Treatments for Endometriosis and Pelvic Pain
OBGYN Matters Endometriosis and Pain Management Clinic aims to operate an outpatient clinic with a comprehensive patient centred approach to the care of women with endometriosis and pelvic pain.
Mr Christian BarnickSpecialist in laparoscopic surgery and endometriosis
As in all areas of medicine, the key to successful treatments for endometriosis is in the careful selection of the right treatment for each individual patient. Patients have different needs and it is important that these are acknowledged and that treatment is centred round them. For many conditions medical treatment is sufficient to either control symptoms or cure the disease. However, endometriosis is particularly resistant to medical treatment and often surgery is required to achieve treatment aims.
Most gynaecologists are able to perform keyhole surgery for treatments for endometriosis but the extent of their expertise in this area varies widely. What Mr Barnick aims to do is to perform this type of surgery to the highest possible standard, thus maximizing the success of surgery and minimizing possible complications, even in cases of advanced stage IV endometriosis.
Christian Barnick is a consultant at OBGYN Matters and is an expert in the management of endometriosis and endometriosis surgery. He runs the Endometriosis centre at OBGYN Matters and also the Endometriosis centre at the Homerton University Hospital NHS trust in East London.
He has been managing endometriosis for over 20 years. His main interest is in the laparoscopic, surgical excision of endometriosis. He has three operating lists every week during which he performs complex surgery for endometriosis and also keyhole surgery for fibroids and other benign gynaecological conditions. Each year he performs more than 250 operations for endometriosis alone.
He is well recognized as an expert in the field of complex keyhole surgery and is one of only a few surgical trainers in laparoscopic surgery accredited by the Royal College of Obstetricians and Gynaecologists.
The Endometriosis surgical team at the Portland Hospital
What happens at the first appointment?
At the first appointment (30-60mins) a detailed history is taken and a carefully examination is performed. Patients are asked about their symptoms and the extent to which their quality of life is being affected. A trans-vaginal Ultrasound scan is used to visualise the pelvic organs.
The information gathered forms the basis upon which a detailed individual treatment plan is made in discussion with the patient.
Information is provided about endometriosis and all available treatment options. At this appointment there is also the opportunity to discuss issues concerning details of treatment and any future fertility concerns. Any other necessary investigations are arranged (blood tests, MRI) and if indicated a laparoscopy (looking inside the abdomen) and/or a hysteroscopy (looking inside the womb) are arranged. If desired, these can normally be performed within a few weeks.
Two weeks following this surgery there is a further consultation. This is arranged to check patient progress following the surgery and to give a full explanation of the operative findings. This includes a review of all the surgical images and a DVD is often provided to further improve understanding of the nature of the endometriosis and the surgery that has been performed.
This is also an opportunity to discuss fertility plans and future treatment options.
What is Endometriosis?
Endometriosis is a condition where tissue similar to the lining of the Womb (endometrium) is found elsewhere in the body, usually the pelvis. It is a benign (non-cancerous) but often painful condition, which is characterized by the presence of endometriotic deposits mainly in the pelvis (the ovary, areas around the womb, on the bladder and the intestines).
Each month this tissue breaks down causing internal bleeding which has no way of leaving the body. This leads to inflammation, pain and the formation of scar tissue. In the ovary the endometriosis tissue can bleed and cause fluid contained areas which are called endometriomas (chocolate cysts). These cysts are usually detected by an ultrasound scan.
Endometriosis is very common, it is estimated that endometriosis is present in between 10% – 25% of young women and up to 35% of women with fertility problems
What are the Symptoms/Signs of Endometriosis?
Although women may not show any signs of endometriosis, the common symptoms of endometriosis include:
- Painful and or heavy periods.
- Premenstrual pain
- Pelvic pain possibly radiating to back and thighs
- Moderate to severe pain at the time of ovulation
- Painful sex
- Pain when passing urine and or blood in the urine
- Pain and difficult with opening bowels
- Bleeding from the bowel with the periods
- Difficulty in becoming pregnant
The amount of endometriosis does not always correspond to the amount of pain and discomfort. A small amount of endometriosis can be more painful than severe disease depending on the site of endometrial deposits. The majority of women with this condition will experience some of these symptoms. Some women will have no symptoms!
Why does Endometriosis Occur?
The exact cause is unknown, although a few theories have been put forward:
- Genetic predisposition to the condition
Researchers are looking into the gene that could identify women predisposed to endometriosis. A woman who has a mother or sister with endometriosis has a six times greater risk of developing endometriosis.
- Retrograde menstruation
Some of the menstrual blood flows backwards through the fallopian tubes and into the pelvis. Some of this endometrial tissue implants and causes endometriosis.
- Lymphatic or circulatory spread
Blood vessels and lymphatic channels carry Endometrial tissue into the pelvis where it proliferates.
- Immune dysfunction
There are theories suggesting an altered immune response that could lead to the development of endometriosis possibly by failing to prevent implantation of endometrial tissue that has entered the pelvis by retrograde menstruation.
How is Endometriosis Diagnosed?
History and Examination:
A thorough history may highlight suspicion about endometriosis. The commonest symptom is pelvic pain which may be worst around menstruation or after intercourse. However, many women have atypical symptoms and the diagnosis is often delayed or missed altogether. A vaginal examination may demonstrate painful symptoms or reveal nodules of endometriosis in the pelvis.
An ultrasound scan may show the presence of endometriosis cysts, although not all cysts are caused by endometriosis and some types of endometriosis may not be seen on a scan.
This is the only definitive way to diagnose endometriosis. In this operation a telescope is inserted into the pelvis under general anaesthesia via a small cut near the navel. This allows the surgeon to see the pelvic organs and any endometrial spots or cysts. It may also be possible to surgically treat the endometriosis at the time of diagnosis.
Slide showing endometrial glands and stroma from outside the womb
Treatment for Endometriosis
Aims of treatment:
- Pain relief
- Reducing endometrial growth
- Removing the endometriosis by excision
- Delaying recurrence of the disease
- Optimizing and preserving fertility
For effective long-term treatment of endometriosis various treatments are available. The treatment varies according to a variety factors:
- Age at diagnosis
- The severity of symptoms
- The severity of the disease
- Most importantly, the desire to have children
The treatment is carried out as a partnership between the patient and doctor.
Conservative management (‘wait and see’)
If the symptoms are very mild, fertility is unaffected or if menopause is approaching, this approach may be suitable.
Drug treatment for endometriosis
- May bring about an improvement in the pain symptoms
- May shrink or slow down the progression of the condition
- Is commonly used before surgery or before IVF treatment
- Delays recurrence of the disease
- Is NOT effective in the long term
Commonly used drugs:
- Medroxyprogesterone (Provera)
- Dyhydrogesterone (Duphaston)
- Norethisterone (Primulut)
- Triptorelin (Gonapeptyl)
- Goserelin (Zoladex)
- Leuprorelin (Prostap)
GnRH virtually stop all ovarian activity. They stop the ovaries working and thus reduce the production of oestrogen. This results in a temporary but reversible state of menopause (not actual menopause). These drugs are used prior to surgery to shrink and reduce the vascularity in the endometriosis and to facilitate surgical treatment.
These drugs are given as an injection once a month for three to six months but may be sometimes used for longer.
- Combined oral contraceptive pill
- Mirena coil
- Depo- Provera
With the exception of the oral contraceptive pill the Mirena coil and Depo-Provera, none of these drugs offer effective contraception and alternative contraception must be used.
All of the hormonal treatments have potential hormonal side effects, these include:
- Hot flushes, sweating
- Mood wings
- Vaginal dryness
- Decreased sex drive
- Osteoporosis with longer use
If these menopausal side effects are severe or treatment is prolonged then Hormone Replacement Therapy is given in the form of Tibolone, a synthetic steroid with oestrogen like activity.
Gonapeptyl or Zoladex must NOT be taken:
- If there is any suspicion of possible pregnancy
- During breast feeding
- If abnormal vaginal bleeding is present
Because there is an initial hormone surge with this treatment, symptoms of endometriosis and ovarian cyst size may temporarily increase with the first injection of GnRH. Similarly, the first period after the injection may be irregular and painful. These problems usually settle down after the second injection. Gonapeptyl is not a cure, as the symptoms recur when the treatment is discontinued, although the interval of reappearance of symptoms varies from one person to another.
It is important to remember that the use of Gonapeptyl or Zoladex does not guarantee contraception.
Surgical treatment options for endometriosis:
Diagnostic laparoscopy with or without treatment.
This is a technique in which a thin telescope is inserted into the abdomen to inspect the pelvic organs. A 1 cm incision is made within the umbilicus and the abdomen is filled with gas. This distention allows the surgeon to inspect the pelvic organs to confirm the diagnosis of endometriosis.
Another small incision is made close to the pubic hairline to insert a second surgical instrument to manipulate the pelvic organs . If any endometriosis is seen then a further incision is made to allow treatment to the affected areas. The surgeon will then either burn out or remove the affected areas. Conservative, laparoscopic surgery, depending on the severity of the disease, aims to excise, ablate or vaporize the endometrial tissue. This can be achieved using a number of different energy sources (diathermy / laser / harmonic scalpel). The endometriosis may be ablated or excised. It is not clear exactly what the best option for treatment is but at OBGYN matters we aim to excise all the endometriosis wherever possible.
Patients may be discharged on the same day, though in some cases an overnight stay is needed. The duration of stay depends on the extent of the endometriosis and the amount of post-operative pain. It is important to realize that extensive surgery can be achieved through keyhole surgical techniques.
Endometriosis in the pelvis on the Utero-sacral ligament
Endometriosis is excised using mono-polar scissors
Endometrriosis fully excised
Endometriotic cysts (endometrioma)
This is the commonest cyst in the ovary that requires treatment. Endometriomas can cause pain and infertility. Repeated surgery on endometriomas will decrease ovarian reserve and thus fertility. These ovarian cysts can either be treated by cyst removal (cystectomy) or cysts destruction (drainage and coagulation).
Which type of surgery is better for endometriomas ?
- reduces the risk of the cyst coming back (Recurrence) but there is a possibility of more ovarian tissue being destroyed.
Draining and coagulation (burning)
- This destroys less ovarian tissue and may be better for fertility treatment.
- The risk of the cyst coming back is higher.
A pre-operative measurement of Anti Mullerian Hormone (AMH) may be helpful in assessing ovarian reserve and in planning the type of surgery that is performed.
This decision is made in discussion with the patient taking into account their desire for having a baby.
Risks of Surgery:
All surgery has some risks. In this particular instance these depend on the type of surgery and extent of endometriosis.
All operations have risks associate with:
- Deep vein thrombosis.
In surgery for mild endometriosis the risk of major complications requiring a laparotomy occurs in about 1 in 1000 cases.
In more surgery for severe endometriosis there are increased risks of:
- Damage to bladder and ureters.
- Damage to bowel
- Damage to nerves and blood vessels
- Risk of delayed complications including bowel injury and haematoma (collection of blood in the abdomen).
If any of these complications occur, a laparotomy (open surgery through a larger cut) may be need to correct the damage or to stop bleeding.
Combination therapy for endometriosis:
If the endometriosis is severe or is covering large areas of the pelvis it may not be possible to excise all the endometriosis at the first laparoscopy. This particularly occurs in stage IV disease, when the bowel or ureters are involved by endometriosis. In this situation the ovarian endometrioma are drained, adhesions divided and as much of the endometriosis as possible is excised. This is then followed by a 6 months course of LHRH anologues (Gonapeptyl, Zoladex, Prostap). These are given to switch off any remaining endometriosis, reduce inflammation and reduce the blood supply to the pelvis. This in turn helps in making the endometriosis less bloody, thus enabling a more complete excision at a second laparoscopy.
Radical surgery that includes removal of the ovaries and the uterus is considered only if the symptoms are extremely severe and of long duration, fertility goals have been accomplished, and all other forms of treatment have been exhausted.
Pain Management in endometriosis:
- Diclofenac (Voltarol)
Painkillers reduce pain but do not prevent the recurrence of endometriosis.
Neurogenic pain is best treated with nerve block or drugs that work directly on the nervous system. We have close links with a pain management team if these are deemed necessary.
Many women will seek to use complementary therapies to help with their endometriosis. This may often help to deal with difficult, persistent symptoms, or energy levels which can be very low in endometriosis. At present there are no clinical trials that conclusively show benefit but many women still find this approach useful. Options include acupuncture, Chinese or Western herbs, homeopathy and dietary changes.
We have close ties to various clinics within the Harley Street area and can arrange appointments if this is an area which needs to be pursued.
Endometriosis and Infertility:
There is a definitive link between endometriosis and infertility. Endometriosis is seen in about 20 to 35% of women referred to the fertility clinics worldwide.
Endometriosis can affect fertility in various ways as it:
- Distorts the pelvic organs
- Changes the position of tubes and ovaries and creates adhesions
- Alters hormonal function
- Interferes with Ovulation
- Creates a hostile inflammatory environment
- Causes decreased implantation of the fertilized egg
Pain during sex may also cause additional problems!
Surgical treatments for endometriosis, the division of adhesions and restoration of normal pelvic anatomy improve pregnancy rates. Excision or ablation of endometriosis both improve pregnancy rates.
IVF treatment removes gametes (sperm and oocytes) from the hostile, inflammatory, pelvic environment created by endometriosis and thereby maximises the chances of conception
How long should one wait after surgery to get pregnant?
It is probably advisable to start trying to get pregnant without delay! Evidence suggests that pregnancy rates are highest in the first six months following surgical treatment. In addition, there is evidence that women with endometriosis have an earlier decline in their fertility with age and an earlier menopause.
The decision when to try start trying to conceive may be assisted by tests such as a baseline FSH and Anti-Mullerian Hormone (AMH) as they give some idea of ovarian reserve and future fertility chances.
If women are not pregnant within 6 months of trying and are over 35 it is probably best to proceed straight to IVF as fertility will only decline over time.
Are success rates of IVF lower in women with endometriosis?
Compared to other patients, there is some evidence that pregnancy rates in IVF may be lower in women with endometriosis. There is evidence that women require a higher dose of drugs to stimulate the ovaries in endometriosis.
Ovarian reserve may be decreased in women with severe endometriosis and stimulation of ovaries may produce fewer eggs.
Can pregnancy rates be improved in endometriosis?
There is evidence that in cases of severe endometriosis, long suppression of ovaries by GnRH analogues may improve implantation. Before proceeding to the first IVF cycle, women are given three courses of Gonapeptyl after which they are started on the IVF drugs. This is a variation of the long protocol for IVF. The AMH level may also be useful as it allows fine tuning of the IVF drug dose and may improve pregnancy rates.
Operating on small endometriomas is best avoided especially in the presence of a low AMH level as it may further decrease ovarian reserve.
Preventing Recurrence of Endometriosis:
Endometriosis is a disease that can recur with the painful symptoms coming back. About 25% of women are likely to have recurrence of endometriosis within five years. In a few women, this recurrence comes earlier. This probably depends on how well the initial surgery is performed and how much of the endometriosis is removed, however, it is important to discuss the various methods of reducing the risk of recurrence.
In this treatment the ovarian hormones are suppressed, thus lowering the risk of endometriosis
Combined contraceptive pill - these given in three monthly courses are the most effective means of suppressing endometriosis. They may cause some breakthrough (irregular) bleeding.
Progesterone only pill.
Depo-provera – is reasonably effective, but can cause abnormal bleeding.
Mirena contraceptive device.
Mirena for Endometriosis
Mirena is a small T-shaped intrauterine contraceptive device that has been used for endometriosis. It contains the hormone progesterone, which is released into the uterus over a period of 5 years. It is a very effective contraceptive and a few studies indicate that it may be effective for the treatment of endometriosis.
How does it work?
The Mirena probably works by suppressing the growth of the endometrial implants causing them to waste away. It may also reduce some endometriosis-induced inflammation (swelling). The Mirena usually stops menstruation and thus reduces the pain that occurs with periods. It may also stop ovulation, although this is not always the case.
This IUCD may be introduced in out-patients but it may be preferable to have it inserted at the time of laparoscopic surgery.
More on “Treatments for Endometriosis” below:
For further information:
The National Endometriosis Society
Westminster Palace Gardens
1-7 Artillery Row
Tel: 0207 222 2781
Tel: 0870 7743665