Endometriosis Part 3

I’ve talked about the possible causes of endometriosis, the signs and symptoms as well as the ways to diagnose it.

Today I’m going to focus on why we manage it and how.

The two reasons we treat women with endometriosis are:

1. Pain

2. Fertility

There are different approaches to treating women depending on what their symptoms are and what their preference is. Often it is not just one approach, but a team of people to help overcome obstacles associated with endometriosis so women can get on with life without debilitating symptoms.

For women who are debilitated due to the symptoms they have, it’s often a good idea to sit down with the gynaecologist and discuss some realistic short, medium and long term goals that you want to achieve. This can be something as simple as being able to walk to the letterbox to grab the mail or walk to the coffee shop and get a coffee without pain to getting back to work, managing the kids and running a household.

There are a few different ways to structure the answer to this question. I think I’m going to outline this in conservative, non-hormonal, hormonal, surgical and allied health.

1. Conservative:

This has often been tried before where the heat pack is used during periods but things like yoga, meditation and mindfulness can also be beneficial for managing symptoms of pain. They may not necessarily on their own be effective, but in combination with other treatments it can be helpful for those women wanting to avoid more medical techniques.

There has been some research looking at dietary changes which have become quite popular, but unfortunately they are yet to prove any benefit.

2. Non-Hormonal:

For those women who have very heavy and painful periods but are fine throughout the rest of their cycle and trying to avoid hormones, medication such as tranexamic acid may work for you. It is called an anti-fibrinolytic. It works by decreasing the amount of contractions the uterus has and therefore reducing the flow and the amount of clots passed during your period. It does NOT prolong your period but makes it lighter and less painful.

It is taken 3 times a day for 1-2 days before your period starts for about 3-4 days. It is on prescription so will need to be prescribed by a Doctor. See your GP or Gynaecologist and make sure it is right for you.

3. Hormonal:

To be honest, hormonal treatments are the main stay for endometriosis treatment, especially progesterone.

It is effective as a trial of treatment for those with signs and symptoms of endometriosis, who are not wanting to fall pregnant and are at the time wanting to avoid surgery. A good starting point is often the combined oral contraceptive pill (COCP) with oestrogen and progesterone . It can be used continuously to avoid a period or monthly. It is designed to keep your hormones at a constant level instead of the ups and downs in your normal menstrual cycle and at a lower level than your normal hormonal levels. In that way it makes the period lighter and less painful.

For those women already diagnosed with endometriosis, different forms of progesterone are used, often after surgery to suppress the disease for those not wanting to conceive. Mirena is a very popular choice as it works locally at the level of the uterus, reducing the amount of bleeding, pain, it stops ovulation in 7/10 cycles as well as being a contraceptive. It gets a bit of a bad wrap when you read about it on line with regards to pain and bleeding and for some this is true. With respect to bleeding, it is without question in most cases lighter, but for the first 6 months it can be unpredictable and you can spot or have light bleeding at any time. It usually improves after 3 months and stops after 6. With respect to pain, if you are already sensitised to pain due to endometriosis or any other pain for that matter eg. a car accident, complications related to surgery etc. then you will be very aware of a Mirena and will most likely not manage with it and want it removed. This is ok. This is when Implanon- the rod in the arm and the progesterone only pill (POP) may be a better alternative.

Implanon also gets a bad wrap because of bleeding or weight gain and the POP is not a great contraceptive and requires you to be quite diligent with taking it every day.

In the end, it’s your choice as to what you use or if you use any at all. The main aim with hormones though is to suppress the disease to avoid having it come back. The Gynaecologist can help you make those decisions, but ultimately it’s up to you.

4. What about surgery?

It is important to know that the first surgery is the most successful with respect to management of pain. Repeat laparoscopies to remove endometriosis are not effective for treatment which is why Gynaecologists will often recommend suppression treatment after surgery or once the symptoms return.

Repeat laparoscopies can often make pain worse due to increasing your hypersensitivity to pain. Surgery causes pain and there decreases the pain threshold making pelvic pain worse, and the cycle continues. There is no benefit in repeat laparoscopies within short succession of each other.

Research has shown that surgery is beneficial for those women who have minimal to mild disease (stage 1 and 2) to resect the disease in order to get pregnant naturally. Unfortunately there has been no research into getting pregnant either naturally or with IVF with respect to stage 3 and 4 disease. I have seen many women with severe disease who have completed their families and never knew they had the disease. Often there are other factors involved including their age, ovarian reserve and potentially sperm quality and quantity of their partner.

What we don’t know is if the problem with getting pregnant with severe disease is due to the ovaries being involved with endometriomas and removing or draining these cysts improves fertility or if it makes no difference. Watch this space as this is going to be an area of interest for research in the future.

5. Allied Health

Practitioners such as physios, sex therapists, psychologists and pain specialist also play a role. I think I’ll leave this one for next time. This overlaps a lot with chronic pelvic pain and is a big topic in itself.