Diagnosis & Treatment of Endometriosis
Endometriosis is a disease affecting women and is characterized by the growth of the uterine lining (endometrium) outside of the uterus. The uterine endometrium during the first half of the menstrual cycle increases in thickness and during the second half, acquires a spongy-like consistency to facilitate embryo implantation. If there is no pregnancy, the uterine endometrium sheds along with the menstrual blood during the menstrual period. The same cyclic changes also occur in the endometrium of endometriosis which causes bleeding into the abdomen or other organs, inflammatory reaction, development of adhesions (scar tissue), or appearance of cysts filled with blood which, over time, acquire a consistency of liquid chocolate (chocolate cysts).
Endometriosis Symptoms - Their frequency and Intensity
Endometriosis - common sites
Cyclic changes in endometriotic lesions (described above) are responsible for symptoms of the disease such as:
- Painful menstrual periods
- Pain during or after urination
- Pelvic pain unrelated to menstruation
- Heavy, prolonged menstrual periods
- Pain during and after sexual intercourse
- Pain during or after bowel movements
The frequency and intensity of these symptoms varies and there is no direct relationship between symptoms and severity of endometriosis. Some women have advanced endometriosis and few, if any, symptoms; others have severe symptoms with minimal disease. The intensity of symptoms is most likely related to the local inflammatory reaction and production of substances, such as prostaglandins and cytokines, by the endometriotic cells and cells of the immune system.
Endometriotic lesions, although benign, may spread like cancer from the reproductive system to other organs and sometimes even to distant locations away from the pelvis. We have seen women with endometriosis of the bladder, bowel, liver, lungs, arms, thighs, and even brain. If endometriosis spreads outside of the pelvis, it can cause generalized symptoms and/or symptoms of pain or bleeding in other organs. In general, any symptom or change in the body that undergoes cyclic changes coincidental with the menstrual cycle, should be suspect of being endometriotic in origin.
The choice of treatment in endometriosis depends on several factors such as:
- Woman’s age
- Severity of symptoms
- Fertility status
- Stage of the disease
- Prior treatments (if any) and treatment response and side effects (if any)
Endometriosis of the diaphragm
These factors as well as patient-specific indications and contraindications, advantages and disadvantages, and risks and benefits of different treatment options need to be thoroughly discussed and considered prior to treatment selection.
Endometriosis Medical Treatment
Medical treatment can supress endometriotic lesions and decresae the size of endometriomas. Pain improvement is observed in over 80% of patients but the effect is gradual over a period of six months of typical treatment. Because all medications used in the treatment of endometriosis change the hormonal status of the patient, there may be a variety of side effects. GnRH agonists are the most commonly used hormones. They include Depot Lupron, Zoladex and Synarel. They lower estradiol levels to less than 20/pg/mL, causing menopausal symptoms and changes. After endometriosis is suppressed, the GnRH agonist may be used for a longer period of time with estrogen added back to control the symptoms and changes of menopause. Danocrine is an anabolic steroid that lowers the estradiol level only 10-60 pg/mL, suppressing the menstral cycle and endometriosis without severe menopausal symptoms. Increase in appetite and weight gain are the major side effects. Birth control pills, especially those with strongly progestational properties when given as a long-cycle regimen, may control pelvic pain symptoms but generally have only a limited effect on endometriosis. Their side effects, however, are tolerable by most patients. Progestogens alone can control pelvic pain symptoms in some women. Their effect on endometriosis and their side effects are similar to those of birth control pills.
New Endometriosis Treatment Methods
Several new hormonal preparations are being tested for effectiveness in controlling endometriosis and pelvic pains. Our Endometriosis Institute has recently completed a clinical study on a new drug, Abarellx, which is a GnRH antagonist. Abarellx is more effective than GnRH agonists and seems to have fewer and less bothersome side effects. It should be approved for clinical use within the next year or two. We currently are investigating a new approach to the management of endometriosis and pelvic pains. This is based on a local intravaginal-rather than systemic-administration of the hormones such as intravaginal Danocrine. We are expecting a similar clinical effect as with oral administration but without systemic side effects. In the future, we anticipate that a new class of medications-the immunomodulators-will become available to treat endometriosis and pelvic pains more effectively.
Surgical Endometriosis Treatment-Advanced Laparoscopic Surgery
Advanced laparoscopic surgery for chronic pelvic pains and suspected endometriosis should be performed by a surgeon with the necessary skills and expertise in the resection of such lesions and in an operating room equipped for such a surgery. Endometriotic implants should be resected, vaporized or fulgerated and care should be taken to perform as complete as possible resection of deep infiltrating endometriotic nodules which are usually the cause of pelvic pains. To reduce pain transmission, nerve interruption procedures such as uterosacral (US) nerve abalation or presacral neurectomy should be considered. Adhesions (scar tissues) should be completely resected and measures preventing their reformation should be applied. Endometriotic cysts should be resected with their capsule using ovarian tissue-sparing technique-rather than be drained. The surgeon should also be prepared to resect endometriotic lesions that may involve other organs such as the bowel or bladder. Appendectomy should also be performed if there are adhesions or if endometriosis involves the appendix.
Our Approach to Endometriosis Treatment
At the Endometriosis Institute, our objective is to help you select the endometrisois treatment option that is most appropriate in your case. Our overall goal is to remove or suppress endometriosis, to delay its recurrence, control its progression, and to take care of its symptoms without adversely affecting your fertility and without exposing you to undesirable side effects of treatments. We recognize that different women may respond differently to the same treatment, both in terms of the effectiveness and side effects, and that there is no one treatment that would be effective in all women. Our Endometriosis Institute at all times has several ongoing clinical research projects and we frequently have new medications for clinical trials before they become generally available. Such clinical studies, including medications, may be at no charge to you. For more information, please call 630-954-3636.