Endometriosis pain typically starts one to two days prior to bleeding. In the beginning stages, endometriosis is usually cyclical (it comes and goes with the menstrual cycle). At later stages if the endometriosis becomes invasive, there can be dense fibrosis or scarring that may give the pain a more constant character. Approximately 10% of endometriosis is invasive. This means that it grows deeper in the tissue to which it is attached. Common medical terms for this type of endometriosis are Deep Infiltrating Endometriosis or Deep Fibrotic Endometriosis.
Endometriosis can be treated in a number of ways. There are many medical options such as birth control pills and shots, intrauterine devices and injections such as GnRH agonists that put the body into a menopausal state. These therapies only make the endometriosis dormant and does not "cure" it. The stronger therapies such as GnRH agonist injections are limited in their duration of safe use. Some newer evidence shows promising results using aromatase inhibitors to decrease the estrogen stimulation to the endometriosis. It is important to realize that none of these therapies get rid of the disease. They are useful, however in patients whose pain is controlled on the medicines and allows some patients to avoid surgery.
The only therapy ever shown to "cure" endometriosis is surgery. That being said, it provides a "cure" in only 50-60% of patients. Surgery combined with post operative medical therapy tends to give patients the longest pain free interval after treatment.
It can be difficult for a physician to adequately know the extent of the disease prior to surgery. Symptoms and physical exam in the office are very important. In Europe and South America, some institutions are using vaginal ultrasound to locate implants in and around the rectum. Skilled ultrasonographers can deterime the location, size and depth of endometriotic nodules. I am beginning to impliment this technique into my practice. Hopefully, this will allow me to better predict the extent of the diseae prior to surgery.
Surgery for endometriosis can be very complex. The endometriosis is often located around areas that are of concern the the gynecologic surgeon. These include the bowel, bladder, vagina and ureters. I feel it is important in planning your surgery for endometriosis to choose a surgeon who has experience in working around these areas and are trained in dealing with the complications or injuries that may occur.
One common practice is to perform a hysterectomy in patients with painful periods. Sometimes a hysterectomy is performed without knowing if endometriosis is present. If the uterus is removed without removing the surrounding endometriosis, patients may have continued pain or future complications. I have come across a few patients who have had a hysterectomy performed, either vaginally or through an abdominal incision, who had endometriosis left behind. In these cases, I have discovered endometriosis growing into the wall of the rectum, the bladder and the vagina, and completely encasing the ureters.
In many patients with painful periods and endometriosis, it is not necessary to have a hysterectomy performed. If the endometriosis does not involve the uterus, it is often adequate to remove the endometriotic implants and nodules throughout the pelvis and abdomen, thus preserving fertility. This is especially important in young patients.
