If young women begin experiencing severe menstrual cramping or pelvic pain, their OB-GYNs often look for signs of endometriosis, one of the most common yet complex gynecological diseases and one responsible for a significant portion of gynecological surgeries each year.

This disease is so common, in fact, that 95 percent of women experience superficial endometriosis, which comes and goes unnoticed during the menstrual cycle. But for two to eight percent of women, endometriosis can become an ongoing problem resulting in episodic or chronic pain, the threat of infertility, and other significant risks, particularly when endometrial growth becomes a danger to other organs.

When OB-GYNs in the Mid-South region are faced with a case of endometriosis that is difficult to diagnose or treat, they often refer their patients to Dan Martin, MD, an OB-GYN practitioner with UT Medical Group and professor with the University of Tennessee Health Science Center. With more than three decades of experience, Martin has learned much about the growth and treatment of this disease.

Endometriosis, the presence of endometrial tissue outside the uterine cavity, is generally confined to the pelvic and lower abdominal cavity. It can be very invasive and deceptive in its presentation. Martin likens the development of endometrial cells to pimples. Some can look terrible but exist only on the surface of tissue, causing little pain or damage, others can be less exaggerated in presentation but burrow deep into tissue, proving a challenge to locate and remove. What's more, endometriosis travels via peritoneal fluid and can invade other organs, most commonly the ovaries and uterus, but also the bowel, lung cavity, kidneys, and less commonly, the stomach.

Martin likens endometrial tissue to steak gristle, white, rope-like material compared to healthy pink tissue it grows on. Since endometrial cells affix to the peritoneal surface, when left untreated, it can spread by growing outward or inward. What makes treatment challenging is that, "It's often difficult to tell how deep the damage goes; it can get close to the bladder, or go through the diaphragm and into the lung cavity," he noted. Martin is currently treating three patients who had to have kidneys removed because of the invasive nature of endometriosis. One thing Martin has learned during his lengthy practice — he started seeing patients in the late 1970s — is not to second-guess the disease. He quotes a fellow colleague, Donna Vogel of the National Institutes of Health, who has said, "Studying endometriosis is like nailing Jello to a tree," it's a difficult disease to live with and understand.

Endometriosis is most commonly diagnosed in young women in their late 20s or early 30s, prime reproductive years for women. Since menstruation is largely responsible for the introduction of endometriosis, the ovaries are the closest and most compatible implantation site for endometrial cells. If the growth of endometrial tissue becomes too wide spread, then it can envelope the ovaries, making infertility a real concern. As the disease becomes more pronounced, it can also cause episodic or chronic pain.

"The question is always, how much of the pain is being caused by endometriosis, because the symptoms can be confused with interstitial cystitis, diverticulitis, or scar tissue in the pelvis," said Martin. That is another aspect of the illness that makes diagnosis and treatment difficult. Sometimes, even after a woman has had a hysterectomy, pain can persist.

There is no best weapon for treating the disease, said Martin, in part because it can be so difficult to detect. Instead, he uses a "flock" of weapons, including hormonal suppression with male hormones, birth control pills, progesterones, laparoscopic surgery, and hysterectomy surgery. The challenge, he says, is in getting it under control. Once that takes place, "then the body can take care of it," said Martin.

During the 1970s, hysterectomies were a common form of treatment for the disease. But with the development of laparoscopic surgery and the use of lasers in the 1980s, doctors were able to burn only affected areas, thus saving reproductive or other organs.

According to Martin, he must burn deep enough to ensure that the lesion is completely removed without negatively impacting the surrounding organs. Up until the 1980s, doctors knew to look for darkened lesions on the surface of the peritoneum. They were obvious and easy to identify. But with the development of laparoscopic equipment, Martin said doctors have been able to better identify more subtle, clear amenorrheic lesions that indicate the presence of endometriosis. This also has enabled more exact diagnoses of the disease earlier and in younger women.

The questions Martin often asks when seeing a patient are: Is it normal endometrium in the wrong place (meaning outside the uterus); is it invading the peritoneum tissue; is it invading more deeply into the tissue, meaning extending 5 millimeters or more. For endometriosis to go deep takes three to 20 years.

"Many women have been told that their menstrual pain is just part of life, the pain might become more intense during periods, then subside afterward." Martin said it's important not to ignore the pain. If it persists, even episodically, it's best to seek treatment and catch endometriosis in the earliest stage possible.

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