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Endometriosis (Part 2): Treatment And Management

Endometriosis is a disease in which the endometrium (tissue that lines the inside of the uterus) grows outside of the uterus. Endometriosis most commonly occurs in the lower abdomen or pelvis, but can appear anywhere in the body. It is a painful disorder that varies in severity, and can lead to a myriad of problems, both short and long-term. In the previous article, we discussed the signs, symptoms and diagnosis of endometriosis. In this article, we'll look at the complications, treatments, and management of this disease. What are the potential complications of endometriosis?

Aside from the problems related to untreated endometriosis, the most severe complication of endometriosis is infertility. It is estimated that as many as 1 out of 3 women have trouble getting pregnant, and are said to suffer from some form of impaired fertility, due to endometriosis. But how does this happen?

Every month, the ovaries typically release one egg, which travels through the fallopian tubes, and may be fertilized by a sperm cell. The resulting zygote is implanted into the uterus, and pregnancy begins. Endometriosis can create multiple obstacles. Endometrial tissue can get implanted in the ovaries, fallopian tubes, or other organs, and create blockages. Thereby impeding the movement of egg and sperm, and also preventing fertilization. The chances of infertility do not correlate with symptoms of endometriosis, but increase over time.

Endometriosis can also increase the risk of infections. Endometriomas, cysts, and endometrial tissue in and around the ovaries can grow in size and, rarely, rupture. This increases the risk of widespread infection. Endometrial tissue, if it ends up in the intestines or urethra, can lead to constipation and urinary retention. The latter increases the risk of urinary tract infections (UTIs). Rarely, endometriosis can also lead to cancer of the ovaries due to chronic inflammation of the ovaries. Note that endometriosis itself is not cancer, and the risk of ovarian cancer is very low to begin with. Nonetheless, there is increased risk of ovarian cancer with endometriosis.

How is endometriosis treated?

Endometriosis can be treated with medical therapies or surgery. The type of treatment used depends on the age of the individual, overall health, other underlying conditions, desire for future childbearing, and the severity of symptoms. A definitive diagnosis of endometriosis requires a biopsy through laparoscopy, which is a surgical procedure. Since this is invasive and time-consuming, the following medical options can be used for initial treatment of pain in women with suspected endometriosis:

  • NSAIDs - Nonsteroidal anti-inflammatory drugs (NSAIDs) are good for pain control and can be obtained over-the-counter. Ibuprofen, naproxen, ketoprofen, mefenamic acid, and nimesulide all work to reduce the pain of menstrual cramps.

  • Birth control pills - Combined oral contraceptive pills or birth control pills, can regulate the hormones, especially estrogen, responsible for endometrial growth during menstrual cycles. Extended use of oral contraceptives may reduce or even eliminate the pain.

  • Danazol - It is a synthetic derivative of testosterone, which is the dominant sex hormone in men. Administration of danazol can block the follicle-stimulating hormone (FSH) and luteinizing hormone (LH) from the brain, which reduces the level of estrogen and, in turn, the size of endometrial tissues. The use of this drug is largely replaced by a better alternative, GnRH.

  • GnRH - Gonadotropin-releasing hormone (GnRH) is normally produced by the body and is the principal regulator of puberty and the menstrual cycle. GnRH agonists or antagonists, when given exogenously, can block estrogen production and stop menstruation, creating a state of “temporary menopause”.

  • Progesterone - Progestins or progesterone-only therapies can halt periods and growth of endometrial tissues. These are available as levonorgestrel-containing intrauterine devices (IUDs), etonogestrel implants, medroxyprogesterone acetate injections, and progestin-only pills (POPs).

As with any medical therapy, discontinuation can result in resumption of endometriosis and its symptoms. Therefore, continued use of the prescribed medication is recommended until advised by the doctor. If either one, or a combination of one or more of the above-mentioned therapies fail, then diagnostic laparoscopy is recommended.

Let’s look at the surgical options for treatment of endometriosis:

  • Minimally invasive surgery - For those wishing to have children in the future, the doctor would recommend conservative surgery to remove endometrial tissue. This is most commonly done through laparoscopic surgery. Laparoscopic surgery is a minimally invasive surgery that is done with the help of a camera, inserted through a small incision in the abdomen. Another incision is made to pass surgical instrument(s) inside the abdomen and extract endometrial tissues.

  • Removal of uterus and ovaries - Surgical removal of the uterus (known as hysterectomy) and sometimes the ovaries (known as oophorectomy) may be considered for those who have no desire to get pregnant, have severe and debilitating endometriosis, are unmanaged with other therapies, and are past a certain age. However, with the removal of these organs, one can enter a menopausal stage earlier than normal which increases the risk of heart diseases and osteoporosis. Additionally, around 10-15% of women have a recurrence of endometriosis.

As there’s no single best treatment for endometriosis, it is advisable to discuss the most suitable treatment option with the doctor.

Can endometriosis be cured and prevented?

Unfortunately, there is no cure for endometriosis yet. But, it can be successfully managed with the therapeutic approaches mentioned above. As for prevention, there isn’t sufficient data to suggest any recommendation. It appears that there is no way to prevent endometriosis, but the chances of endometriosis can be reduced by reducing estrogen levels. This can be done by:

  • Birth control pills - oral contraceptive pills can reduce estrogen levels and possibly prevent endometriosis.

  • Exercise - Exercising at least 150 minutes a week can help in reducing body fat and therefore estrogen levels.

  • Diet - A diet rich in fibers, high in plant-based products, low in animal products and processed carbohydrates can help in lowering body fat. This, in turn, leads to less conversion of certain hormones into estrogen and lowers the circulating levels of estrogen.

  • Alcohol - Regular intake of alcohol can raise estrogen levels in the body and therefore increase the risk of endometriosis. Abstaining from or minimizing the intake of alcohol to 1 drink a day can lower estrogen levels.

We hope this article helped you and provided you with all the needed information. If you have any questions or would like to schedule an appointment with one of our doctors, feel free to reach out to us! _______________ References Kasper, D. L., et al. Harrison's principles of internal medicine (20th edition.). New York: McGraw Hill Education., 2018. (pg. 2798, 2812-2814) Ralston, Stuart H. Davidson’s Principles and Practice of Medicine. 23rd ed. Elsevier Health Sciences, 2018. (pg. 836-837)


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