Endometriosis is a condition that affects about 10% of all women. It is defined as the growth, adhesion or progression of endometrial tissue (lining of the uterus) outside of the uterine cavity. These growths respond to the cyclic changes in hormones just like the tissue lining the uterus. This results in cyclic bleeding, formation of scar tissue, inflammation and sometimes chronic pelvic pain.
The most common symptom of endometriosis is cyclic pelvic pain usually occurring 1-2 days before the menstrual period and ending with the menstrual period. Sometimes the pain progresses to more days during the month. The average age of diagnosis of endometriosis is 28 years. It is likely that there is a genetic link as many women have a family history of endometriosis. There are many theories about why endometriosis occurs, retrograde menstruation (menstrual blood going out into the pelvis through the fallopian tubes) is a popular theory. About 30-40% of women with endometriosis will have a difficult time conceiving. Surgical treatment and in vitro fertilization can be very helpful.
Diagnosis is usually made by history and laparoscopic (minimally invasive) surgery to view and remove implants in the pelvis. Surgery is not always successful and can cause additional scarring. To avoid surgery, it can be helpful to put a woman with suspected endometriosis on a trial of hormones (such as low dose birth control pills) to stop the ovaries from secreting estrogen. It is thought that when the endometrial implants are no longer stimulated by estrogen the cyclic pain will cease or decrease significantly. If there is a significant decrease in cyclic pain then we can be relatively assured that the woman has endometriosis.
Treatment of endometriosis usually starts with the least invasive approach. The type of approach depends on the woman's symptoms, intensity of symptoms, response to previous treatments, and fertility issues.
Conventional treatments for endometriosis include:
The use of hormonal therapy to inhibit stimulation of the implants. There are many different types of hormones that can be used. The most common hormonal treatment is the use of combination (estrogen and progestin) birth control pills or progestin-only birth control methods such as pills, Mirena IUS ® or Depo Provera® shots. These hormonal treatments alleviate symptoms in approximately 75% of women. Other hormones include gonadotropin inhibitors, GnRH agonists and aromatase inhibitors. These hormones have many more side effects and are usually used when birth control methods fail. Hormonal therapy is often times used before surgery and after surgery as well to improve outcomes.
Surgery such as laparoscopy or open laparotomy can be used to remove or ablate implants, cysts, and adhesions. In severe cases, women who do not wish to preserve their fertility can consider removal of the ovaries with or without hysterectomy for definitive treatment. Unfortunately, if the woman suffers from menopausal symptoms after surgery hormonal therapy with estrogen can re-stimulate endometrial implants and cause pain.
Here are some of my thoughts about the treatment of endometriosis from an integrative women's health perspective:
Developing a supportive collaborative patient relationship is critical. For many women, it has been a long, frustrating and painful road getting to the diagnosis and treatment of endometriosis. It is important for me as a provider to offer education, listen empathetically, and empower women to make informed decisions about their care.
In addition to the use of hormonal therapy, anti-inflammatory therapies can be implemented. Endometriosis causes inflammation in the pelvis as evidenced by the increased presence of macrophages and prostaglandins. Adopting an anti-inflammatory diet and using anti-inflammatory herbs can be quite helpful. The use of non-steroidal anti-inflammatory medications such as ibuprofen that reduce prostaglandin activity can provide substantial pain relief.
Feelings of depression and/or anxiety should be addressed. These feelings can amplify pain and have a substantial impact on the quality of life. So they should be identified and treated along with the endometriosis.
Explore mind/body approaches to coping with pain and the emotional responses to illness. Imagery can be used to manage pain, difficult emotions, and face infertility. Yoga can open the pelvis, promote body awareness and relaxation. Meditation can help women focus on the present and become aware of negative thought patterns that can contribute to poor health outcomes. Laughter yoga can lift the mood and increase the release of endorphins.
Finally, alternative healing systems such as traditional Chinese medicine, homeopathy and ayurveda may also be helpful in the treatment and management of endometriosis. These healing systems address underlying constitutional issues and they each approach healing in different ways.
