What exactly is endometriosis?
In this post, we’ll briefly discuss a fairly common yet enigmatic female pathology—endometriosis. A basic definition of endometriosis is the presence of endometrial cells in places outside of normal location on inner lining of the uterus. Some of the more common sites of endometriosis include the ovaries, uterine ligaments, and bowel. The most common symptoms of endometriosis are infertility, pelvic pain, and bladder pain. Most physicians are aware of endometriosis as a cause of pelvic pain, however, many do not fully appreciate the effect it has on a woman’s fertility. For example, up to 50% of infertile women have endometriosis, even though she may not have any pain symptoms.
The management options for endometriosis, like many gynecological conditions, can be grouped into three categories: 1) expectant (i.e. doing nothing and waiting to see if the problem improves without intervention), 2) medications, and 3) surgical treatment. Expectant management might be reasonable option in some situations, especially in light of the fact that about 25% of women will actually have spontaneous regression of their disease after 1 year. However, since the other 75% of women will have either persistent disease or progression of it, intervention in the form of medicines or surgery is usually recommended.
Most gynecologists today recommend medications and “birth control” pills in particular as the main stay of treatment for women whom they believe may have endometriosis. The problem with such an approach is threefold. First, birth control pills have not been clinically proven to be any more effective than simple pain relievers like ibuprofen for the relief of endometriosis related pain. Secondly, birth control pills do nothing to improve long-term infertility that is caused by endometriosis. In fact, the birth control pill actually contributes to the risk of infertility through its effect on cervical mucus function. Finally, the cumulative risks (especially of cancer) most pronounced in long-term use of the pill do not justify their use for this when much safer treatments are available. The second most commonly used type of medication for endometriosis is an intramuscular injection of a medication known as Lupron (leuprolide). While this medication is much more effective at relieving pain than any other medications, it is fraught with its own problems of annoying side-effects and health risks. The Lupron muscular injection acts by putting a woman’s body into a chemical menopause state—hence the source of both the most bothersome side-effects (hot flashes, night sweats, etc.) and the health risks such as osteoporosis.
The most effective and definitive treatment for pain and the only treatment that preserves or restores fertility in patients with endometriosis is surgical. The purpose of surgery in this setting is to either excise or destroy all endometriosis lesions. The trend of increasing laparoscopic surgery has been a particularly beneficial situation for women with endometriosis. Personally, I have found the robotic laparoscopic system effective enough for even the most severe forms of endometriosis that only a few years ago would have required a large abdominal incision and about 3-4 days in the hospital for recovery. Now, these same types of patients go home the same day. I truly believe that a good surgeon knows when not to operate; and believing strongly in the Hippocratic principle of “do no harm” I am cautious about recommending surgery for anyone. However, the medical science to date still shows that surgical treatment remains the “gold standard” in terms of treatment for this troublesome condition known as endometriosis.