Endometriosis

Endometriosis occurs when cells from the endometrial lining of your uterus are found in places they do not naturally occur. Oftentimes endometriosis growths attach on to organs outside of the uterus such as the ovaries, colon, or appendix. Treating endometriosis involves removal of growths and prevention of new ones.

Every month when it is time for you to have a period, your body sheds the inner lining of your uterus through your vagina; this is called menstruation. The cells that are inside the lining of your uterus are called endometrial cells. During menstruation when your uterine lining begins to break loose to be shed, a reaction occurs. Each of the endometrial cells releases microscopic amount of prostaglandin which causes the uterus to cramp and contract in order to efficiently expel the lining.

During menstruation the uterus should contract from the top to the bottom in order to effectively expel the lining. In patients with endometriosis, they experience endometriosis bleeding--- where the uterus contracts from the bottom up and can force endometrial cells up through the fallopian tubes and into the abdominal cavity. The endometrial cells then attach themselves inside the abdominal cavity where they continue to live and cause problems. Endometriosis pain symptoms are usually moderate to severe and are not a direct reflection of the number of endometrial growths.

Every month as you move through your cycle, these growths (in addition to the normal endometrial cells inside your uterus) swell up with prostaglandin which can cause nausea, vomiting, diarrhea, bloating, cramping (mild to severe), and even flu like symptoms.

What are the symptoms of endometriosis and how are they different from regular menstrual symptoms? Endometriosis symptoms are typically more severe, interfere with work/school/life, and are not remedied by over the counter medication. Endometriosis is categorized in five stages based upon what we find during surgery, not based on your pain level. These stages are minimal, mild, moderate, severe, and extensive. Treating endometriosis is dependent on how severe your individual case is.

Painful Periods: Women who have had such painful periods that they stayed home from work or school are likely candidates for endometriosis. Endometriosis pain symptoms do not respond well to over-the-counter medication and oftentimes require prescription pain killers to reduce pain. If you have painful periods or suspected endometriosis and you delay treating endometriosis, the pain will get progressively worse.

Painful Intercourse: When endometrial cells spill into the abdominal cavity, the most common place for them to settle down is right at the top of the vagina. Intercourse may aggravate these growths and cause the release of some prostaglandin which will cause you to feel symptoms after or during intercourse.

Painful Bowel Movements: If you have endometriosis down near the rectum, you may experience endometriosis pain symptoms in the lower left quadrant of your abdomen prior to and during a bowel movement. Typically this pain will alleviate slightly after a bowel movement because the stool is no longer pressing on the endometrial growths.

Infertility: Only 15% of endometriosis patients have infertility. The biggest misconception is that the more severe cases of endometriosis are the patients whom become infertile - this is not true. We are not entirely sure why women become infertile. One theory suggests that for some reason, endometriosis patients are not able to make the chemicals necessary to allow a fertilized egg to attach to the uterus wall correctly. Hormone treatment for endometriosis may or may not be successful in helping infertility.

Appendicitis: Appendicitis can occur when endometrial growths adhere to the appendix. Depending on severity, you may have to have your appendix removed. Sudden, intense pain in the appendix area should not be ignored.

Interstitial Cystitis: If we were to take 100 patients with endometriosis, about 85% of them would likely also have Interstitial Cystitis (IC). Therefore, when treating endometriosis in a new patient I ask them about symptoms with their bladder (frequency, pain, etc). These symptoms need to be evaluated at the same time as your endometriosis.

Other unusual symptoms:You may have other abdominal pain or pain unassociated with your cycle. You may notice that strange, seemingly unrelated symptoms show up in pairs or around the same time of the month. Women may also experience fibroids - there is about a 50% correlation between women with endometriosis and fibroids. Treating endometriosis is about managing and eliminating symptoms of the disease while preventing new ones from forming.

Remember: Endometriosis can occur any time, with women of varying ages. As soon as you start having symptoms, get checked out by a gynecologist who specializes in endometriosis because the longer you wait, the worse it will get (typically). If you are asking yourself “what are the symptoms of endometriosis”, this is a sign something abnormal might be going on. Also, there is no magic cure for Endometriosis; there is no hormone treatment for endometriosis and no quick fix. Diagnosing and treating endometriosis requires dedication on your part and a dedicated specialist. We recommend finding an Endometriosis doctor who is also a skilled surgeon.

An ultrasound can provide us with quite a bit of information. During an ultrasound we will see if there are any dark spots within the walls of your uterus which would indicate that endometrial cells have grown there (we call this Adenomyosis). However, to officially diagnose Endometriosis or Adenomyosis with 100% certainty, a laparoscopic surgery is required.

Diagnosis of endometriosis in other areas of the body are also only done through a laparoscopic surgery. It is really important to select a gynecologist that specializes in endometriosis because you want not only the diagnosis but also treatment simultaneously (which is to remove the growths during the laparoscopic diagnosis). Select a gynecologist with a lot of experience (80-100 laparoscopic surgeries per year) that will also continue to treat you after surgery for any lingering symptoms you may have.

Laparoscopic Surgery Process

By the time you come to my surgery center for your laparoscopy, you will have already signed a consent form with the details of your surgery. Before you go to sleep, my anesthesiologist will administer a spinal medication (epidural) in addition to your general anesthetic that will take away pain from your mid-section to your feet. This medication will last from 24-46 hours preventing you from feeling pain during the surgery (yes, your body still registers the sensation of pain even though you are unconscious) and for the first few days of recovery. Our main goal is to ensure that you wake up after surgery with minimal or no pain as this will decrease the time it takes for you to recover.

During surgery I will make a 5mm incision in the belly button and fill your abdomen with carbon dioxide to allow us space to look around. I'll put another 5mm incision down by the pubic hair and one 5mm incision by each hip. I then insert a small camera into your abdomen and begin looking around. My goal is to find visual confirmation of endometriosis, other abnormalities, and find the source of your endometriosis pain symptoms.

Initially, I look at the back of the bladder, the front and back of the uterus, the left and right fallopian tubes and ovaries, the left and right sides of the pelvis, the cul-de-sac where the rectum is, the appendix, liver, and gallbladder. This is to gather information as to where your endometriosis is. If you do have endometriosis, we begin photographing the different areas that are affected. During this process we will classify your endometriosis (minimal/mild/moderate/severe/extensive) based on a complex scoring system.

When we find presence of endometriosis we don’t leave it in—we remove it. There are a number of ways to remove the endometrial growths depending on where the growths sit. I prefer to use a method that does not involve cauterizing as was once used in the past. Instead, I will cut a small hole in the growth and fill it with saline or a numbing solution in order to separate it from the rest of the surrounding tissues. Now I can safely cut the growth out without doing any damage to underlying tissues, blood vessels, etc. The holes will heal within 72 hours as long as you stay active during recovery. What does “active” mean? This doesn't mean running a marathon but it does mean getting up and walking around for a few minutes every hour.

In addition to searching for endometrial growths, we may also find adhesions. An adhesion occurs when two normal tissues become stuck together. An example of this would be a fallopian tube that has become attached to the abdominal wall. If I find any adhesions, I have to free those up. Being active after surgery (walking a few minutes every hour) also helps prevent new adhesions as the tissues inside your body heal. Treating endometriosis through laparoscopic surgery and removal is very important.

Treating endometriosis oftentimes requires more than one treatment method. In addition to surgery, the following treatments may be recommended based on your individual needs:

Birth Control Pills: Birth control pills prevent ovulation and help keep a steady source of estrogen in your body (remember, estrogen feeds endometrial growths). Although there is no permanent hormone treatment for endometriosis, the hormones found in birth control pills can be very helpful for many women. We will usually recommend that you take birth control pills continuously in order to prevent your cycle (skipping the placebo/sugar pills in your pack of pills).

Non-Steroidal Anti-Inflammatories: Ibuprofin, Motrin, Alieve, and Advil are all available over the counter and prevent the release of prostaglandin. Prostaglandin release during menstruation can contribute to endometriosis pain symptoms and painful endometriosis bleeding. These only help with symptoms and are not for treating endometriosis.

Lupron/Zoladex: These medications put you into a false menopause by bringing your estrogen levels down. Injected just under the skin on your abdomen, Lupron/Zoladex serve as a temporary hormone treatment for endometriosis. Side effects from this medication are unpleasant; however, we combat this through the use of a minimal amount of estrogen without affecting the medication’s success. These medications are very expensive and are only approved for use for a six month period.

Mirena IUD: Mirena IUD is a type of IUD (intrauterine device) that is inserted into your uterus to prevent pregnancy and lasts for up to five years. The Mirena releases progesterone directly into the uterus, eliminates a monthly period is a large percentage of women and can help endometriosis pain symptoms and endometriosis bleeding. In comparison to Lupron or Zoladex, the Mirena is just as effective, is significantly cheaper, and lasts much longer. The Mirena IUD might be considered a long-term temporary hormone treatment for endometriosis that can be inserted during an office appointment. If you are coming in for a laparoscopic surgery, we may be able to insert the Mirena IUD at the same time.

Progesterone Injections: I do NOT recommend this treatment. Excess progesterone in your body contributes to low estrogen levels. Additionally, you will likely experience cramping, weight gain, acne, oily skin, and other horrible side effects that will only make you feel worse.