More than 5M women in the U.S. have endometriosis, a condition where cells that are similar to the endometrial lining cause inflammation and can lead to pelvic adhesions. It can cause severe pain with every monthly cycle. At CIGC, our focus is performing the most minimally invasive procedures to treat GYN conditions, including endometriosis.
WHAT IS ENDOMETRIOSIS?
Endometriosis is the presence of cells that are similar to the endometrium (the lining of the inside of the uterus) in a location outside of the uterus.
HOW DOES ENDOMETRIOSIS CAUSE PROBLEMS?
Because the tissue functions like the lining of the uterus, it grows and thickens with each menstrual cycle. It also breaks down and bleeds every month. Normal endometrial tissue exits the body through the vagina during a period, but endometriotic tissue is trapped. This can cause pain and irritation to the surrounding tissue, sometimes causing scar tissue, adhesions (organs sticking together), and infertility. Some women may have severe debilitating pain, while others have no symptoms at all. Endometriosis occurs most commonly within the pelvis but has been reported in nearly every other location of the body. Endometriosis on the ovary can cause cysts called endometriomas, which are filled with menstrual debris.
HOW COMMON IS ENDOMETRIOSIS?
Endometriosis is relatively common, affecting women of child-bearing age. More than five million women in the US have endometriosis. Endometriosis affects women of all ethnicities but may be more common among Caucasian women. Rates are higher among women with very painful periods or chronic pelvic pain. Women with infertility are more likely to have endometriosis.[1-2]. Having a first-degree relative with endometriosis increases the risk of having endometriosis.
1. Journal of American Medical Association, 2003
2. Obstetrics and Gynecology Journal, 1995
3. American Journal of Obstetrics and Gynecology, 1980
WHAT CAUSES ENDOMETRIOSIS?
It is not known what causes endometriosis. There are several theories:
- Retrograde menstruation: Endometrial cells that are shed into the uterus during a period are carried backwards 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.
- Faulty immune system: The immune system is unable to detect and destroy endometrial tissue outside of the uterus.
Symptoms can vary greatly depending on the location and severity of the endometriosis.
- Painful menses
- Pain with bowel movements
- Pain with sexual intercourse
- Low back pain
- Bowel or bladder symptoms, especially near the time of a period (for example, blood in urine or stool that only occurs during menses)
It is thought that endometriosis causes pain due to active bleeding, release of biochemicals that cause inflammation and pain, and even increased nerve sensitivity related to the implants. Adhesions and cysts created by endometriosis can cause significant pain as well. The extent of endometriotic implants is not correlated with the amount of pain a patient reports. It is possible for a patient to have severe debilitating pain yet only very small implants.
- Fertility and Sterility Journal, 2008
- Human Reproduction Journal, 2000
HOW DO I KNOW IF I HAVE ENDOMETRIOSIS?
A definitive diagnosis can only be made by direct visualization of the endometriotic lesions. The best way to do this is by a diagnostic laparoscopy where a small thin camera is inserted into the abdomen and the entire pelvis can be inspected. Suspicious lesions can be resected for a diagnosis. Classically, endometriosis looks like dark brown “powder burn” spots within the pelvis, but it can also appear as raised reddish patches, whitish lesions, clear blebs, or yellowish-brown lesions.
Adhesions can also be present and can vary widely in severity. Endometriosis is classified by the American Society of Reproductive Medicine according to the location, depth, and spread of the disease, in order of stage and severity.
There are several advantages to proceeding with a diagnostic laparoscopy. Once the endometriosis is identified, it can also be treated by resection or ablation. For patients who are found NOT to have endometriosis, this may help to avoid a long course of medical therapy directed toward the wrong diagnosis.
Since endometriotic lesions are very small, they are unable to be seen by imaging studies, such as ultrasound or CT scan. Exceptions to this are if endometriotic cysts are present in the ovaries.
HOW IS ENDOMETRIOSIS TREATED?
Endometriosis is treated either medically, surgically, or a combination of both. Treatment is directed at pain control, halting the progression of disease, and infertility treatment. Since endometriosis can vary widely from patient to patient, treatment must be tailored to each individual, depending on her specific conditions and goals.
Medical management includes management of pain with analgesics, as well as hormonal suppression. Bear in mind that medical management is used to treat symptoms, but does nothing to improve fertility, treat adhesions, or resolve endometriomas.
Pain from endometriosis is most commonly treated with nonsteroidal anti-inflammatory drugs (NSAIDS) such as Ibuprofen, Motrin, and Advil. They are readily available, inexpensive, have low side effects, and are not addictive. Narcotic medications (such as Vicodin, Percocet, Tylenol #3) can be used for more severe pain but are associated with much greater side effects, and have the potential to create dependence or even addiction.
Hormonal medication is used to inhibit the growth of the endometriotic cells. Since the endometriotic implants grow in response to the rise and fall of hormones during a menstrual cycle, hormonal medication may help slow the growth by suppressing the cycle. Since many women experience their worst symptoms during their periods, hormonal management that stops periods from occurring can be helpful. Unfortunately, the effects of hormonal medication are temporary. Symptoms of endometriosis usually return once the medication is stopped.
Below are types of hormonal medications available.
COMBINED ESTROGEN AND PROGESTIN ORAL CONTRACEPTIVES
- Birth control pills
Advantages of these are that they are generally well-tolerated and can be taken indefinitely.
- Depo Provera: Progesterone is given as an injection in the muscle every three months. Most women will have either very light periods or no period at all with prolonged use. Possible side effects include weight gain, irregular bleeding, fluid retention and depression. Prolonged use may result in the loss of bone mineral density, but this usually returns to normal levels once the medication is discontinued and menstrual cycles resume.
- Oral Progesterone: High-dose progesterone taken daily will usually cause menstrual cycles to cease. This is a much cheaper option but can have unpleasant side effects such as weight gain, irregular bleeding, and mood changes.
- Mirena Intrauterine Device (IUD): This type of IUD is implanted with levonorgestrel, a progesterone that is slowly released into the uterus. Unlike the other progesterone-only methods, systemic side effects such as weight gain and mood swings are uncommon. There is no loss in bone-mineral density. Irregular bleeding may occur for some women. Over 20 percent will not have a period at all after one year of use. Once inserted, the Mirena IUD is effective for five years but can be removed if the patient wishes to get pregnant. One study showed that the Mirena IUD was as effective as Depo-Lupron in managing pain due to endometriosis.
- Implanon: A matchstick-sized rod embedded with progesterone is inserted just under the skin of the upper arm. Once implanted, it is effective for three years and slowly releases the hormone into the body. The most frequent side effect is irregular bleeding. Less common side effects are weight gain, acne, and mood changes.
- This medication is given as an injection either once per month or once every three months. It greatly reduces the amount of estrogen in the body and produces a temporary menopause-like state. Some studies have shown it to be more effective than birth control pills in treating endometriosis-related pain. It is not usually used as a first-line medication because it is very expensive and has significant potential side effects, such as loss of bone density, hot flashes, mood swings, depression, vaginal dryness and weight gain. Treatment is generally limited to six months due to risk of severe osteoporosis.
- This oral anti-progesterone medication is generally given for up to six months. Because it acts like a weak male hormone, it can cause unacceptable side effects such as weight gain, acne, oily skin, increased facial hair, and smaller breasts, in addition to hot flashes, mood swings, and muscle cramps. It can also have a negative effect on cholesterol levels.
Surgical management is often performed for acute pain, symptoms that have failed medical management, presence of infertility, or presence of a pelvic mass. Surgical management is divided into two categories: definitive and conservative.
Hysterectomy with or without removal of the ovaries is for women who do not desire fertility or for women for whom conservative surgery has failed. 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 preserved, the chance that symptoms will return is six times higher than if they are removed. Hysterectomy will cure adenomyosis, a form of endometriosis that is in the wall of the uterus.
Conservative surgery preserves the uterus, tubes and ovaries as much as possible. Surgery is focused on removing endometriosis and improving symptoms. This is usually done for women who are not yet finished with childbearing or who have a milder form of the disease. Conservative surgery improves pain (80 percent of women reported improvement in their symptoms six months after surgery), 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 fulguration – Burning the endometriotic implants to destroy the abnormal endometriotic implants.
Endometriosis resection (or endometriosis excision) – Removing the endometriotic implants. Resection is more effective than fulguration for deep-infiltrating endometriosis.
PHOTOS: OVARIAN ENDOMETRIOMAS & RESECTION OF ENDOMETRIOMA FROM OVARY
An ovarian endometrioma is a benign, estrogen-dependent cyst found in women of reproductive age. It can be a cause of infertility.
Approximately 17 percent of subfertile women have endometriomas. Removing the endometrioma prior to IVF treatments can improve success rates of conceiving and carrying to term.
Resection of Ovarian Endometriomas – Endometriomas should be completely removed and not just drained. If it is not removed, there is an 88 percent chance it will return.
Medical management of endometriomas larger than one cm has not shown to be effective.
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 post-operative chronic constipation and urinary dysfunction.
ACUPUNCTURE – There are very few studies regarding use of acupuncture for the treatment of pain due to endometriosis. One study showed that it was more effective than traditional Chinese herbal medication.
DIET – At this time, there are no dietary guidelines for the treatment of endometriosis.
WHY CIGC FOR ENDOMETRIOSIS TREATMENT?
Although endometriosis is a relatively common condition, it is never easy to be diagnosed. You need to find an endometriosis specialist who will be by your side throughout the entire process: from your diagnosis, to exploring your options, to your endometriosis surgery or management.
If your case of endometriosis requires surgical management, you may require a Hysterectomy. However, there are also procedures that can preserve the uterus, tubes, and ovaries as much as possible, and at CIGC, our focus is performing the most minimally invasive procedures to treat your condition based on your long term plans.
Why shouldn’t my OB/GYN perform my endometriosis surgery?
Your OB/GYN may be a good doctor, but they are a generalist, not a surgical specialist. The majority of the practice of an OB/GYN is dedicated to Obstetrics care, so your doctor does not get nearly enough patient volume or practice to learn the best surgical techniques. The average OB/GYN performs 27 hysterectomies per year, while the average GYN surgeon performs 400. Since a heavy surgical volume is necessary to develop and maintain surgical expertise, it is easy to see why you should see a CIGC surgeon for your endometriosis surgery.
At CIGC, our specialists have made a commitment to minimally invasive endometriosis removal. We perform a higher volume of cases, see a wider range of case types, and undergo comprehensive training sessions. Our surgeons have learned advanced techniques and procedures, and have learned to perform even the most complex GYN surgeries with the lowest 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.
Always look for the most minimally invasive endometriosis removal possible.
Did you know that 60 percent of hysterectomies in this country are still performed open, which results in severe pain, higher complication rates, and a longer recovery period? Many clinics are also employing robotics, which require more incisions and leave more scars – not to mention they are more expensive. At CIGC, we have the advanced training to perform the surgery laparoscopically with just two small incisions. Our procedures have less pain than open and robotic surgeries, and allow the surgeon to be more thorough, yet with minimal scarring, that allows our patients recover more quickly.
As a patient and consumer, you should be discriminating and analytical when choosing a surgeon. Know that CIGC surgeons are true surgical specialists: they are board-certified, fellowship-trained, and concentrate completely on GYN surgery.
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