Endometriosis: Non-Surgical & Post-Surgical Treatment

Endometriosis will respond to the hormone estrogen and can cause pain with menstrual cycles, pain with sexual intercourse, infertility, and unrelenting chronic pelvic, back, hip-and leg pain. Not everyone has every symptom, and some individuals have had pregnancies. Endometriosis is a factor in up to 40% of cases of unexplained infertility.

Endometriosis affects 10-15% of the female population.

 Endometriosis is a surgical diagnosis. This means it cannot be definitively diagnosed by taking your history, physical examination, blood or urine tests, x-rays, ultrasounds, MRI, or CT scan.  A diagnosis can be presumptive and interventions can be attempted with medication to alter hormones in order to alleviate symptoms. 

2 key points to remember about Endometriosis:

1) There is no correlation between the symptoms the person is experiencing and whether endometriosis is present.  (You may have severe cyclical pain that seems like it is endometriosis, but it is not).

2) There is no correlation between the severity of the symptoms and the extent of endometriosis present. (You may have extensive endometriosis and have pain that is tolerable or managed by medical interventions.  Conversely, you may have only a few endometriosis lesions and experience debilitating pain with periods.)

For these reasons, laparoscopic surgery may be the best way to have definitive diagnosis and/or treatment. 

(CAUTION: Hardcore Science-y stuff ahead.  But it is very useful to understand.)

Every organ has different tissue types. Each tissue type within an organ can produce tumors, benign and malignant.

The ovary has 3 tissue types:

1) Eggs and follicles (aka cysts) produce germ cell tumors

2) Connective tissue (aka the tissue that holds the ovary together) produce stromal tumors

3) Epithelial tissue (aka covering over the outer surface of the ovary)  produce epithelial tumors. Approximately 70% of all ovarian tumors are epithelial. Epithelial tumors can be serous, mucinous, clear cell, or endometrioid.

These subtypes are based on how the tumors look under the microscope.

There is evidence in the medical literature that clear cell and endometrioid ovarian tumors may develop from endometriosis. Literature review shows only a mild association between endometriosis and the development of ovarian cancer. The relationship of endometriosis and ovarian cancer is not confirmed.

A literature review published in early 2014 using the keywords “endometriosis” and “ovarian” found 1 prospective cohort study, 10 retrospective cohorts, and 5 case-control studies. All of these studies, except for one, did not include operative confirmation of endometriosis. Authors found a consistent association between endometriosis and clear cell and endometrioid cancer, but the authors concluded that the association linking endometriosis and ovarian cancer is not sufficient to impact current clinical practice.

Therefore, to summarize what is known at this time, there is an association between epithelial cancers of the ovary and endometriosis, but there is currently not enough evidence to warrant alteration in endometriosis treatment.

Pain is always real. Often, we can find what is causing the pain.  In many of these patients, we can alleviate the pain. When the source of the pain is not immediately found, we work to exclude the most deleterious diagnoses at first.  A klist of possible diagnoses is generated and then we sequentially rule out diagnoses until we have a more specific idea s to the cause and thus, a clearer picture of what can help.

Endometriosis can present as menstrual pain, pain intermittently throughout the month, or continuous pain. Response, or lack of response, of symptoms to medications, such as hormonal modifiers and contraceptives does not necessarily rule in or rule out the presence of endometriosis.  However, they can help to identify when the cause of the pain is hormone dependent.