February 15, 2019 by John Fernandez and Tanya Racoobian
Managing Endometriosis: Options for Relief
Pelvic pain is one of the most common reasons women visit their doctor. It can signal one or more reproductive health conditions, but does not apply to all. Some women who report no pain or discomfort are surprised to find out they have endometriosis, a condition that affects about 5 million women in the United States, according to the U.S. Department of Health and Human Services.
“Endometriosis often goes undiagnosed, or is misdiagnosed because the symptoms can mirror other disorders that cause pelvic pain,” said John Diaz, M.D., a gynecologic surgeon at Baptist Health’s Center for Robotic Surgery. “The only way to truly diagnose it is by looking inside the abdomen surgically to remove and test the endometrial tissue found.”
What is Endometriosis?
Endometriosis occurs when tissue that normally lines the uterus and is shed during menstrual cycles stays behind and continues to build up. The leftover blood can develop into a ball of cells, or cysts sometimes referred to as endometriomas. The body’s way of eliminating the old blood and multiplying cells can cause them to spill out of the reproductive organs and travel to areas outside the confines of the uterus.
“What happens to this blood is kind of like traffic,” Dr. Diaz says. “In an effort to leave the body, it takes the path of least resistance and can travel to other areas within the body and proliferate.”
This process can occur in any woman of childbearing age and others who are menstruating. Once diagnosed, endometriosis is a chronic condition that exists until a woman reaches menopause. While some women with endometriosis experience severe pelvic pain and heavy, debilitating menstrual periods, many can be non-symptomatic and unaware they have the condition.
Abnormal growth of endometrial tissue can occur in different areas. Most commonly, endometriosis is found on and around the ovaries. Doctors often discover it during a cystectomy, the removal of an ovarian cyst. Displaced endometrial tissue can spread to the bowel and appendix as well. It’s also been found in noses and lungs, but these cases are very rare, says Dr. Diaz.
Making the Right Diagnosis
“A lot of symptoms and an imaging exam may hint towards a diagnosis of endometriosis, but the only sure way to know is by diagnostic surgical exploration,” Dr. Diaz said. “Treatment depends largely on symptoms, and more pronounced symptoms do not always correlate to a severe case of the disease.”
He says each patient’s symptom index is different. “Some women can have mild discomfort, and then we find they have extreme cases of endometriosis. Other women may present with severe pelvic pain, and when we look inside with the camera, the amount of endometriosis doesn’t correlate to the severity of their pain.”
Dr. Diaz adds another common way endometriosis is found is when a woman with no symptoms is having difficulty getting pregnant. The endometriosis is discovered during a fertility work up.
Up 50 percent of women being evaluated for fertility have evidence of endometriosis. While it doesn’t necessarily always interfere with conception, Dr. Diaz says, endometriosis will contribute to infertility in about 25 percent of these women.
Treating a Chronic Condition
Because endometriosis is a chronic disease, treatment is aimed at managing symptoms, Dr. Diaz explains.
“There’s no magic bullet for curing endometriosis,” he said. “Treatment is dependent on symptoms and usually requires a combination of surgical intervention and medical management to remove the endometriosis and prevent it from coming back,” Dr. Diaz said.
Medication can be anti-inflammatory drugs, such as ibuprofen. However, managing endometriosis medically usually requires hormone treatment, he said. Birth-control pills are most often prescribed. In addition to suppressing the hormones that promote the growth of endometrial cells, birth-control pills can have other benefits.
“Women who take birth-control pills for five or more years have a decreased risk of ovarian cancer,” Dr. Diaz said. “Depo-Lupron, an injectable contraceptive, is also effective in shutting down the ovaries to prevent estrogen from fueling the growth of cells.”
Minimally Invasive Surgery
Surgical options for endometriosis can include excision – removal of the endometrial growth – or ablation, which involves cauterizing the abnormal cells with a laser or other surgical tool.
A less invasive surgical option for treating endometriosis is robotic surgery. Dr. Diaz, an experienced robotic surgeon, performs all gynecological surgeries with the help of a surgical robot. He says the robotic approach has several proven benefits compared to traditional laparoscopy. Advantages include less post-operative pain, less bleeding and a quicker recovery.
“Robotic surgery is particularly beneficial in removing endometriosis,” Dr. Diaz says. He explains that the 10-times magnification and ease of manipulating the robot’s arms to provide a 360-degree view enable the surgeon to identify and get rid of more of the endometriosis.
“The robot allows us to overcome issues that surgeons can run into with laparoscopy,” Dr. Diaz said. “We can be more thorough and effective with the robot by finding deeper tissue and removing it while sparing surrounding organs.”
Endometriosis and Heart Disease
A diagnosis of endometriosis often translates to years of managing a chronic condition. However, it can help ward off another disease that can be fatal to women. For the first time, research suggests endometriosis can increase a woman’s risk of heart disease.
A recent study by researchers at Brigham and Women’s Hospital in Boston revealed women with endometriosis can have a 60 percent higher risk of developing heart disease than those without the gynecological condition. Young women age 40 and under had an even higher risk, according to the research outcomes published in the Circulation: Cardiovascular Quality and Outcomes, an American Heart Association (AHA) publication. Heart disease is the number one killer of women in the U.S., according to the AHA.
“The heart disease indicator is another important reason for women to get a proper diagnosis of endometriosis,” says Dr. Diaz. “While we don’t know exactly why endometriosis occurs, we now know that women of childbearing age who have it are three times more likely to have heart disease. Studying the link between the two diseases is an important factor in helping reduce cardiac risk factors for many women.”
Dr. Diaz says one theory is that ovaries help protect against heart disease, and women with endometriosis have a higher rate of their ovaries being removed. He urges physicians and patients to remain aware of heart disease and appreciate the significance of identifying risk factors.
“It’s especially important for women with endometriosis to live a healthy heart lifestyle by being active, eating well and not smoking in an effort to reduce their cardiac risk factors,” Dr. Diaz said.