Treatment Strategies for Endometriosis

Endometriosis is commonly defined by the presence of endometrial tissue growing outside the uterus most commonly on the ovary and in the peritoneum, resulting in inflammation, adhesions, distortions of the pelvic anatomy, and infertility.

Possible Sites of Endometriosis

The disease is usually limited to the pelvis and lower abdominal organs

  • Reproductive tract
  • Urinary tract
  • Gastrointestinal(GI) tract
  • Surgical scars and umbilicus
  • Lungs
  • Rarely, pericardium, pleura, central nervous system (CNS), nose, and eye.

Incidence of Endometriosis

The prevalence of endometriosis in women undergoing laparoscopy for evaluation of infertility is 25-50%

Risk factors:

  • Low body mass index (BMI)
  • Alcohol use
  • Smoking

Symptoms of Endometriosis

A classical triad of dysmenorrhea, dyspareunia, and infertility is characteristic of the disease. The symptoms are often cyclical meaning that the pain is worst right before periods or during the period and then improves.

Signs of Endometriosis

Bimanual pelvic examination may reveal tender uterosacral ligaments, cul de sac nodularity, induration of rectovaginal septum, a fixed uterus, adnexal masses, and generalized or localized pelvic tenderness.

Diagnosis of Endometriosis

  • Ultrasound can pick up an Endometrioma and severe pelvic adhesions but cannot really image peritoneal implants.
  • Laparoscopy remains the gold standard in the definitive diagnosis of endometriosis within the peritoneal cavity from the diaphragm to the pelvis.
  • On Laparoscopy, many typical and atypical peritoneal lesions ranging from a single 1mm peritoneal implant to more than or equal to 10 cm endometrioma and cul-de-sac obliteration have been described.

Classification of Endometriosis

According to the number of lesions and degree of infiltration, endometriosis is categorised and divided into four stages or grades:

If there is one symptom that defines Endometriosis, it is recurrent or persistent debilitating pain. Pain that changes and destroys daily lives, and careers, and more importantly wrecks the mental framework of even the sanest women. One of the common questions that patients ask is how to approach the treatment for endometriosis.

Endometriosis is a chronic disease. In that sense, there is no cure for endometriosis. However, you can reduce the symptoms with the right treatment. Communication is the key to finding a treatment that fits you. You will need to discuss your options with your doctor and ask any questions you may have.

Women with endometriosis have either pain or fertility problems or they have both. Treatment of endometriosis focuses on resolving or reducing pain due to the disease or on improving fertility. 

Factors to consider for the endometriosis treatment approach 

Depending on the patient, the treatment approach is different. Your doctor will consider several factors when prescribing medical treatment or advising surgical treatment. These factors include: 

● The preferences of the woman

● The type of disease (peritoneal disease, ovarian cyst, or deep endometriosis) 

● The severity and type of pain symptoms 

● The wish to become pregnant immediately or at a later stage 

● The costs and side effects of some treatments 

● The age of the woman 

● The treatments patient has already received. 

● The doctor (country, expert center) 

This means that two women with endometriosis could receive different treatments. One woman could receive different treatments over time depending on her preferences, her age, and her wish to become pregnant. Important to remember is that medical treatment works only under proper medication. Stopping medical treatment often means that the symptoms recur.

Strategies to relieve the pain from endometriosis

When it comes to pain relief, most strategies are effective. There are various therapies applicable to the need of the patients.  

Pain-relieving medication: There are several different medications to help relieve your pain. These can range from over-the-counter remedies to medications from your doctor. In more severe situations, doctors refer to a specialist pain management team. In the most common form, a Tranexamic acid and mefenamic acid combo works well to reduce both flows as well as pain and is available over the counter.

Patients can safely consume it up to three times a day and every month without any side effects. For those whose pain is more severe, more drastic measures are needed. 

Drastic measures to treat severe pain from Endometriosis

Hormone treatments: These treatments reduce or stop ovulation (the release of an egg from the ovary) and therefore allow the endometriosis to shrink by decreasing hormonal stimulation. Some hormone treatments are contraceptives and will also stop you from becoming pregnant. They include: 

  • The combined oral contraceptive (COC) pill or patch has given continuously without the normal pill-free break. This usually stops ovulation and temporarily either stop your periods or makes your periods lighter and less painful.
  • An intrauterine system (e.g. Mirena), helps to reduce the pain and makes periods lighter. Some women using an IUS get no periods at all. It is easy to insert and works for 5 years. For women seeking long-term benefits from pain and who have already had children, this is my absolute favourite. 
  • Progestogens in the form of tablets for daily doses or injections, which people take on a 3-month basis. Not very popular as a choice because of few side effects. 
  • GnRHa (gonadotropin-releasing hormone agonists) is used as an injection every month. They are very effective but can cause menopausal symptoms after using them for more than 3 months. Doctors use them extensively for women battling infertility with endometriosis and undergoing IVF.  Since the use of such injections before embryo transfer increases pregnancy rates. 

Some doctors start with oral contraceptives first to see if the pain is relieved and if the treatment is working. If it happens in a couple of months then they switch over to the Mirena system since that does not require any daily medicine intake. Moreover, it is equally effective and needs a change only after 5 years. 

What is the role of Surgery in women who experience pain?

Surgery has a much larger role in women who are not looking toward fertility than in those who are.

For women with endometriosis, surgery can be in various forms:

1. If doctors are forming a laparoscopy for some other reason and they find areas of endometriosis, then it’s prudent that they destroy those areas so that they don’t grow larger with time. 

2. If doctors find large endometriotic cysts, they will need removal as they do not respond to medicines and other therapies well. The surgery needs to combine with other long-term therapies like Mirena to consolidate the results achieved with surgery. Otherwise in just a few months, the disease will come right back. This is a major area of concern since in most cases, the surgery is the only procedure and in just a few months, patients come back with severe symptoms.

3. Sometimes patients require surgery because the other methods are unable to relieve pain. The other therapies cause some side effects. Surgery manages to release the adhesions between the various organs inside and thus relieves pain. However, it is temporary. Other long-term therapies need to be in place after that.

4. Sometimes endometriosis is so advanced that it causes problems to surrounding structures in the body. For example; it may engulf the ureters and thus cause obstruction. Without any release, it may destroy the kidneys. The disease may hinder the smooth functioning of the bowels and this could be a reason for surgery too.

5. Lastly, sometimes doctors need to operate just to prove that the problem is endometriosis and not cancer. Endometriosis does not lead to cancer but the differentiation between the two may not be clear from ultrasound and other basic tests and thus a biopsy is needed. 

Alternative Therapies to Cure Endometriosis

The following measures are helpful to some women: 

  • Exercise, which may improve your well-being and may help to improve some symptoms of endometriosis 
  • Cutting out certain foods such as dairy or wheat products from the diet 
  • Psychological therapies and counseling. 

Regarding Complementary therapies Although there is only limited evidence for their effectiveness, some women may find the following therapies help to reduce pain and improve their quality of life: 

  • Reflexology 
  • Transcutaneous electrical nerve stimulation (TENS)
  • Acupuncture 
  • Vitamin B1 and magnesium supplements 
  • Traditional Chinese medicine 
  • Herbal treatments 
  • Homeopathy

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