Endometriosis affects 1 in 10 reproductive-aged women across all races. Endometriosis occurs when the endometrium, or lining of the uterus, grows outside of the uterus in the pelvis and abdomen. Endometriosis can grow on the ovaries, fallopian tubes, intestines, bladder and lining of the pelvis, and has been identified in almost every organ of the body. Endometriotic implants grow in response to estrogen and can trigger an inflammatory response in the pelvis. This inflammation is what causes painful symptoms.
What are the symptoms of endometriosis?
The classic presentation of endometriosis is painful periods. Pain typically begins before your period and continues until after the period is over. Patients with endometriosis often describe pain in their lower abdomen that travels to their back and down their legs. Other common symptoms include pain with sex, pain with bowel movements, painful urination and pelvic pain outside of periods. Endometriosis can also cause infertility. Up to 7 in 10 women with pelvic pain and infertility will have endometriosis. Finally, some patients with endometriosis are asymptomatic or have very mild symptoms. The severity of symptoms does not correlate with how much endometriosis is present at the time of surgery.
How is endometriosis diagnosed?
Endometriosis is under diagnosed because the only way to definitively confirm endometriosis is with a biopsy performed during surgery. On average, patients see seven doctors over seven years between symptom onset and diagnosis. In the primary care setting, endometriosis is a clinical diagnosis based primarily on history and physical exam. There are no accurate blood tests for endometriosis however medical providers can use imaging (such as an ultrasound) to narrow their diagnosis for endometriosis. Medical professionals can presume endometriosis in patients with classic symptoms and begin treatment without surgery. The more symptoms a patient has, the more likely they will have endometriosis at the time of surgery.
How is endometriosis treated?
Patients with painful periods should start by taking non-steroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen, naproxen or celecoxib. We recommend starting two to three days before your period begins and continuing through the entire cycle. If your pain does not improve, your doctor may recommend a hormonal medication to help relieve your symptoms. Hormonal options include the combined (estrogen and progesterone) birth control pill, progesterone only pill, depo provera shot, the progesterone intrauterine devices (IUDs), and gonadotropin-releasing hormone (GnRH) agonists and antagonists. Partner with your provider to review the risks and benefits of each method and to understand which options are best for you.
Who should consider surgery for endometriosis?
If your symptoms do not improve with medications, surgery may be the next treatment option for you. The goal of surgery is to both diagnose and treat endometriosis. During surgery endometriosis implants are removed and/or destroyed. Depending on your life stage, your surgeon may recommend fertility sparing surgery or removal of your uterus (hysterectomy) with or without removal of the ovaries. Research shows long-term symptom relief following surgery for endometriosis. However, endometriosis can recur after surgery, and recurrence is more common with fertility sparing procedures. Typically, this surgery is performed through a minimally invasive approach (either laparoscopic or robotic) and does not require an overnight hospital stay. Surgery for endometriosis can be very difficult due to the scarring endometriosis causes. Consult with your provider to ensure your surgeon is experienced with endometriosis surgery.
The goal of an expert endometriosis surgeon is to educate our patients using evidence-based research and patient reported outcomes in order to give our patients the best quality of care. We want to be your partner in making surgical decisions to improve your quality of life. Our experts will help guide you through the operative experience, from the initial consultation to recovery. Using an interdisciplinary team, we treat the most refractory and complex cases. Our priority is respecting women’s fertility choices in regard to ovarian and uterine conservation.
Why should patients care about endometriosis?
Many patients suffer from painful periods without knowing why. Patients whose quality of life is impacted by their pelvic pain, painful periods, painful sex or infertility should seek consultation with their doctor about treatment options. You should not be missing work, school, social events or limiting your daily activity due to painful periods. Partner with your health care provider to determine if you suffer from endometriosis.
Written by Christine Foley, MD Obstetrics and Gynecology Specialist and Minimally Invasive Gynecologic Surgery (MIGS surgeon), Women & Infants Hospital