Diagnosis and Treatment of Endometriosis
Endometriosis occurs when endometrial cells — the same cells that make up the lining of the uterus — are present outside the uterus. Endometriosis affects approximately 10 percent of women. In the United States, more than 6.5 million women have endometriosis¹.
Endometriosis is a complex GYN condition that can be difficult to diagnose. Treating endometriosis early with surgical diagnosis and removal addresses symptoms such as pain and infertility. Endometriosis has no cure, but should always be treated by an advanced laparoscopic GYN specialist. The physicians at The Center for Innovative GYN Care® (CIGC®) are trained to diagnose and remove this disease effectively, with our state-of-the-art DualPortGYN® technique for endometriosis excision.
In addition to advanced laparoscopic training, CIGC surgeons have either completed fellowship training in Gynecologic Oncology, or have worked extensively with a GYN Oncologist to learn the most advanced GYN surgical techniques possible.
Endometriosis is a complicated disease, and often requires this type of training to ensure safe, effective, and complete surgery. Going far beyond “deep excision” of endometriosis, training in Gynecologic Oncology and its associated procedures allows for a far more comprehensive approach to surgery. Endometriosis extensively involving bowel, bladder, ureters, and other structures in the pelvis can be safely and effectively managed with this type of training.
CIGC believes in access to surgery for all patients with endometriosis when it is necessary. In this regard, CIGC accepts all major insurance plans, thereby avoiding the problems associated with “endometriosis specialists” often charging very high rates for their services. Surgery is a very important part of the treatment process for endometriosis. Surgery should always be considered as the first line of therapy for diagnosis and management of the disease, and for staging and fertility planning. Access to affordable, high quality specialists is essential to ensure that all patients with endometriosis receive the best care possible.
Normal uterus, tubes and ovaries without endometriosis.
Stage 1 early endometriosis. Small lesions involving the left uterosacral ligament and sidewall.
Stage 1 early endometriosis. Note the black and clear lesions involving the left uterosacral ligament.
Stage 2 endometriosis. Deep black implant involving the posterior cervix.
Stage 2 endometriosis. Deep clear lesion involving the right uterosacral ligament and sidewall.
Stage 3 endometriosis. An Endometrioma to the left ovary.
Stage 3 endometriosis. Dense thick adhesions involving the right sidewall and cul de sac (base of the pelvis).
Stage 4 endometriosis. Black implants of disease are seen on the uterus, an endometrioma (cystic collection of endometriosis)to the ovary, and a swollen tube due to blockage from the disease. Adhesions are seen connecting the uterus and ovary to each other and to the bowel just beneath the uterus.
Stage 4 endometriosis. There is a large Endometrioma extending to the base of the pelvis (black) and involving the ovary, bowel, and left sidewall.
While researchers are studying possible causes behind endometriosis, no one knows for sure what causes this disease. Possible causes include1:
- Genetic factors: Endometriosis can often be inherited through genes
- Hormones: Estrogen promotes endometriosis
- Researchers are studying whether or not endometriosis is a problem with the female endocrine system
- Surgery: A surgeon may accidentally pick up and misplace tissue from the endometrium during surgery to the uterus (adenomyosis) or the abdominal area, such as a cesarean section (C-section) or hysterectomy
- Retrograde menstruation: Cells from the endometrium that are shed into the uterus during a period are carried backward through the tubes and into the pelvis, where they can implant
- Transport by circulation: Endometrial cells are carried from the uterus to other areas of the body via lymphatics and blood vessels
- Embryonic cell growth: Cells within the abdomen and pelvis turn into endometrial cells
- The immune system: Problems with the immune system may lead to failure in detecting and destroying endometrial tissue outside of the uterus
A common symptom of endometriosis is intense period pain. Women who may have endometriosis experience this symptom, often as early as the first menstrual cycle. The symptoms can be controlled with early diagnosis and treatment, which prevents long-term complications such as infertility and chronic pelvic pain.
Symptoms of endometriosis can include³:
- Pain with period
- Pain with bowel movements
- Pain with sexual intercourse
- Pelvic pain
- Intestinal pain
- Lower back pain
- Bowel or bladder symptoms, especially near the time of a period (for example, blood in urine or stool that only occurs during periods)
The diagnosis of endometriosis can only be made by direct visualization and removal of the lesions through a diagnostic laparoscopy, where a small thin camera is inserted into the abdomen and the entire pelvis can be inspected. It is not possible to accurately make the diagnosis without surgery. Classically, endometriosis looks like burn spots within the pelvis, but it can also appear as raised reddish patches, whitish lesions, clear blebs, or yellowish-brown lesions2. Any suspicious lesions can be resected for a diagnosis.
- One or more relatives with endometriosis
- Abnormalities in the reproductive and menstrual tracts
- Short menstrual cycles, i.e., less than 27 days
- Heavy menstrual periods that last longer than seven days
- Never having given birth
- Starting your period at an early age
- Going through menopause at an older age
- Having a history of high estrogen production
- Low body mass index
Endometriosis can cause infertility. This can happen at any stage of the disease due to chronic inflammation. In fact, up to 50 percent of women with endometriosis suffer from infertility4. This occurs because the endometrial cells have “mini periods” outside the uterus each month, causing inflammation, pain, and scarring. Inflammation and scarring from endometriosis results in infertility due to:
1. Tubal Scarring, preventing transport of the egg down the tube to the uterus by blocking the tubes
2. Inflammation, which impairs fertilization between egg and sperm, transport through the tubes, and decreased implantation of the embryo into the uterine lining for pregnancy
3. Endometriomas, or the formation of large cysts of endometriosis in the ovaries, can destroy ovarian tissue and can decrease ovarian reserve — the number of eggs remaining in the ovaries — as well as decrease egg quality
Surgery is the most important first step in the diagnosis and proper treatment of endometriosis. Endometriosis is a small volume disease most often not diagnosed by ultrasound, CT scan, or MRI since the implants of the disease are very small, often less than one cm. This is too small to be detected by these imaging studies. Because of this, patients with pain and/or infertility — in all reproductive ages — must have a laparoscopy to both diagnose and remove the disease at the time of surgery⁶. OBGYNs often bypass surgery and make the diagnosis clinically, without surgical removal and confirmation. This allows the disease to spread, causing increasing inflammation, pain, and, ultimately, infertility. Surgical removal controls pain, confirms the diagnosis, halts the progression of the disease, and most importantly diagnoses the condition early so that progressive infertility does not occur.
Conservative surgery preserves the uterus, tubes, and ovaries and removes only the endometriosis to confirm the diagnosis, control pain symptoms, and to manage infertility. Conservative surgery with excision of disease will decrease pain, but it does not cure endometriosis. Forty to 80 percent of women will have a recurrence of pain within two years of surgery. Following conservative surgery with medical management can help extend the length of pain control.
Endometriosis excision — This procedure removes endometriotic lesions. These lesions can develop on tissue within the pelvic cavity, including nerves. In some cases, women with mild cases of endometriosis may experience intense pain depending on the location of the lesions. Thorough removal of endometriosis is essential for relief of pain. Burning, or cauterization, of endometriosis lesions is less effective than excision, mainly due to ineffective removal of the disease. Burning of endometriosis implants cannot be used when the disease involves the bowel, bladder, ureters, or pelvic sidewall and vessels, since significant injury can occur to those structures.
Excision of Endometriosis. This picture shows endometriosis that has been completely removed where it has involved the lining (peritoneum) of the pelvis.
As a point of illustration, this picture shows excision on the left and right, and an area of cauterization - or burning - in the middle. The burned area was later removed. Burning does not remove all the disease, especially for deep lesions.
Endometriosis fulguration (burning) — Burning the endometriotic implants to destroy the abnormal endometriotic implants. Excision (removal), not burning, should be the primary treatment for the surgical management of endometriosis8.
Resection of ovarian endometriomas — Endometriomas should be completely removed, not just drained, and the ovary preserved. If it is not removed, there is an 84 percent chance it will return7. It is not necessary to remove the ovary, although this is often done, and will decrease fertility options.
Definitive Surgery – Long-Term Solutions
Hysterectomy — Hysterectomy, with or without removal of the ovaries, can be performed for women who do not desire fertility, or for women for whom conservative surgery has not been sufficient to manage the pain. Of all of the methods to treat endometriosis, a hysterectomy with removal of both ovaries results in the best long-term pain control. If the ovaries are not removed, the chance that symptoms will return is six times higher than if they are removed. However, for many younger women who have completed childbearing but do not want ovarian removal, hysterectomy only — or partial hysterectomy — does provide significant pain relief. Hysterectomy will cure adenomyosis, a form of endometriosis that is in the wall of the uterus.
Presacral neurectomy — For women with extreme pain that is concentrated in the middle of the pelvis, cutting the nerves that sense pain in the middle of the pelvis can improve symptoms. For women with generalized pain, or pain in areas other than the middle of the pelvis, this procedure has not been shown to be more effective than resection or fulguration of endometriosis. Risks of this procedure include postoperative chronic constipation and urinary dysfunction.
After the diagnosis and surgical excision of endometriosis has been completed, medical suppression is used to decrease the time to recurrence of the disease. It is important to note that suppression of endometriosis with medical therapies is always more successful and of longer duration after complete resection of all disease. Endometriosis almost always returns since estrogen allows endometriosis to grow. Decreasing the amount of estrogen in a woman’s body decreases the growth rate of endometriosis. The best way to decrease estrogen is to prevent ovulation, which produces high levels of estrogen. Suppression of ovulation through medical therapies such as birth control, IUDs, Depo-Provera, Lupron, Orilissa, and others decrease the growth rate of endometriosis9. Medical management is not used to treat adhesions, has minimal impact on infertility, and is not effective for the management of even small endometriomas.
Pain from endometriosis is most commonly treated with NSAIDs such as ibuprofen, Motrin, and Advil. Narcotic medications (such as Vicodin, Percocet, Tylenol-Codeine #3) can be used for more severe pain but are associated with much greater side effects.
Hormonal medication is used to inhibit the growth of the endometriotic cells by stopping the production of estrogen. The best way to control estrogen is to control ovulation. Note that even with ovulation stopped, estrogen is still present, and endometriosis will grow, although somewhat slower. Since many women experience their worst symptoms during their periods, hormonal management that stops periods from occurring (by stopping ovulation) can be helpful. Unfortunately, the effects of hormonal medication are temporary. Symptoms of endometriosis usually return once the medication is stopped. Advantages of these are that they are generally well-tolerated and can be taken indefinitely.
The CIGC Difference
Choosing the right specialists for endometriosis removal is an essential part of managing the condition. If removed incorrectly, endometrial implants can continue to cause pain and affect fertility. Many women spend tens of thousands of dollars out-of-pocket for specialist care. At CIGC, we accept most major insurance, ensuring our patients can focus on getting healthy.
CIGC surgeons are trained in both advanced laparoscopic procedures and techniques, as well as training in Gynecologic Oncology techniques and practices. This gives CIGC surgeons a higher level of training and experience to deal with very complex cases of endometriosis. Our specialists understand what women with endometriosis suffer through and we put the needs of our patients first. Our exclusive procedures were designed by our specialists, which is why so many women travel from around the world for DualPortGYN endometriosis excision.
Although endometriosis is a relatively common condition, it is not easily diagnosed and treated. OBGYNs often delay the diagnosis by not performing surgery early in the disease process or with long-term medical therapy, thereby allowing the disease to progress causing increasing pain and infertility. Access to a specialist, such as those at CIGC, ensures early diagnosis and treatment to control endometriosis in its early stages, thereby preserving fertility options and controlling pain. At CIGC, our focus is on performing the most minimally invasive procedures to treat your condition based on your long-term plans, taking into account your desire for fertility.
Your OBGYN concentrates much more on Obstetrics, not surgery. Most OBGYNs do not have the training or surgical volume to learn and develop the best surgical techniques. The result is either a delay in care in performing surgery, or inadequate removal of all endometriosis implants at the time of surgery. Surgical specialists, on the other hand, only perform surgery and have the additional training and skills required to perform better and safer surgery. At CIGC, our specialists have made a commitment to minimally invasive endometriosis excision. We perform a higher volume of cases, see a wider range of case types, and undergo comprehensive training. Our surgeons have expertise in advanced techniques and procedures and have learned to perform even the most complex GYN surgeries with low complication rates. Whether you are undergoing a definitive surgery or a conservative surgery for your endometriosis, when you have it done at CIGC, you know you are working with specialists who concentrate only on this type of procedure.
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If you’re considering endometriosis excision, our specialists are ready to provide an evaluation of your symptoms and conditions and recommend an appropriate solution.
This PDF presentation provides information on the connection between endometriosis and fertility.
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