Endometriosis Foundation

I just returned from the World Congress of the AAGL. Our keynote speaker was Padma Lakshmi. She is a co-founder of the Endometriosis Foundation of America. She is better known for her show on Bravo network, Top Chef. She shared her endometriosis story with us and her devotion to education of this debilitating disease.

She suffered with pelvic and abdominal pain for 26 years before she was finally diagnosed with endometriosis. After finding a surgeon skilled in surgical excision of endometriosis she began her road to recovery. Three surgeries later she is now pain free and has a beautiful daughter.


I echo her statement and the opinion of the Endometriosis Foundation of America, that surgical excision is the "gold standard" treatment for endometriosis. The current average years to diagnosis is around ten years. As we educate parents and young women about the signs and symptoms of endometriosis, hopefully we can begin to prevent the most severe forms of the disease that can affect so many aspects of women's lives.

Painful periods and endometriosis

I will have a patient come for help who has had a long history of painful cramping with her period.  Occasionally these patients will have had a hysterectomy performed at an early age because none of the medical therapies have worked to control her pain.  Painful periods can have many causes.  I would like to discuss one of the most common - Endometriosis.

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.

Treating Endometriosis

As my surgical practice continues to evolve, I am seeing many more patients referred from other physicians and from patients for surgical management of endometriosis. Due to the nature of my fellowship with the AAGL and Dr. Liu, I have become a fan of excising endometriosis as opposed to just coagulation/vaporization with electrical energy or laser. This is especially true in the cases of extensive endometriosis.

Endometriosis can be treated in many different ways. Initially it is prudent to control symptoms of endometriosis with medical therapy in patients who may not want surgery. Common medical therapies for endometriosis include medications such as ibuprofen, birth control pills, depoprovera injection, levonorgestrel IUD, danazol and depo-lupron. The goal of any of these medical therapies is to control the symptoms of endometriosis. They do not cure the disease. Symptoms usually recur when therapy is stopped and some of the medications can only be used for a limited time.

Although surgical excision is not the perfect treatment for endometriosis (the perfect treatment is not available) it does provide the highest cure rate of any therapy. Surgery combined with post operative medical therapy has been shown to give the longest pain free period for patients with endometriosis.

Surgical excision of endometriosis requires very advanced laparoscopic skills. These are by far the most difficult surgeries I have encountered. Endometriosis tends to cause a great deal of internal scarring. Also approximately 10% of endometriosis is of an invasive nature. It does not stay on the superficial lining tissue of the pelvis treated with coagulation or vaporization.

To make it more difficult, invasive endometriosis may involve structures such as the bowel or rectum, the bladder, the ureters, the cervix and uterus and the vagina. Except in the cases of endometriosis of the vagina, cervix and rectum, it can be very difficult to know the extent of endometriosis prior to surgery. I have assisted many surgeons in residency and practice, who have looked inside and ended the surgery because the disease was too extensive and beyond their skills to treat surgically. This is appropriate. Many of these patients are pushed to the realm of Lupron. Although Lupron can treat symptoms in some patients, I have found through experience that it does not control symptoms of invasive endometriosis where tissue damage has already occurred.

A recent article in Ob.Gyn. News stated that failure of medicines to control pain does not suggest that endometriosis is not the cause. In fact some of the most advanced cases of endometriosis I have encountered are in patients in their mid to late twenties who have never had a surgical diagnosis or treatment.


Because of the uncertain nature of endometriosis, having a surgeon skilled in advanced laparoscopy is essential. On his website, www.endometriosissurgeon.com, Dr. David Redwine lists questions that you should ask your physician prior to endometriosis surgery. These questions will assure the most appropriate surgical management of your disease.

Rectovaginal Endometriosis

Rectovaginal Endometriosis

I recently had a patient who was referred to me for treatment of pelvic pain and pain with intercourse. She had multiple prior surgeries for “endometriosis”. During one of her prior surgeries she was noted to have “adhesions of her rectum to the uterus.

On her office exam, there was a nodule behind the uterus that I could feel. It appeared to be pulling her rectum into the back side of the uterus. This is the third patient I have seen with this similar presentation and history.

During surgery, she was noted to have a nodule of endometriosis that pulled the rectum forward and blocked her normal “pelvic cul-de-sac” (the area between the uterus and the rectum. During dissection, this nodule was dissected off the uterus and the rectum and freed up. After identifying the rectum, ureters and uterine blood vessels, the nodule was removed.

When treating endometriosis surgically, it is important to use the physical examination to know what to expect at the time of surgery. It is also important for the surgeon to feel comfortable removing endometriosis in difficult areas such as over the ureters or bowel. There are many times endometriosis surgeries are performed and the surgeon takes a look and then stops the surgery because the endometriosis is too bad or in locations “too risky” to remove.

This patient is an ideal example of the necessity to know how to identify and adequately excise the endometriosis encountered during surgery.