Endometriosis Treatment and Support

How can endometriosis be diagnosed?

There are a number of diagnostic tools that physicians use that may raise suspicion of endometriosis, but the only definitive method of diagnosis is through minimally invasive laparoscopic surgery and biopsy of affected tissue. If you suspect you have endometriosis, ask your physician about these different diagnostic tools (see below). Don’t be afraid to get a second opinion if you feel that you need more information about endometriosis diagnosis.

Definitive Diagnosis

Laparoscopic Surgery

• Laparoscopic surgery is achieved by first making 2-4 small incisions on the skin of the abdomen. Through those small incisions, ports are created to the abdominal and pelvic cavities inside, which are inflated with sterile CO2 gas.  The doctor will then use a  tool called the laparoscope, which is a camera, through these ports to examine the tissue and organs in the abdominal and pelvic cavity. 
• Upon examination of the pelvis, the doctor can search specifically for endometriosis lesions. If suspicious areas are found, samples can be taken for biopsy and confirmation of the disease will be made by a pathologist, who will issue a pathology report.
• Thorough biopsy of lesions is a method that can also be used to remove endometriosis lesions.

Diagnostic tools used to assist in definitive diagnosis

While there are diagnostic tools used to raise suspicion of the disease or find congenital abnormalities that may be exacerbating symptoms, they cannot specifically confirm if a patient has endometriosis. Instead, these tools can be used in conjunction with diagnostic laparoscopy and an accompanying pathology report.

Consultations

• A physician may be able to suspect that you have endometriosis based on the information you provide during your consultation. 
• It will be beneficial to explain your symptoms and pain with as much detail as possible. Bring in previous medical records, journals, symptom trackers or any materials that can provide essential information. 
• Be prepared to ask questions. Visit this page to learn more about preparing yourself for an appointment.

Pelvic Exams

• A focused pelvic exam is typically considered to be a preliminary step in the diagnosis process.
• The exam will include examining the pelvis and pelvic organs and will evaluate for specific points of tenderness.

Ultrasounds

• An ultrasound may be used to gain additional information, sometimes during the same visit as the initial pelvic exam. This device is used to send sound waves to produce images of the inside of the body. It is a safe method of imaging that does not expose one to any radiation. There are two main types often used by OB/GYNs:
• Transvaginal Ultrasound: Rather than using the probe on the outside of the stomach or pelvic region, it is inserted into the vagina. This can be done during any phase of the menstrual cycle.
• Sonohysterography: During the ultrasound, sterile saline fluid will be injected through the cervix and into the uterus. The fluid helps produce much greater detail and allows for the doctor to examine the contour of the uterus and endometrial cavity. Thisis typically used to find underlying causes of abnormal bleeding, miscarriage or infertility, and can help to look for growths and scarring. This specific type of sonogram is best performed during the  first half of the menstrual cycle.

 CTs

• Computerized tomography (CT) scans produce images of bones, vessels, and tissues similar to normal X-rays but in greater detail. 
• This form of imaging is often conducted in emergency rooms to often rule out endometriosis-related emergencies such as ovarian torsion or a cyst rupture.

MRIs

• Magnetic resonance imaging (MRIs) produce very detailed and clear images of tissues and organs and can be used to assist in definitive diagnosis.

How can endometriosis be treated?

Conservative Surgery

While there is no definitive cure for endometriosis, there are several options that have proven highly effective and have provided symptom relief for patients. Conservative surgery is an endometriosis surgery technique that is most often performed when endometriosis lesions can be well-recognized and specifically removed, leaving healthy organ tissue intact. Only the affected tissue is removed in this approach. While there are many different techniques of conservative surgery, laparoscopic excision surgery is the gold standard of treatment for endometriosis.

Deep-excision is performed during laparoscopic excision surgery, where the surgeon carefully excises or removes the entire lesion from wherever it is found, including the tissue beneath the surface. Endometriosis acts like an iceberg -  despite the disease being identified above the surface of the tissue, the majority is implanted into the tissue below the surface. This is why it is so important to find a surgeon who removes lesions in their entirety. For information about identifying a proper excision surgeon and preparing for your visit to the doctor please visit this page.

It is ideal to have surgery with minimal use of heat and electricity. Often times, surgeons will use techniques such as ablation with a laser or cauterization (energy generated from electricity) to “burn off and destroy” endometriosis lesions. However, this increases the chance of not fully removing the endometriosis lesions and risks damaging the surrounding healthy tissue. This does not mean that lasers and high-energy devices cannot be used during surgery, as they can often be helpful for coagulation (stopping bleeding), but they should not be used for removing lesions themselves. Ablation or cauterization only remove the tissue on the surface but neglect the tissue growing beneath the surface. In most cases, ablation/cauterization surgery will not be effective for long-term management of endometriosis because the tissue remains below the surface. Excess scar tissue can also form using these methods due to the high energy and heat applied to surround healthy tissue. In many cases, the inflammation following ablation and cauterization can be another source of pain. We do not recommend ablation/cauterization surgery. Excision surgery is the gold standard for treatment. If a patient is considering surgery, it is important that they ask their surgeon the method for removal.

Definitive Surgery

Definitive surgery is performed when there is diffuse involvement of endometriosis to a particular site, and involves the removal of organs. The most common form of definitive endometriosis surgery is a hysterectomy (removal of the uterus). This can either include or exclude removal of the ovaries and cervix depending on the form of hysterectomy the patient and physician agree upon. As undergoing a hysterectomy is a serious decision, it is crucial that the patient and physician fully discuss the necessity for this procedure and that the patient is comfortable with their decision.

It is a common myth that having a hysterectomy will cure endometriosis. There is no cure for endometriosis and a hysterectomy is rarely the best treatment. Most endometriosis is located in areas other than the reproductive organs. If you simply remove the uterus and do not excise the remaining lesions, patients will continue to have pain. Decisions regarding a hysterectomy should be made with a doctor experienced in treating endometriosis and should only be performed if agreed upon by the patient. For more information, see Endometriosis and Hysterectomy.

How can symptoms be managed?

There are many ways of obtaining endometriosis relief, but it must be noted that the options below do not treat the endometriosis itself - they rather serve to alleviate some of the symptoms caused by the condition. These include:

• Low-Dose Oral Contraceptives
• Hormonal intrauterine device (IUD) (Rather than copper)
• Other hormonal therapies that provide long-acting progesterone medication (Injection or implant) 
• Painkillers such as non-steroidal anti-inflammatory drugs (NSAIDs)
• Hormone (GnRH) therapy 
• Acupuncture
• Changes in diet
• Exercise

Not everyone is the same

While all of the above options could be helpful to relieve symptoms, every patient will benefit differently from each treatment. What may work for one person, may not for another. Endometriosis is a disease that still requires much more research. It is crucial for each patient to trust their own judgment, work with their physician, and find the pain management strategy that works best for them if they decide to explore alternative treatment measures.

How to choose your doctor

As the medical community’s understanding of endometriosis is constantly growing, it is essential to choose a doctor who keeps track of these updates and is highly experienced in this condition’s diagnosis and treatment. A physician should be willing to discuss the impact of endometriosis on all aspects of a patient’s life and should share their findings in an organized, compassionate, and structured way.

Due to the limited amount of knowledge and training in endometriosis, it has a tendency to be misdiagnosed and mistreated. This is why in order to choose the right doctor, it is crucial that patients themselves are knowledgeable about the condition. Patients should ask their physician the right questions, which in the case of endometriosis all center around the patient’s period. If symptoms are worsening or synchronizing around the time of the patient’s period, this must be noted. These symptoms can include abnormally heavy or painful periods, but also painful bowel movements, diarrhea, nausea, vomiting, etc. If two or more of the symptoms do in fact coincide with a patient’s period, then a presumptive diagnosis should include endometriosis.

When patients receive a diagnosis of endometriosis, they will begin to explore their treatment options with their physician. This should ensure a thorough discussion, where the physician explains the risk and benefit of each treatment. Again, patients should draw on their own knowledge and research which they have performed to ensure their physician is providing them with the best treatment for their particular case. If at any point a patient feels uncomfortable with their physician, or loses trust in the care they receive, they should not hesitate to seek a new provider.

To learn more about choosing a doctor, visit this page.

References

• Hsu, A. L., Khachikyan, I., & Stratton, P. (2010). Invasive and non-invasive methods for the diagnosis of endometriosis. Clinical Obstetrics and Gynecology, 53(2), 413–419. http://doi.org/10.1097/GRF.0b013e3181db7ce8

• Endometriosis, Serdar E. Bulun, MD

• Assessing research gaps and unmet needs in endometriosis. PubMed.gov