Most, if not all, women will agree that having a monthly cycle is not fun. Cramping, bloating, tampons, pads, making sure you don’t get invited to Diddy’s white party, there’s a lot of think about. For a certain subset of women, however, approximately 10% of reproductive aged women, it’s significantly worse. Endometriosis can be a painful and debilitating condition that takes over a women’s pelvis. Simply put, endometriosis is uterine (endometrial) tissue that implants outside of the uterus. It does not belong there. Every month as a woman goes through her cycle, the hormones cause these abnormal implants to get irritated and inflamed, just as the lining in the uterus does. Endometriosis can implant on the bowel, bladder, deep in the pelvic cavity, even some cases where it gets up into the lungs. Because of these abhorrent locations, symptoms of painful sex (dyspareunia), painful bowel movements (dyschezia), and painful periods (dysmenorrhea) are the first questions we may ask if a woman is concerned about endometriosis. Of note, the only way to definitively get the diagnosis of endometriosis is with surgical biopsy of the lesions, especially because there a number of pathologies that can cause pain similar to endometriosis (IBS, urinary tract issues, musculoskeletal pain, fibromyalgia, etc.)
Ok, now that I’ve convinced all of you that you have endometriosis, let’s talk about treatment options. Treatment options are separated into 2 broad categories. Fertility sparing (meaning a woman who may still want children and thus would like to preserve her ovaries and uterus), or women done with childbearing.
The first line and easiest treatment for pain control in endometriosis is birth control. This can be oral contraceptives, depo provera shots, or an IUD (IUD Birth Control: It Had A Bad Rap But Let’s Examine The Facts and You should have a period. Your period shouldn’t have you! for some more info on birth control). The general mechanism of action with these is hormonal control, and thus control of the monthly inflammation that comes from having a period.
Another hormonal medication that has been used in the past is Danazol.
Danazol works in endometriosis because it reduces the amount of estrogen and progesterone circulating through the system. However, it can cause an upshot of testosterone, so the side effect profile is not ideal (think 14 year old boy: acne, hair growth, deepening of the voice…. #nothanks), and it is not used very often anymore.
For women that still have symptoms despite these interventions, a GnRH agonist can be considered. Now these meds basically put a woman into menopause. They shut everything down. It doesn’t sound ideal, but for a lot of endometriosis sufferers, this is the only option that gives them relief from their pain.
If, on ultrasound, there is an obvious and large endometrioma (the noun for a collection of endometriosis found in the ovary (need a refresher? Lady Bits Exposed: Why Knowing Your Anatomy Matters), then there is a stronger indication for surgery. The challenging aspect to surgery is there is no correlation between a woman’s findings on exam and her pain level. I’ve had patients that I take to the operating room for unrelated reasons, and their pelvis is full of endometriosis lesions. Other women who choose to undergo surgery because they want clear answers and they have the smallest pinpoint lesion and nothing else. The other challenge with surgery is there is a 40% chance that within 3 years the pain will be back necessitating an additional surgery.
For women who are done with their fertility, and none of the medical/ conservative options have worked, the next and usually best step is a hysterectomy and a removal of the ovaries. In a premenopausal woman, removing the ovaries will of course, put them into menopause. It is ok to take estrogen post operatively to get cardiac, cognitive, and bone benefits, but of course this is case dependent.
It is always best to address any concerns with your physician. Pain can originate from a number of different things. It is often frustrating for both the patient and the provider to try and get a clear diagnosis as well as an effective treatment plan. For some more information: http://endometriosis.org/endometriosis/