inflammation commonly linked with silent endometriosis. Notably, BCL6 is present in over 50% of women with unexplained infertility and approximately 65% of women who have experienced two or more IVF failures.
Symptoms
Endometriosis frequently results in severe pelvic pain, particularly during menstrual cycles. Some individuals also experience pain during intercourse or while using the restroom, and it may contribute to infertility issues.
Not everyone with endometriosis exhibits symptoms. However, for those who do, pelvic pain is a prevalent symptom, especially noticeable:
- during or following sexual activity
- while urinating or having bowel movements.
Additionally, some may suffer from:
- intense menstrual bleeding or spotting between cycles
- abdominal bloating or nausea
- mental health challenges like depression or anxiety.
Although symptoms typically lessen after menopause, this is not always the case.
The symptoms of endometriosis are diverse and wide-ranging, which can lead to challenges in diagnosis by healthcare professionals. Those experiencing symptoms might not recognize they have the condition.
Causes
Endometriosis is a multifaceted condition that impacts numerous women worldwide from their first menstrual cycle to menopause, transcending ethnic and social boundaries. Various factors are believed to play a role in its onset. Currently, endometriosis is thought to develop due to:
- Retrograde menstruation, occurs when menstrual blood containing endometrial cells reverses through the fallopian tubes into the pelvic cavity while blood is exiting the body during menstruation. This can lead to the deposition and growth of endometrial-like cells outside the uterus.
- Cellular metaplasia, is a process where cells transform from one type to another, causing cells outside the uterus to become endometrial-like and begin proliferating.
- Stem cells, which may originate the condition, subsequently spread throughout the body via the bloodstream and lymphatic system.
Additional factors might also influence the development or maintenance of ectopic endometrial tissue. For instance, endometriosis relies on estrogen, which exacerbates the inflammation, proliferation, and discomfort associated with the ailment. Nonetheless, the interplay between estrogen and endometriosis is intricate, as the absence of estrogen does not invariably equate to the absence of the condition.
Impact
Endometriosis has significant social, public health, and economic impacts. It can impair quality of life through intense pain, exhaustion, depression, anxiety, and infertility. Certain individuals with endometriosis suffer from incapacitating pain that hinders their ability to attend work or school.
Painful intercourse resulting from endometriosis can disrupt or deter sexual activity, impacting the sexual health of those affected and their partners. Effectively managing endometriosis is crucial as it upholds the human right to the highest attainable standard of sexual and reproductive health, enhancing quality of life and overall well-being.
Prevention
Currently, there is no established method to prevent endometriosis. However, increased awareness and early diagnosis and treatment may decelerate or stop the disease’s progression and lessen the long-term impact of its symptoms, which may include the risk of central nervous system pain sensitization. At present, a cure does not exist.
Diagnosis and Management
Women who experience symptoms indicative of endometriosis postpartum, including persistent pelvic pain, heavy menstrual bleeding, or pain during sexual activity, should seek a medical assessment. Healthcare professionals can provide diagnostic clarity using clinical evaluations, imaging studies, and occasionally, laparoscopy.
Postpartum management of endometriosis includes various treatments such as hormonal therapies, pain management techniques, and sometimes surgical procedures. The selection of treatment is based on symptom severity, disease progression, and the patient’s reproductive intentions.
Diagnosis
A detailed history of menstrual symptoms and chronic pelvic pain is fundamental in suspecting endometriosis. While various screening tools and tests have been proposed, none have been validated for accurately identifying or predicting the disease in individuals or populations. Endometriosis frequently exhibits symptoms similar to other conditions, leading to delays in diagnosis.
Ovarian endometrioma, adhesions, and deep nodular forms of the disease often necessitate the use of ultrasonography or magnetic resonance imaging (MRI) for detection. Histological verification, typically obtained after surgical or laparoscopic visualization, can aid in confirming the diagnosis, especially for the most prevalent superficial lesions. However, the requirement for histological or laparoscopic confirmation should not delay the initiation of empirical medical therapy.
Treatment
The management of endometriosis depends on the severity of the symptoms and the individual’s desire for pregnancy. Currently, there is no cure for the condition.
A variety of medications are available to help manage the symptoms of endometriosis.
For pain relief, non-steroidal anti-inflammatory drugs (NSAIDs) and analgesics such as ibuprofen and naproxen are commonly prescribed.
To control pain, hormonal treatments, including GnRH-analogues and various contraceptive methods, are also effective. These hormonal therapies can be administered through:
- Hormonal intrauterine devices (IUDs)
These methods may not be suitable for those seeking to conceive.
Fertility medications and procedures are often utilized for individuals struggling to conceive due to endometriosis.
Surgical intervention is sometimes employed to excise endometriosis lesions, adhesions, and scar tissue. Laparoscopic surgery, which involves a small camera for internal visualization, enables doctors to make minimal incisions.
It is advisable to discuss treatment alternatives with a healthcare provider.
Treatment decisions are influenced by personal preference, efficacy, side effects, long-term safety, cost, and accessibility.
Promoting awareness can lead to early diagnosis. Timely intervention can decelerate or stop the disease’s progression and alleviate chronic symptoms.
Besides consulting their physician, individuals may benefit from the advice and emotional support offered by local patient support groups.
Certain treatments carry side effects, and symptoms related to endometriosis may recur after treatment cessation. Treatment selection is based on individual effectiveness, potential adverse effects, long-term safety, cost, and accessibility. Many prevalent hormonal therapies are unsuitable for individuals with endometriosis desiring pregnancy, as they interfere with ovulation.
The success of reducing pain symptoms and improving pregnancy rates through surgery often depends on the disease’s extent. Moreover, even after successful treatment, lesions may recur, and abnormalities in pelvic floor muscles can lead to chronic pelvic pain.
Physiotherapy and complementary treatments may alleviate secondary changes in the pelvis, including the pelvic floor and central sensitization, in some cases. For infertility associated with endometriosis, treatment options include laparoscopic surgery to remove endometriotic lesions, ovarian stimulation with intrauterine insemination (IUI), and in vitro fertilization (IVF), although the success rates for these treatments can vary.
Challenges and priorities
In numerous countries, both the general public and frontline healthcare providers often lack awareness that distressing, life-altering pelvic pain is abnormal. This ignorance contributes to the normalization and stigmatization of symptoms, resulting in considerable diagnostic delays. Consequently, patients who could gain from medical management of symptoms frequently do not receive treatment due to the limited recognition of endometriosis among primary healthcare providers.
Diagnostic delays often hinder timely access to available treatments for endometriosis, such as non-steroidal analgesics, oral contraceptives, and progestin-based contraceptives. The limited capacity of health systems in numerous countries results in sub-optimal access to specialized surgeries. Moreover, particularly in low and middle-income countries, there is an absence of multi-disciplinary teams equipped with the diverse skills and tools necessary for the early diagnosis and effective management of endometriosis.
Primary care providers are supposed to help with the early detection and basic treatment of endometriosis, but there aren’t enough tools to accurately predict which patients and groups are at the highest risk. Furthermore, significant knowledge gaps remain, highlighting the necessity for non-invasive diagnostic techniques and medical treatments that preserve fertility.
The resolution of these challenges represents the current emphasis on the response to endometriosis.
