Endometriosis Treatment: 1 of 5 things you really need to know about endometriosis
A Comprehensive Guide to Understanding Endometriosis
(Dr Eric Daiter, Board Certified in Reproductive Endocrinology and Infertility)
- What is endometriosis?
- Problems caused by endometriosis: its symptoms
- Diagnosing endometriosis
- Treating endometriosis
- What to expect after treatment for endometriosis
It is easy to become confused, and even frustrated, by all of the different treatment options suggested for endometriosis. The purpose of this section is to explain specific treatments that are reasonable for different types, and symptoms, of endometriosis.
The stages of endometriosis, and the different types of visible lesions, are not reliably correlated to clinical symptoms (the character or amount of pain or the degree of reduced function, including fertility). Therefore, treatment based directly on the woman’s symptoms is more common and is reasonable. For example, if a woman with suspected endometriosis has no discomfort and is fertile then the benefit of treatment is low or theoretical at best. Alternatively, if a woman with little visible endometriosis has extreme pain with her menses then aggressive management in the regions of the pain is often (at least in our own personal experience) very beneficial. Knowing when the benefits of treatment outweigh the risks involved with treatment is very important. A complete medical history should identify the entire range of symptoms. The physician should also consider, assess, and attempt to rule out other possible causes for each of these symptoms. When endometriosis is suspected, and the symptoms are interfering with the woman’s life to the point where she would rather undergo treatment than continue living with the untreated symptoms, then treatment makes sense.
When the primary goal of treatment is to enhance fertility in a woman with suspected endometriosis, laparoscopic surgery has been shown to be most effective. All the medications that are used to treat endometriosis cause at least transient (temporary) problems with ovulation (which further reduces fertility) and most of these medications are contraindicated during pregnancy. Additionally, none of the medications used for medical management of endometriosis have been shown to effectively increase a woman’s fertility.
Our office routinely suggests a basic infertility evaluation prior to endometriosis surgery whenever the goal is to enhance reproductive potential. This includes an “egg evaluation” (including hormone blood work and an ovulation history), a “male factor evaluation” (including a semen analysis), and a “pelvic factor evaluation” (including a hysterosalpingogram and a postcoital test). Specific treatment alternatives can then be discussed in the context of all of these test results.
Most of the published clinical research that has shown positive effects on a woman’s natural reproductive potential (fertility) after surgical treatment of endometriosis was performed on moderate to severe stage endometriosis. The greatest increases in fertility were following pelvic repair and reconstruction in women with anatomic distortions, obstructive lesions, or extensive adhesions due to advanced endometriosis. This makes sense since surgery can often structurally correct these anatomic problems. There is less convincing literature to support the effectiveness of pelvic repair in minimal to mild cases of endometriosis, however, this research does exist. One of the first articles to demonstrate the effectiveness of (increase in fertility following) surgical treatment for minimal and mild endometriosis was published in The New England Journal of Medicine in 1997, and subsequently many other articles have supported this finding. The reason why removal of minimal superficial lesions of endometriosis increases fertility is less clear, but many researchers believe that molecular messengers released by these small endometriosis lesions in the pelvis have a toxic effect on fertilization, embryo development or implantation.
When the primary goal of treatment is reduction in pain thought to be due to endometriosis (including lower pelvic pain, pain with bowel movements and pain with urination), then both medical management and surgical treatment have been shown to be very effective.
Medications that have been shown to be effective at reducing the pain caused by endometriosis include Danazol, Lupron, and Depo-Provera. A significant reduction in pain is reported in about 85% of women on medical management using these medications, however, women frequently avoid them since they often take 3-4 months to become effective, they have serious potential side effects, and they cause temporary infertility. Women on Danazol for several months often complain of androgenic side effects, including but not limited to an increase in male pattern hair growth (face, back, upper abdomen), weight gain (central obesity), acne or oily skin, and a decrease in breast size. Women on long term Lupron often complain of side effects related to low estrogen because Lupron “turns off the ovaries” to produce a pseudo menopause hormonal state that is associated with hot flashes, mood swings, and insomnia. Websites also refer to many other possible side effects but these are uncommon in my personal experience. Women on several months or years of Provera often complain about unpredictable break through bleeding and a chronically depressed mood. Provera can also result in long-term anovulation for up to a year after discontinuing the medication, so this should be considered when fertility might be desired after treatment.
Surgical treatment of endometriosis can be highly effective at reducing the pain due to endometriosis, significant pain relief can often be achieved within days or weeks, and this relief of pain most often lasts many years. If conservative surgery to remove endometriosis and repair the pelvis is ineffective at reducing or eliminating lower pelvic pain with your current health care provider, then consideration of a second opinion with another endometriosis surgeon, management using medications (despite their side effects), or definitive surgery (including hysterectomy) may be advisable.
Other treatment options that are usually not discussed thoroughly in U.S. medical schools include alternative or natural treatments, which are generally based on treatment of the whole person not just the body. Acupuncture has been a part of Traditional Chinese Medicine for thousands of years and often involves the insertion of fine sterile needles into specific locations along with herbal formulas. Naturopathy is based on the belief in the power of the body to heal itself and treat focuses on diet, lifestyle, herbal remedies, and cleansing treatments. Holistic therapies may be combined with the Western Medicine approaches.
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