Endometriosis
What is endometriosis?
Endometriosis is defined as the finding of endometrial glands and stroma (tissue that makes up the structure of the lining of the uterus) outside of the uterus.
This type of tissue, known as endometrium, is normally found only inside the uterus and makes up the lining of the uterus. This is the lining of the inside of the uterus that is normally shed with each menstrual cycle.
What causes endometriosis?
Debate continues over the root causes of endometriosis.
Older theories of spread of cells from the uterus via the lymph nodes and blood vessels do not seem to be supported by any real evidence. Further, we know well that almost all women have endometrial cells from the uterus go into the pelvis during menstruation - this is called retrograde menstruation. Because it happens so frequently and relatively few women have endometriosis there must be factors at work other than retrograde menstruation.
Those other factors include immunologic dysfunction, alterations in inflammatory processes, and various genetic factors.
This all leads to the typical characteristics seen in endometriosis. Those characteristics include scarring, inflammation, and invasion across tissue planes other benign disease would not go.
What types of problems can endometriosis cause?
Most commonly, endometriosis is associated with painful menses, painful intercourse and infertility.
However, other problems are often seen in women with endometriosis associated pain. Those other problems include migraine headaches, chronic fatigue syndrome, irritable bowel syndrome, fibromyalgia, pelvic floor muscle spasm, interstitial cystitis, and depression. These problems may not necessarily exist in a patient because she has endometriosis instead they are problems called co-morbidities. In medical terms this simply indicates a problem that exists with another problem.
Why does endometriosis cause pain?
It is interesting that a woman can have severe endometriosis or mild endometriosis and not have any pelvic pain. So, there must be other factors at work in regulating how much pain a woman experinces from endometriosis.
In general, pain is caused by multiple factors that make up an individual's pain threshold (the amount if pain it takes before one actually feels pain). These factors are genetic, experiential, and psychologic.
However, regardless of one's pain threshold there is no doubt that endometriosis in and of itself can act as a pain generator. Endometriosis acts as a pain generator through multiple mechanisms. Endometriosis causes a significant amount of inflammation . This inflammation can result in scarring and nerve damage. It is this scarring and nerve damage that leads to stimulation of the spinal cord and ultimately the brain to detect continuous pain signals. When this becomes long term and severe phenomena such as spinal wind-up and neuroplasticity occur leading to difficult to treat chronic pain.
What is the optimal treatment for endometriosis associated pain?
Please remember as you read this that the question above was "endometriosis associated pain". A lot of women have endometriosis but no associated pain (although they may have infertility or subfertility) thus they do not require treatment for pain associated with endometriosis.
Remember what I said above - endometriosis can cause pain via multiple mechanisms. Thus, a gynecologist who truly understands (at least what can be understood at this point in time) both endometriosis and pain is likely to offer you a multimodal approach that pays respect to other pain issues as well as the central nervous system pain problem. So, the pain management aspect and the endometriosis treatment aspect go hand in hand.
However, for the sake of brevity, I will focus on simply treating the anatomic and inflammatory disease of endometriosis. In general, just like many other diseases there can be both medical and surgical treatments. Medical therapies that actually treat endometriosis really only exist in one class of drugs - the aromatase inhibitors. Other medical therapies such as birth control pills, gonadotropin releasing hormone agonists (lupron, synarel, and zoladex), progesterones, and danazol simply suppress pain associated with endometriosis by reducing inflammation, decreasing local estrogen responsiveness, and acting on the estrogen receptors in the spinal cord (which partially explains why some of these therapies suppress pain not associated with endometriosis). So, in the long run, when using these treatments (often with significant side effects) there is a suppression of pain (which may be all one needs for a period of time) only and no real treatment of endometriosis.
However, the aromatase inhibitors (letrozole and anastrazole) are medications that have been shown in animal models to actually decrease the anatomic volume of endometriosis. This is important because it is often that distortion of anatomy that leads to pain.
As I mentioned above there is another option - surgical management.
What is the optimal surgical management for endometriosis?
I believe, after more than a decade of experience and seeing many women treated incorrectly that the optimal surgical management for pain associated with endometriosis is radical resection of endometriosis. This means during surgery I will remove the maximum amount of visible endometriosis regardless of its location. This means removing it from the root and cutting deeply underneath the disease until nromal tissue is left behind.
Previously, some very well meaning gynecologists believed -and many still do - that it was equally acceptable to do surgery to burn or "fulgurate" endometriosis. I believe this technique is unacceptable. It doesn't make any sense to burn a disease leaving behind most of the disease and adding the damage caused by burning tissue.
I have seen a high number of women in my office who have had multiple (up to 17) surgeries to burn endometriosis with no long lasting effect. It is both dangerous and foolish to continue to operate on someone using the same technique with no long term pain relief. As of this date in the Fall of 2012 I have re-operated on fewer the 10 women for pain associated with endometriosis after they have already had a radical resection of endometriosis. This is a very useful technique. Another reason the technique is so successful is because I am not only focusing on pain relief but also focusing on the other pain issues in both a multimodal and multidisciplinary fashion. Thus patients get the best of both medical and surgical pain management for their endometriosis associated pain.
If I am planning for future fertility can I have a radical resection and keep my reproductive organs?
Absolutely! My goal is to work within your reproductive needs. We have had a lot of success in this scenario for minimizing or eliminating pain while maintaining fertility.
If I want to keep my ovaries - can I?
I perform radical resection of endometriosis on many young women. In order to both treat the pain and maximize future health outcomes I believe it is best to optimize the production of natural hormones. In order to do this I must leave the ovaries in. Contrary to popular belief I do not believe this decreases the efficacy of the procedure. Remember, the key to the procedure is maximally removing endometriosis.
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Feel free to contact me directly with any questions: drlevey@pelvicpainnewyork.com
This content was written entirely by Dr. Kenneth A. Levey
daVinci surgeon
robotic surgery for endometriosis
robotic surgery for fibroids
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