Endometriosis is one condition that can be difficult, both in diagnosing and managing. It’s important to know what your options are and what to look for, however, so here are some things to keep in mind if you think you could benefit from an appointment with your gynecologist.
Endometriosis happens when endometrial glands and stroma occur outside the uterus. It’s not definitively known what causes endometriosis, but it is not the same as endometrial cancer. Endometriosis affects about 1 in 10 women in the United States, although many more are undiagnosed.
Endometriosis can cause dysmenorrhea (painful periods), dyspareunia (painful intercourse), chronic pain, and infertility. Dysmenorrhea is dull or crampy pelvic pain that typically begins several days before menses, worsens during the menses, and can continue for several days afterward. These symptoms can range from minimal to severely debilitating. Many of the symptoms of endometriosis overlap with other conditions.
Women with endometriosis often begin to experience it during their reproductive years along with pelvic pain (including dysmenorrhea and dyspareunia), infertility, or an ovarian mass. During pregnancy, lesions and their symptoms often disappear and improve, which has been attributed to the altered hormonal environment.
There are no laboratory findings for endometriosis. This means that endometriosis is often diagnosed by laparoscopy to perform a biopsy of a lesion. Then, a treatment plan can be created based on symptoms (e.g. pain, infertility, mass), symptom severity, disease extent and location, reproductive desires, age, medication side effects, surgical complication rates, and cost.
For women with mild to moderate pain (e.g. pain that doesn’t cause regular absence from school or work) and no ultrasound evidence of an endometrioma, use of nonsteroidal anti-inflammatory drugs (NSAIDs) and continuous birth control pills is the first line of treatment. This regimen is highly effective for most patients. For women who cannot or choose not to use estrogen therapy, progestin-only contraceptive pills with an NSAID are used.
Women whose pain doesn’t respond to first-line treatments are offered laparoscopy for diagnosis and treatment. Surgery can excise endometrial implants, endometriomas, and adhesions. Surgery can be conservative (retaining the uterus and ovarian tissue) or definitive (removing of the uterus and possibly the ovaries in women who have completed childbearing), depending on factors like age and family plans. After surgery, hormonal suppression (usually with continuous oral contraceptives) can help prevent the recurrence of symptoms.
Women with severe symptoms (e.g. regularly missing school or work because of pain) that don’t respond to first-line treatments or are recurrent are offered treatment with GnRH agonist with add-back hormonal therapy or laparoscopy.
Surgical resection of endometriosis or nerve transection procedures are offered to women who do not respond to medical therapy or who have recurrent symptoms. Surgical resection reduces pain by destroying the endometriotic implants.
Endometriosis should be viewed as a chronic disease that requires a lifelong management plan with the goal of using medications to avoid the need for surgery. It’s important to note that treatments don’t improve fertility, diminish endometriomas, or treat complications of deep endometriosis. The treatment of infertility associated with endometriosis involves a combination of surgery and assisted reproduction technology.
Endometriosis can be difficult to manage, so it’s important to partner with your gynecologist to find the best treatment plan for you and your body. To meet with our expert team, contact our New York City office by calling or filling out our online form.