Endometriosis is an extremely painful chronic condition, which often also leads to infertility or subfertility, that affects about 10 percent of women worldwide. It is characterized by growth of endometrial-like tissue, which normally lines the inside of the uterus, outside of the uterus on pelvic organs, the abdomen, bowel, and beyond. This tissue is not the same as the endometrium, characterized by very different behavior and unique molecular profiles.
Eventually, personalized “theranostic” (therapy and diagnostic) tools will exploit these unique molecular profiles and lead to far better diagnosis, therapy and monitoring approaches. Research is accelerating in this area, which is already very pervasive in other diseases such as cancer and various immuno-inflammatory conditions. Meanwhile, the only therapies that are available to actually treat endometriosis, not just the symptoms, are purported to be hormonal options and excisional surgery. However, there are major limitations to the argument that hormonal therapies actually work very well to treat endo rather than simply reduce symptoms.
Thus, in a word, “can endometriosis be treated without surgery?”, the answer is a resounding NO ! That is not to say that hormonal and other treatments, mainstream and integrative-holistic, can’t help make your life better. They can. Let’s unpack this a little bit to give you a roadmap of the options.
Understanding Endometriosis
The exact cause of endometriosis is technically unknown, but we know it is influenced by genetic, genomic, hormonal, immunologic and environmental epigenetic factors. In other words, it is “multi-factorial”. This means the reason you may have endo could be different from why your friend or even your sister does. Endo can also behave very differently because different factors are probably in play in different people. This makes a “standard treatment” hard, if not impossible, to recommend to any given patient. This is changing with the advent of endometriosis bio-molecular pathway research, which will lead to highly individualized targeted treatments. But this is not part of what is available today.
Diagnosis of Endometriosis
Diagnosing endometriosis is very challenging, because the symptoms can mimic other conditions. This is part of the reason that diagnosis is often delayed by 5-10 years and intentional or inadvertent gaslighting is rampant, depending on which specialist was consulted. The doctor may be looking at you through a general practice medical lens, or intestinal, urologic, neurologic or other lenses in forming their opinions.
Rule # 1 is to listen to the patient. This is almost never done to an appropriate extent. Why? Because today’s medical system limitations often lead to five to ten minute visits with a semi-interested and overworked provider who is likely under-informed regarding endometriosis.
When rule #1 is broken, an appropriate evaluation and testing is not likely to be done. Ideally, a clinical suspicion leads to testing that may include ultrasound or MRI, various blood tests, testing for associated conditions and so on. None of these will reliably lead to a diagnosis of endo but can lead to appropriate specialist referrals to get to the root cause of pain, such as endo.
Rule #2 in medicine, in general, is to get a diagnosis before recommending treatment. This is because treatments can be ineffective when treating the wrong condition or, worse, can lead to complications and side effects. Unfortunately, in the author’s strong opinion, this is often violated specifically in endometriosis treatment. A common standard is to offer hormonal therapy to patients to see if it might work because the diagnosis might be endometriosis and endo is, in part, fueled by hormones. This may or may not be reasonable depending upon individual circumstances and choices.
This brings us to rule #3, that we’ll cover next, which proposes that patients should be offered treatment options to select from after informed consent about the potential risks vs the potential benefits based on the best possible scientific evidence. This is not always done very well and certainly depends on the “trust factor” with your selected specialist(s), since scientific evidence is subject to interpretation. Most patients do not realize this.
Conventional Treatment of Endometriosis
Traditional treatment for endometriosis often involves medication or surgery. Medications can include pain relievers and hormonal therapies. In the near future medications will include targeted biomolecular non-hormonal therapies, but they are not here yet. Pain relievers are obviously a symptom reducing band-aid and are not intended to treat, so we will not discuss them here either. They can certainly help in overall management but we will focus on “treatment” in this article.
Hormones aim to either shut down ovarian function (in other words, cut off estrogen) or at least regulate the menstrual cycle, and progesterone analogs, to potentially reduce the growth of endometriosis tissue.
Surgery is used for definitive diagnosis of endo as well as treatment by removing any lesions or implants that are found. In some cases the two modalities can be used hand in hand, but the order in which they are used and the nature of the proposed hormonal therapy are important considerations.
Hormonal Treatment
International guidelines are very confusing and inconsistent regarding hormonal therapy. Because of this, recommendations can vary between practitioners. We won’t delve into all of these options here but the following are excellent summary articles on this important topic.
Read More: Endometriosis Guidelines: A Closer Look at a Potential Source of Confusion in Treatment Debates
The important points to consider are as follows:
- The ONLY way currently to definitively diagnose endometriosis is through biopsy, usually performed during surgery.
- Starting treatment that can cause extreme side effects and potential long-term harm without first getting a definitive diagnosis seems imprudent. So, if a practitioner offers hormones because they “think” you have endo based on history, examination and perhaps some scans, at least get a second opinion from an endometriosis specialist. This approach is within international guidelines but can cause you a world of misery and potential harm if not managed in expert hands.
- Hormone therapy for endo boils down to either reducing or eliminating estrogen, or increasing progestational agent levels to try to medically eliminate endo lesions.
- Endometriosis cells differ from endometrial cells that are found in the uterus by being relatively resistant to synthetic progestin or natural micronized progesterone therapy.
- Hormonal therapy is known to reduce pain when endometriosis is the cause. However, studies have shown that it fails to actually retard the growth of endometriosis tissue when objectively tested in pathology laboratories after hormonal therapy. Further, hormonal therapy cannot eliminate scars or fibrosis caused by endo and this fibrosis by itself can be a cause for pain.
- While unproven, under some circumstances it may be prudent to use less toxic hormonal therapy options to potentially reduce the risk of endo recurrence after surgery.
Surgical Treatment
When symptoms, history, physical exam, scans and laboratory evidence all point to endometriosis as a strong possibility to be the root cause of pain, and/or infertility, minimally invasive surgery should be considered to find out for sure. If endo is diagnosed, then medical hormonal therapy may make sense as part of a highly individualized treatment plan under the guidance of an endo specialist.
The caveat to considering surgery is that there are, of course, potential risks and complications even though it is minimally invasive. These risks can be minimized in the hands of an expert surgeon, but they should be considered in a risk-benefit discussion.
More importantly, assuming you have identified an expert endo excision surgeon, surgery is the cornerstone to current effective treatment. While incompletely proven, for many reasons, it appears that excision of endo lesions rather than burning away (fulguration) is a better and safer approach. To discover more about surgical considerations, consider the following articles.
Read More: Breaking the Cycle: Understanding Endometrioma Recurrence After Surgery
Integrative Holistic View of Endometriosis
Since the cause of endo is incompletely understood, but highly multifactorial, and because the reason endo is present in any given individual may vary, either surgery or hormonal therapy or both may fail. Failure is relative. In other words, failure may be defined as no immediate pain improvement, persistent subfertility, or it may mean recurrence years later. These are very different scenarios, requiring different approaches. Also, it’s important to consider whether or not associated conditions have been addressed, such as SIBO or other microbiome irregularities, other inflammatory immune-modulated disease and so on. Finally, pelvic floor physical therapy is not just a symptom band-aid but a critical co-treatment for pelvic floor function before and after surgery. These topics are all beyond the scope of this article but you can discover more by reading the following articles.
Read More: Pelvic Floor Physical Therapy: What you Need to Know
If expert excision surgery and supportive hormonal therapy, when used, fails to alleviate pain then supportive pain management can still improve quality of life. This can be mainstream pain and anti-inflammatory medications, nerve block injections, electrical stimulation modalities and/or more holistic approaches including acupuncture, acupressure, mind-body biofeedback approaches such as HeartMath, herbals, aromatherapy and more.
Read More: Integrative Therapies for Endometriosis
Kicking it up a notch, here is something you do not see covered much other than in a very superficial manner. It is not rocket science, but is not simplistic at the potential treatment level either. However, it is something you can implement in a proactive way at any point in your journey. Specifically this is the impact of nutrition and lifestyle choices, as well as well-selected and targeted supplements, but drilled down a lot further than simply eating right, exercising and de-stressing.
Upcoming bio-molecular therapies will target specific biological pathways that we are now beginning to better understand. Many pathways are already identified, many not. The problem is that there are no mainstream medical therapies yet which can target these pathways safely and effectively. We know from other related genomically modulated inflammatory diseases, like cancer and auto-immune disorders, that these treatments take a while to develop and offer safely. Meanwhile, many of the genomic, metabolic and epigenetic abnormalities that influence endo are known or at least partly known. With few exceptions, while it is too early to safely use pharmaceutical agents to modulate these abnormalities, nutrients, specific exercise, toxin avoidance, and even state of mind can affect the same pathways abnormalities without risk.
Nutrigenomics and Epigenetics
How do toxins or stress adversely affect your health, while healthy diet and exercise positively influence your health? In large part, relatively new sciences like metabolomics and genomics, and their derivatives, explain this. You are born with your genes and, so far, you can’t alter that deck of cards. Some genes may be “bad” and increase your risk of endo, as well as other diseases. However, not everyone with some bad genes develops disease. The most famous examples are identical twins who inherited the exact same genetics yet might look a little different (e.g eye or hair color) and often get different diseases. Why?
Anything and everything you eat, drink, get exposed to via skin or breathing, or even think about or emote, can affect your genes through epigenetics. This means these substances and neurochemicals, good or bad, can turn genes on and off. Of course it is infinitely more complex than that and multiple genes affect one process in many cases. However, you can actively modulate your inflammatory and oxidative state. Do we know what veggie or what thought or what toxin turns what specific gene on or off? No. But we do know how these gene controlled pathways synergize and work together to create health or facilitate disease.
Conclusion
Surgery is a cornerstone to definitive diagnosis of endo and serves as very important part of treatment. The path to success is a correct diagnosis, attention to detail and a highly individualized treatment plan. This can only be carried out in consultation with endometriosis specialists in medical and surgical management.
Unfortunately, it is not easy to find someone or a team that can fit your needs but it is a crucial step forward to seek out the best you can. The more complex your situation (e.g. possible advanced disease or repeat surgery) the more you need an excision surgeon with master surgeon skills. Ideally you want a specialist who is not only a surgeon but also capable of guiding you through any additional treatment options you may need, mainstream and holistic. While a master excision surgeon and integrative endo specialist is hard to come by, many have a team that can fulfill your needs.
References:
Endometriosis: Etiology, pathobiology, and therapeutic prospects
Brassica Bioactives Could Ameliorate the Chronic Inflammatory Condition of Endometriosis
Diet and risk of endometriosis in a population-based case–control study
