Unquestionably, women and adolescents with endometriosis have a significantly impaired quality of life and sexual function. In addition, infertility can be expected with all forms of the disease. Once endometriosis is recognized, laparoscopic excision is considered the best treatment. The goal of laparoscopic intervention is to diagnose and excise all visible and palpable disease. Laparoscopic excision, when performed by a capable surgeon, thoroughly removes all forms of disease, restores normal organ placement and function, and treats pelvic pain and infertility. With Laparoscopic excision, substantial symptomatic relief and resolution of infertility can be expected in most cases.
Other forms of treatment include:
Other surgical approaches include ablation, cauterization, fulguration, or vaporization through the laparoscope. These methods involve only superficial removal of topical lesions in the pelvic region. While such incomplete removal may offer temporary relief, studies have placed recurrence rates at 40-60% within the very first year following this type of surgery.
While removal of the uterus has a role in endometriosis treatment, it should never be considered a definitive cure. Anyone suggesting otherwise does not understand the true pathophysiological nature of the disease. Removal of the uterus and in some cases, the tubes and ovaries (bilateral salpingoophorectomy) may be helpful in limited circumstances, such as in those who have largely invasive disease that may have resulted in “frozen pelvis.” Frozen pelvis refers to the devastating results of advanced, infiltrating endometriosis that has caused the literal “fusing” of the pelvic organs (often including the bowel), literally resulting in immobile pelvic structures. Each case for hysterectomy should be very carefully evaluated and should also include meticulous excision of all disease at the time of the procedure.
Studies have shown that misplaced endometrial tissue responds to hormones and goes through a menstruation-like process in reaction. To that end, estrogen is like fuel for fire in the disease process of endometriosis. Popular medical treatments have largely been designed to stop estrogen secretions, primarily in the ovaries, to suppress menstruation, and maintain a temporary phase that mimics menopause. Suppression therapies include:
- GnRH-A, or Gonadatropin Releasing Hormone Agonists:
- Lupron®, Zoladex®, Synarel® and Suprefact® are common GnRH-A drugs. They are designed to initially stimulate the ovaries to produce more estradiol (the most potent form of estrogen). In the second phase, after anywhere from approximately 7 to 21 days of constant stimulation, the drugs shut down the "messenger" hormones sent from the pituitary gland to the ovaries. The result is that the ovaries shut down, estradiol levels drop sharply and rapidly, and the patient ceases to ovulate or menstruate– a condition similar to that of menopause. GnRH-As are far from curative; they are intended only to suppress the symptoms temporarily. Indeed, rates of recurrence in the first year following therapy have been indicated to be as high as 74.4%. GnRH-As may also have significantly negative – and long-lasting – side effects ranging from bone density loss to impaired memory function, among others.
- Aromatase Inhibitors: Endometriosis implants act in a devious manner to make their own estrogen through the abnormal expression of the aromatase enzyme, thus creating a self-sustaining life cycle. Similar to GnRH-A therapy, aromatase inhibitors (such as Letrozole®) are a relatively new class of drugs designed to also temporarily suppress estrogen levels; however, they are designed to target not only estrogen production in the ovaries (as with GnRH-A), but also in adipose (fat) tissue and perhaps most importantly, within the endometriosis implants themselves. Again, the measure is temporary and is intended for short-term symptomatic relief only. Side effects are expected to be similar to those experienced with Lupron and other GnRH-A drugs, and recurrence in the long-term has not been adequately studied.
- Progestin therapy: Commonly achieved through the use of Depo Provera®, this therapy is used to artificially create levels of the hormone progesterone which resemble the body’s state in pregnancy. This, in effect, stops the monthly growth of the uterine lining and reduces estrogen production, which in turn stops ovulation and menstrual periods in most women. As with the aforementioned therapies, absence of a period may help some women or girls with temporary symptomatic relief. Again, some may find potential side effects to be intolerable, and the disease recurs when the drug therapy is stopped.
- The Mirena® coil is another progestin therapy. This small, plastic T-shaped intrauterine device (IUD) contains a synthetic progesterone-like substance that is released into the uterus over a five-year period. Little information is available on the use of Mirena for women with endometriosis and its use is largely anecdotal. The Mirena® IUD is a relatively new option for women and girls with the disease, and as such, only limited studies as to its effectiveness, potential side effects and long-term outcomes have been documented.
- Continuous Oral Contraceptives: Continuous administration of an oral contraceptive (OC) may be considered in women and girls with the disease who continue to experience recurrent dysmenorrhea despite cyclic (“normal”) OC use. Such administration works, as with all hormone therapy, by suppressing menstruation and theoretically inhibiting disease growth. Moderate to severe side effects have been reported in studies ranging from weight gain to depression.
Analgesics ranging from over-the-counter NSAIDS such as aspirin or ibuprofen, to prescribed narcotics such as Vicodin® or Percocet® may help reduce – but not remove or treat– some of the symptoms associated with the disease.
Diet & Nutrition:
Many patients are able to effectively reduce and even control their symptoms through a dietary approach. Many women and adolescents with endometriosis suffer from certain food allergies or intolerances (e.g., gluten, lactose), which may also be helped through this dietary approach. A dietary regimen that inhibits prostaglandin production (hormones that contribute to symptoms and cause pain) and promotes anti-inflammatory, healing properties can restore certain deficiencies, achieve hormonal balance, and ostensibly, reduce symptoms. The dietary approach can also address the candida (yeast) concern that many women with endometriosis experience. While no single diet or food approach will work for all women and girls with the disease, it is a non-invasive means of improving overall health. A wonderful resource on this topic for further reading is Endometriosis: a Key to Healing through Nutrition by Dian Shepperson Mills, MA and Michael Vernon, PhD, HCLD.
Still others may adopt “alternative” approaches to alleviating their symptoms. This may include any healing method from the use of herbs to varied pain management techniques. Some of the most popular methods reported by the endometriosis community include:
- Herbal medicines, prepared from the roots, flowers, stems, leaves or bark of plants. These can be inhaled, applied as a topical salve, inserted as a suppository, or ingested orally in a tablet form or a tea. Different herbs may be combined to increase effects. One underlying theory is that treating a presumed weakness in the liver may have a relieving effect on symptoms. Dandelion, Beet leaves, Cascara, Uva Ursi, both Blue and Black Cohosh, Cranberry, Plantain, St. John's Wort, Peppermint, Valerian, Dong Quai, False Unicorn, Evening Primrose Oil, Chasteberry/Vitex, Couchgrass, Red Raspberry, Yam, and White Willow have all been reported as helpful in symptomatic relief. It is extremely important to remember that though herbs are natural, they can be extremely toxic. Anyone considering herbal therapy should seek the counsel of her healthcare provider.
- Acupuncture: According to the philosophy, good health results as a balance and free-flow of Ch'i through "the meridians", while illness is an imbalance, stagnation, or an obstruction of Ch'i in a meridian. Placement of thin needles in the various points linked by these meridians is believed to restore the balance and flow of Ch'i. This will allegedly eliminate symptoms and reduce pain. Acupuncture is not available nationwide. Check with your state medical association for the laws surrounding acupuncture and a possible referral.
- Transcutaneous Electrical Nerve Stimulation (TENS): A technique to control pain in which a small machine conducts an electric current through electrodes placed on the painful areas. When it is successful, pain relief is often very quick. Patients may also purchase portable units for use whenever the pain strikes. See your healthcare provider for more information.
- Shiatsu: A Japanese finger-pressure technique similar to massage, Shiatsu stimulates Ki (the same as Chinese Ch'i) to balance free-flow and eliminate pain. The therapist may also prescribe home exercises to do along with the Shiatsu treatments. Check with reputable alternative healthcare providers in your region for more information.
- Exercise: Exercise is a demonstrated stress reliever, pain reducer and depression fighter. It also provides obvious benefits such as weight control and improved cardiovascular health. For example, swimming and walking are two low-impact, easy-to-do exercises that can be done by many individuals. Seek the assistance of a trained professional who is familiar with your condition and work out a regimen best suited to your needs and abilities.
- Biofeedback: This involves the altering of body processes such as heart rate, muscle activity, skin temperature and brain wave activity. This is done through the use of electrodes attached to the skin, which convert minute physiological, chemical or electrical changes into auditory or visual signals. You are taught to alter responses by relaxing and visualizing changes. Biofeedback is most effective if combined with other relaxation techniques. Ask your doctor for more information.
- Homeopathic therapy: Homeopaths stimulate and bolster healing mechanisms within the body through minute doses of natural remedies that would in otherwise healthy persons, actually produce the symptoms of endometriosis. The credo "like cures like" is the driving theory behind this approach. Consult a licensed homeopathic professional to learn more.
- Osteopathy: Osteopaths believe disease can be relieved by correcting structural problems through the manipulation of muscles, ligaments and bones. Similarly, chiropractic treatment – which differs from osteopathic treatment in that Chiropractors believe disease can be relieved by correcting dislocations (subluxations) in the musculoskeletal system alone – may offer similar relief. Check with your licensed Osteo- or Chiropractic provider.
- Naturopathy: "Nature Cures" is the belief behind this approach. It is a practice based solely on natural methods of healing. This includes (often in combination) fasting, vitamin and mineral therapy, color therapy, colonics, hydrotherapy, herbs, breathing exercises, physical exercise, massage, joint manipulation, and acupuncture, among other techniques or applications. Some licensed Naturopath Physicians are also able to perform minor surgery. Check with your local healthcare providers for more information.
Education about the disease can be a monumental part of the coping process, as can finding a support group and like-minded people who understand. We have included several varied resources on this site to help you on the path towards further empowerment.
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