Endometriosis and the Infertile Patient

principles and practice Endornetriosis and the Infertile Patient M A R Y A N N E WEDELL, RN, PATRICIA BILLINGS, RN, A N D JAMIL A. FAYEZ, MD Approximately one-third of all patients who suffer from endometriosis may not be able to conceive. More than 10% of infertile patients have endometriosis as the causative factor of their infertility. The stressful effect of infertility on the couple’s life may be devastating. The infertility and endocrinology nurse may play a major role in alleviating the painful experience of such unfortunate patients. The pathogenesis, pathophysiology, diagnosis, and therapy of endometriosis are described. The important role of the nurse in the management of patients with endometriosis is emphasized.

Endometriosis is defined a s the presence of functional endometrium outside the uterus. The norma1 endometrium lining the uterus resDonds to hormonal control of the ovaries, namely estrogen and progesterone. The same tissue as its intrauterine counterpart, endometriosis responds to the hormones in the same way. The endometrium bleeds during menses and may spill its contents within the pelvis, resulting in reimplantation. As endometriosis propagates, adhesions and scar tissue increase with each successive menstrual cycle, causing pain and infertility. Endometriosis is a disease of the reproductive years, affecting 20% of the female population, with 75% of all patients between 30 and 40 years of age.’ Endometriosis has been called “career women’s disease” and “private patient’s Submitted: March 1984. Revised: July 1984. Accepted: August 1984. 280

disease,” characteristically being found in the white patient of higher socioeconomic status who has gone to college, married later in life, and postponed pregnancy. This terminology is no longer valid, as endometriosis may affect any patient who postpones pregnancy until late in her reproductive years. Forty percent of patients diagnosed with endometriosis experience an infertility problem. Of all infertility patients, endometriosis appears t o be causative in five to 10% of all cases. The number of patients who have the disease appears to be on the rise. With earlier menarche, later marriage, and postponed and fewer pregnancies, many more noninterrupted menstrual cycles occur by the time a woman reaches 30 years of age. Each of these ovulatory cycles contribute to the metastasis of endometrial tissue. Pregnancy not only reduces the number of menstrual cycles

but also plays a curative role for any existing endometriosis. PATHOGENESIS Endometriosis is characteristically a progressive disease that worsens with time. Almost all women of reproductive age have some menstrual reflux through the tubes, which usually increases when there is a uterine or cervical obstruction to the menstrual flow, a s might result from anomalies. However, a polygenic/multifactorial etiology is involved in endometriosis, since refluxed cells implant only in a few women. The metastasis of endometriosis oia blood and lymph vessels may explain the occurrence of the disease in lungs, kidneys, and other sites remote from the female pelvis. Endometriosis is seen more frequently in women whose mothers and sisters are affected. The likelihood that a first-degree relative

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of a patient with the disease will be similarly affected is approximately seven percent. Estrogen induces proliferative changes and progesterone induces secretory alterations in endometriosis implants. Withdrawal of these sex steroids causes stromal bleeding and rupture of the glands. This induces further propagation of the disease, resulting in more irritation and inflammation of the surrounding tissue. Constant proliferation and irritation may damage pelvic organs, leaving scar tissue and adhesions. A typical example is the endometrioma, an area of endometriosis large enough to be classified a s an ovarian tumor. The endometrioma varies in size from a few millimeters to several centimeters in diameter, and is usually filled with old blood that resembles chocolate syrup. PATHOPHYSIOLOGY While found in other areas of the body, endometriosis most frequently occurs in the pelvis. Endometriosis is usually found on the ovaries and in the cul-de-sac, particularly on uterosacral ligaments and on the peritoneum of the broad ligaments. With the most common site being the ovaries, ovulation may be impaired. Implants involving the tubes may interfere with normal tubal function, interfering with ovum pickup. Adnexal adhesions may distort normal pelvic antomy. A noncongenitally retroverted uterus is usually due to adhesions in the cul-de-sac, causing dyspareunia and infertility. The metastasis of endometrial cells in blood and lymphatic channels may explain endometriosis found in the lungs, kidneys, and other sites. Endometrial implants may secrete prostaglandins that possibly could interfere with adequate ovulation, as well a s with tubal function. July/August 1985 JOG"

These implants may induce the formation of pelvic phagocytes that may reach tubal lumen to destroy the picked ovum and the approaching sperms. SIGNS AND SYMPTOMS One of the paradoxes of endometriosis is the inconsistency of the symptoms. The most common symptom of endometriosis is dysmenorrhea, which seems to worsen progressively. Other symptoms vary and may include dyspareunia and menstrual dysfunction. Pain is not always proportional to the extent of the disease. Bimanual examination may reveal nodules in the cul-de-sac, a fixed retroverted uterus, endometriomas, or no pathology at all. DIAGNOSIS Despite the fact that history and physical examination could be highly suggestive, the only definitive way to diagnose endometriosis is by direct visualization. For the infertility patient, diagnostic laparoscopy provides a means of increasing the fertility potential. A thorough inspection of the pelvis can be made and pelvic factors can be evaluated. Operative laparoscopy allows the surgeon to resect o r scrape endometriosis implants and to drain ovarian endometriomas. THERAPY Endometriosis has been classified in many ways; the latest and most appropriate classification was designed by the American Fertility Society in 1978.* A pointsystem based on number, size, and location of endometrial implants designate mild, moderate, severe, o r extensive disease. A form can be obtained from the

American Fertility Society,* where implants may be mapped and scored. This form is especially helpful in explaining to the patient the areas and extent of her endometriosis, and in comparing patient status pre- and post-treatment. The treatment of endometriosis can be controversial, but needs to be tailored to the patient. Treatment must be conservative for the infertility patient and it may be surgical, medical, or both. Surgery should preserve fertility and actually enhance it. Every effort is made to lyse adhesions, remove endometriosis implants, and drain endometriomas while avoiding any risk to vital reproductive function. For medical treatment, danazol is the most effective drug. A synthetic hormone that inhibits ovulation and causes amenorrhea, danazol is very expensive and its side-effects result mostly from its androgenic properties. Side-effects include increased appetite, increased weight gain, mild hirsutism, acne, muscle cramps, and, rarely, increased sex drive. Antiestrogen properties of danazol sometimes account for sweats and hot flashes, decreased breast size, and atrophic vaginitis. All symptoms subside when therapy is discontinued. Danazol is given orally 200 mg, four times daily. Individual doses may allow the patient to tolerate the medication better and help avoid any gastrointestinal disturbance. Depending on the severity of the disease, therapy may be continued six to 12 months3 Stepwise Approach In our institution, once endometriosis is suspected, laparos* The American Fertility Society, 2131 Magnolia Avenue, Suite 201, Birmingham, AL 35256.

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copy is performed to confirm the diagnosis. Immediately after t h e procedure, findings a r e recorded and mapped on the American Fertility Society classification sheet. Treatment is planned according to the stage of disease. This plan is explained thoroughly to t h e patient by the nurse, using the American Fertility Society endometriosis classification sheet and other material for illustration. Stuge I (Mild) 1-5 During diagnostic laparoscopy, the physician tries to resect all visible implants without risking injury to vital organs. If t h e resection is complete, no further treatment is recommended. Cyclic oral contraceptives will be given to young women not seeking to achieve pregnancy. If the patient desires pregnancy, s h e is instructed to try to conceive for at least one year before s h e is offered a six-month course of danazol in a dose of 200 mg four times a day. Stage II (Moderate) 6-15 When possible, if all endometriosis implants have been resected, endometriomata, if present, a r e evacuated by laparoscopy. The pelvis is cleaned and 200 ml of 32% dextran-70 in dextrose ar e deposited in the cul-de-sac. After surgery, all patients are placed on danazol therapy for six months. After six months, patients a r e given the option of having a second laparoscopic look just before the treatment course is completed, o r of attempting conception for o n e year before the second laparoscopy. For those women who d o not desire pregnancy, n o second laparoscopic look is offered unless the signs and symptoms of endometriosis recur. Stuge I l l (Severe) 16-30

If most endometriosis implants have been resected, endome-

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triomata evacuated, adhesions lysed, and normal pelvic anatomy restored by laparoscopy, the approach to Stage 111 treatment is similar to that for Stage 11 disease. Should operative laparoscopy not be feasible because of disturbed anatomy, the patient is given danazol for six to nine months, according to the severity of the disease. Two weeks before completion of the course of danazol, laparotomy is performed and conservative surgery is carried out. If t h e patient does not desire future pregnancy, total abdominal hysterectomy alone, or combined with bilateral salpingo-oophorectomy, is performed, based on the extent of ovarian involvement. If the ovaries are removed, medroxyprogesterone acetate therapy is given for o n e year before the patient is started on estrogen replacement therapy. Stage IV (Extensive) 31 -54 During diagnostic laparoscopy, some endometriosis implants a r e resected. When possible, endometriomata a r e evacuated. Patients who desire pregnancy in the future receive a nine- to 12-month course of danazol. Conservative surgery is performed by laparotomy two to four weeks before the completion of danazol therapy. Patients who d o not desire future pregnancy a r e given a six-month danazol course, followed immediately by radical surgery. Preoperative suppressive therapy aids surgery by decreasing the number and size of endometriotic areas and by diminishing vascularity and inflammation secondary to endometriosis propagation and irritation. T h e ovaries are rendered inactive and, thus, become less vulnerable to trauma and postoperative adhesions. Prognosis regarding fertility depends on a variety of factors. The patient’s age is a factor because

results are usually less favorable in patients over 35 years of age. Pregnancy rate after treatment is inversely proportional to the severity of the disease, regardless of whether the treatment was medical o r surgical.

THE NURSE’S ROLE The nurse’s role in the care of endometriosis patients is important. Knowledge and understanding of the disease process are vital. Infertility is an emotional crisis for most couples. The patient with endometriosis may feel that infertility is her fault. The patient may view medical treatment of endometriosis with great depression, as danazol treatment will result in amenorrhea for several months.‘ For most infertility patients, time is critical and patients may view the treatment of their endometriosis not as treatment but as just another delay. The patient may view a six-month delay i n her pursuit of pregnancy with great a n ~ i e t yThe . ~ patient’s partner may be overcome with the feeling of disappointment, and may find it difficult to deal with the woman’s feelings of grief. The nurse needs to allow the couple to verbalize their feelings. Time should be provided for the patient to express anxieties and fears and avoid making th e patient feel rushed. Answering questions may be the area where the nurse can be of most assistance. Frequently, questions arise after the physician has left the room. It is assuring for th e patient to feel comfortable in asking questions and to have a phone number for the infertility nurse’s office if s h e should have questions at home. In the office, the nurse needs to reinforce the physician’s explanation and to teach her patient what endometriosis is, so that the

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patient can understand the disease process. The nurse may provide the preoperative teaching before the patient undergoes diagnostic laparoscopy o r laparotomy. After surgery, the nurse may use simple illustrations and explain the scoring system. She can discuss how symptoms will be relieved and how the fertility potential will be improved. An important part in the nurse’s role in the care of the endornetriosis patient is a thorough discussion of the possible side-effects of danazol before treatment. This enables the patient t o know what she can expect while being treated. The most common sideeffect is increased appetite and weight gain. The nurse should advise patients t o maintain an awareness of their eating habits and increase their physical activity in order to minimize weight gain. Food that contains excessive sodium may increase fluid retention, and food that has potassium may reduce muscle cramps. Should mild hirsutism occur, the patient can be advised to tweeze o r use a depilatory agent t o remove this temporary hair growth. Scrupulous cleaning can often ward off acne and the oiliness of skin. Atrophic vaginitis is another side-effect that can be abated by nursing intervention. Use of additional lubricants during intercourse may be recommended. If vaginitis occurs, often simple treatment with povidone iodine (Betadine@)douche is adequate treatment.

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Patients should be informed that breakthrough bleeding may occur during treatment. Occasionally, spotting o r even a menstrual period occurs during the first month of treatment, but not usually thereafter. The nurse needs to instruct the patient to report any bleeding that occurs, in case the patient may need further suppression ( i e . , ProveraB) in conjunction with danazol. The patient needs to understand that all symptoms subside when therapy is discontinued. The physician and the nurse should always include the woman’s partner in the counseling sessions, a s his awareness of the signs and symptoms of the disease, the methods of therapy, the side-effects of medications, and his understanding of the prognosis of the patient’s fertility potential will enable him t o give her better support. The infertility specialist nurse is indispensable for counseling such patients, as this nurse has the time and knowledge to advise the couple when advice is needed o r a problem arises.

CONCLUSION Specific skills are required of the nurse caring for the infertility patient with endometriosis. Individualizing the patient’s care is important in the physical and emotional sense. Dealing with a variety of situations, such a s infertility, pain relief, and medica-

tion, pre- and postoperative counseling makes this area a special challenge for infertility nurses

REFERENCES 1. Hammond CB, Hancy AF. Conservative treatment of endometriosis. Fertil Steril 1978;30:497. 2. The American Fertility Society. Classification of endometriosis. Fertil Steril 1979;32:633. 3. Bultram VC, Belne JB, Reiter R. Interim report of a study of danazol for the treatment of endometriosis. Fertil Steril 1982;37:478. 4. Drnowski WP. Endocrine properties and clinical application of danazol. Fertil Steril 1979;31:237. 5 . Seibel MM,Taymar ML. Emotional aspects of infertility. Fertil Steril 1982;33:137.

Address for correspondence: Jamil Fayez, MD, Department of Ob/Gyn, Wake Forest University, Bowman School of Medicine, 300 South Hawthorne Rd., Winston-Salem, NC 27103.

Mary Anne Wedell is a nurse specialist with the Reproductive Endocrinology Section of the Department of Obstetrics and Gynecology at Bowman Gray School of Medicine in Winston-Salem, North Carolina Patricia Billings is a nurse specialist with the Reproductive Endocrinology Section of the Department of Obstetrics and Gynecology at Bowman Gray School of Medicine in Winston-Salem, North Carolina Jamil A Fayez is a professor of Obstetrics and Gynecology and chief of the Reproductive Endocrinology Section of the Department of Obstetrics and Gynecology at Bowman Gray School of Medicine in Winston-Salem, North Carolina

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