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4 years ago Symptoms No comment

Pain Associated with Minimal Endometriosis

“Minimal” endometriosis does not mean minimal pain. In fact, the opposite may be true- “minimal”, smaller lesions can produce a large number of prostaglandins that can lead to major pain. While this is an older study and “microscopic” endometriosis is debated, it is an interesting study demonstrating the appearance of lesions and the related pain felt. The research was done using laparoscopy under IV conscious sedation. Researchers identified that more pain was felt by the patient for some colors of lesions versus other colors. They also discovered that palpation of the endometriosis lesions produced the pain of cramps, not the uterus. Location of the endometriosis lesions in certain areas reproduced pain in other areas of the body, such as lesions on the utero-sacral ligaments lead to cramps in the back or those on the side wall of the pelvis led to pain radiating down the leg.

Links:

Study:

“A simple analogy that is often used to explain endometriosis to the patient is the example of the eyelash and the eye. The eyelash is a “normal” part of the eye and quite separate from the eyeball. Should a “normal eyelash” be placed on a “normal” eyeball, the eye becomes red with dilated corkscrew vessels. The eye becomes painful but continues to function, though not optimally. The eyeball returns to its normal state once the eyelash is removed. The body reacts in a similar manner when the “normal peritoneum” is exposed to the “normal endometrial tissue.” The peritoneal lining develops red lesions with dilated corkscrew vessels and becomes painful. The pelvic organs continue to function but not optimally, which can lead to infertility. The way to cure the problem is to find and remove the “normal endometrial tissue.” Although this analogy is not perfect, the patients seem to grasp the concept, since they have all experienced an eyelash in the eye scenario….

“Initial work on mapping of pain associated with the endometriosis lesions resulted in some thought-provoking findings. The classic black lesions were found to be painful in only 11% of patients when the lesion was touched. Similarly, white lesions were painful in 20% of patients with red lesions at 37%, and clear lesions at 32% were the most painful (Table 1). These results added further reason as to why initial therapy had such poor results. Surgeons would only “see” the black lesions and removed them, but these were the least painful lesions. The most painful clear lesions were not “seen” at laparotomy and therefore remained, as did the pain. What became apparent next, while mapping the patient, was the fact that the pain extended 28 mm beyond the visible border of the lesion onto what looked like “normal” peritoneum… 

“…Palpation of the lesions of endometriosis produced the cramps, not the uterus. Patients, postoperatively, reported that once they identified the cramps of endometriosis, they noticed that they were different than menstrual cramps. Furthermore, palpation of the endometriosis lesions on patients without a uterus and both ovaries removed reproduced the cramps of endometriosis. This confirmed the findings of other researchers who have concluded that a hysterectomy often does not change the course of the pain of endometriosis since it is the lesions, not the uterus, which are responsible for the cramp-like pain. The location of the lesion in relationship to the pelvis can, in most instances, reproduce the symptoms the patient experiences. Lesions on the utero-sacral ligament, when palpated, cause pain or cramps in the back. Palpation of lesions on the side wall of the pelvis result in pain or cramps radiating down the leg.

“What is most interesting is that right-left orientation of the pelvis does not exist in some patients.12 That is to say, palpation of a lesion of endometriosis on the left side of the pelvis may produce pain that the patient perceives as being on the right side of the abdomen, and the opposite is also true. How many times has a laparoscopy under general anesthesia been done on a patient complaining of right-sided pain where the surgeon saw a normal looking pelvis on the right—only to wake up the patient and tell her, “I saw nothing on the right side of your pelvis that would cause your pain.”

“The data revealing the failure of the approach of “treat and see,” based on what the surgeon observed at laparoscopy under general anesthetic, is strong and reveals that a new approach is needed. An approach based on patient confirmed diagnosis and patient-based analysis of the results of therapy needs to be looked at in greater detail. The only person who knows where the pain starts and ends is the patient herself. She is also the only one who can confirm when the pain is no longer present.”                     

4 years ago Symptoms No comment

What influences pain levels?

Some women might experience minimal pain with endometriosis, while many experience may experience severe pain. Bloski and Pierson (2008) state that “women with minimal or mild endometriosis have been found to have high degrees of pain and infertility, while asymptomatic women have been diagnosed with Stage IV on laparoscopy for tubal ligation. The variability in clinical presentation and stage of disease likely reflects of our lack of understanding of the pathophysiology of endometriosis.” Pain is influenced by several factors- the location of the endometriosis, the “type” or “stage” (clear, black, red, etc) of lesions, how much innervation is there, how much inflammatory chemicals are being released, if adhesions are pulling on anatomy, if other conditions such as pelvic floor dysfunction, interstitial cystitis, or adenomyosis is present. Pain with endometriosis is multifactorial, including irritation of nerves in the pelvis, new nerve growth, heightened sensitivity to pain, inflammation in the pelvis, and pain producing agents in the pelvic fluid (Ferrero, Vellone, & Barra, 2019). Interesting is that one study, from 1986, demonstrates evidence from many years ago, yet misinformation and misconceptions still exist! Differences that could influence pain levels:

“The three most commonly suggested mechanisms for pain production in endometriosis are [1] production of substances such as growth factors and cytokines by activated macrophages and other cells associated with functioning endometriotic implants (7, 8); [2] the direct and indirect effects of active bleeding from endometriotic implants; and [3] irritation of pelvic floor nerves or direct invasion of those nerves by infiltrating endometriotic implants, especially in the cul-de-sac (8, 9). It remains plausible that in any individual more than one or all of these mechanisms may be in operation. The neural irritation or invasion hypothesis has gathered much support in the past decade. Tender nodularity in the region of the cul-de-sac and the areas of the uterosacral ligaments has approximately 85% sensitivity and 50% specificity for the diagnosis of infiltrative endometriosis (10). Women with such findings on pelvic examination may have deep dyspareunia and more severe dysmenorrhea. Those with infiltration of the uterosacral ligaments and/or diseases directly adjacent to or invading the rectal wall may have dyschezia (9). The intensity of pain associated with infiltrative disease has been correlated with the depth of penetration of the lesion. The most severe pain is seen when the disease extends ≥6 mm below the peritoneal surface (10). Both perineural inflammation and direct infiltration of nerves by endometriosis have been observed (11). However, these kinds of perineural changes have been observed most commonly in women with central pelvic disease (i.e., around the uterosacral ligaments and in the cul-de-sac and not in those with lateral peritoneal or ovarian endometriosis).”

*Dyspareunia- pain with intercourse, dysmenorrhea- pain with menstruation, dyschezia- pain or straining with defecation

  • Vernon, M. W., Beard, J. S., Graves, K., & Wilson, E. A. (1986). Classification of endometriotic implants by morphologic appearance and capacity to synthesize prostaglandin F. Fertility and sterility, 46(5), 801-806. Retrieved from https://www.fertstert.org/article/S0015-0282(16)49814-6/pdf 

“The severity of the symptoms of endometriosis has not always correlated well with the anatomic severity of the disease. This lack of correlation may be due to variations in the metabolic activity of the endometriotic implants present at different stages of the disease. Because prostaglandin F (PGF) has been implicated as a hormonal mediator of the clinical symptoms of endometriosis, PGF synthesis and content was measured in implants from 14 patients with mild, moderate, severe, or extensive disease. To assess whether PGF production was related to the status of implants, the authors classified implants, based on gross and histologic criteria, as (1) petechial or reddish; (2) intermediate or brown; or (3) powder-burn or black. PGF production of implants from patients with mild or moderate disease was greater than that of implants from patients with severe or extensive disease (P < 0.05), and PGF content was similar for all stages of endometriosis. Petechial implants produced twice the amount of PGF than intermediate implants (P < 0.05), which in turn produced more PGF than powder-burn implants (P < 0.05). Powder-burn implants did not have the in vitro capacity to produce PGF, and the amount of PGF contained in implants of all classes was similar. Therefore, endometriotic implant PGF production and possibly other biochemical activities are dependent on the physical status of the implant. The classification of implants by morphologic appearance may afford additional assistance in determining the prognosis of the disease and in the examination of the subtle effects of the disease on symptoms.”

  • Wang, Y. Y., Leng, J. H., Shi, J. H., Li, X. Y., & Lang, J. H. (2010). Relationship between pain and nerve fibers distribution in multiple endometriosis lesions. Zhonghua fu chan ke za zhi, 45(4), 260. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/20646536 

“There was significantly different distribution of nerve fibers in multiple endometriosis lesions, which was correlated with dysmenorrhea, anus pain, dyspareunia and chronic pelvic pain, not with clinical staging.”

  • McKinnon, B., Bersinger, N. A., Wotzkow, C., & Mueller, M. D. (2012). Endometriosis-associated nerve fibers, peritoneal fluid cytokine concentrations, and pain in endometriotic lesions from different locations. Fertility and sterility, 97(2), 373-380. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/22154765 

“The presence of endometriosis-associated nerve fibers appear to be related to both the pain experienced by women with endometriosis and the concentration of PF cytokines; however, this association varies with the lesion location.”

  • Wang, G., Tokushige, N., & Fraser, I. S. (2011). Nerve fibers and menstrual cycle in peritoneal endometriosis. Fertility and sterility, 95(8), 2772-2774. Retrieved from https://pubmed.ncbi.nlm.nih.gov/21334610/ 

“There was no difference in the density of nerve fibers across the menstrual cycle in peritoneal endometriotic lesions. These findings may explain why patients with peritoneal endometriosis often have painful symptoms throughout the menstrual cycle.” 

“Position and depth of invasion of endometriotic implants greatly impacts the procedure performed. Deeply infiltrating endometriosis (DIE) consists of endometriotic nodules that invade greater than 5mm into the peritoneal or organ surface. The type of pelvic pain is correlated to the location of the DIE implants and can aid in pre-operative assessment of each patients individualized symptoms (1). Patients with DIE are more likely to have noncyclic CPP, most likely related to the infiltration of subperitoneal or visceral nerves by the implant. This is facilitated by activation of prostaglandins and chemokines associated with local angiogenic and neurogenic environments. This is thought to increase C-type nerve fibers and increase sensation of CPP due to the constant inflammatory state that endometriosis creates (15). The stroma of these lesions expresses receptors for nerve growth factor (NGF), which aids in recruitment of sensory nerve fibers (16). This increase in innervations allows for further pain perception in affected individuals. The increase in these nociceptors is further enhanced by sensitization with estrogen, which is found in abundance due to local implant estradiol (E2) production.”

*angiogenic- forms new blood vessels, neurogenic- forms new nerves, nociceptors-pain receptors

“The pelvis is highly vascularized and enervated, which is why pain impulses from this region are processed and sent to the brain. This, along with multiple other factors, contributes to the pain syndrome that is associated with endometriosis. Peritoneal fluid in women with endometriosis contains high levels of nerve growth factors that promote neurogenesis, the ratio of sympathetic and sensory nerve fibers is significantly altered within endometriotic tissue, and the nerve density within endometriotic nodules is increased.7,8 Also, the cytokines and prostaglandins produced by mast cells and other inflammatory cells attracted to ectopic endometrial-like tissue can activate nerve fibers and can trigger nearby cells to release inflammatory molecules.5,6,8,9

“Another source of pain is nerve fiber entrapment within endometriotic implants.4 The cyclical sciatic pain, weakness, and sensory loss can all stem from endometriotic entrapment of the sciatic, femoral, or lumbosacral nerve roots.9 There are numerous descriptions of sacral radiculopathy occurring in patients with endometriosis, and there are even descriptions of wheelchair-bound patients becoming fully ambulatory after treatment of infiltrative endometriosis.9

“Central sensitization is another mechanism that promotes endometriosis-associated pain. Patients become highly sensitive to subsequent painful stimuli because of endometriosis-induced neuroplastic changes in descending pathways that modulate pain perception.10 In response to a subsequent insult (ie, nephrolithiasis or peritoneal organ injury), women can experience pain from endometriosis as a result of inability to engage descending inhibition pathways.”

“Initial work on mapping of pain associated with the endometriosis lesions resulted in some thought-provoking findings. The classic black lesions were found to be painful in only 11% of patients when the lesion was touched. Similarly, white lesions were painful in 20% of patients with red lesions at 37%, and clear lesions at 32% were the most painful (Table 1). These results added further reason as to why initial therapy had such poor results. Surgeons would only “see” the black lesions and removed them, but these were the least painful lesions. The most painful clear lesions were not “seen” at laparotomy and therefore remained, as did the pain. What became apparent next, while mapping the patient, was the fact that the pain extended 28 mm beyond the visible border of the lesion onto what looked like “normal” peritoneum ((Figure 1). Therefore, if the surgeon only removed the lesion at its border, the microscopic disease in the previously identified normal looking peritoneum was left, and persistence or recurrence of the symptoms was encountered.” 

  • Fraser, I. S. (2010). Mysteries of endometriosis pain: Chien‐Tien Hsu Memorial Lecture 2009.Journal of Obstetrics and Gynaecology Research, 36(1), 1-10. Retrieved from https://pubmed.ncbi.nlm.nih.gov/20178521/  “The more that one looks at the condition endometriosis, the more one realises that it is a unique and complex condition exhibiting a bizarre range of deviations from normal endometrial and myometrial physiology, and presenting with a challenging range of pain‐related symptoms. The changing nature of the pain is not well defined, and the molecular mechanisms leading to pain generation are far from clear. Recent research has begun to reveal some of these links between expression of unusual molecules in the eutopic endometrium and ectopic lesions, microanatomical changes in the pelvic nervous sytem, neuronal dysfunction and the later development of neuropathic pain.” 
  • Miller, E. J., & Fraser, I. S. (2015). The importance of pelvic nerve fibers in endometriosis. Women’s health, 11(5), 611-618. Retrieved from https://pubmed.ncbi.nlm.nih.gov/26314611/

“Several lines of recent evidence suggest that pelvic innervation is altered in endometriosis-affected women, and there is a strong presumption that nerve fibers demonstrated in eutopic endometrium (of women with endometriosis) and in endometriotic lesions play roles in the generation of chronic pelvic pain. The recent observation of sensory C, sensory A-delta, sympathetic and parasympathetic nerve fibers in the functional layer of endometrium of most women affected by endometriosis, but not demonstrated in most women who do not have endometriosis, was a surprise. Nerve fiber densities were also greatly increased in myometrium of women with endometriosis and in endometriotic lesions compared with normal peritoneum. Chronic pelvic pain is complex, and endometriosis is only one condition which contributes to this pain. The relationship between the presence of certain nerve fibers and the potential for local pain generation requires much future research.” 

“Our group discovered that ectopic growths harvested from ENDO rats and women with established endometriosis develop their own C-fiber (sensory afferent) and sympathetic (autonomic efferent) nerve supply. The supply is derived from nerve fibers innervating nearby territories that sprout branches into the growths [10], [11]. This discovery suggests that, rather than the growths alone, it is the ectopic growth’s own innervation that is a major contributor to the maintenance and modulation of pain in established endometriosis.” 

  • Anaf, V., Chapron, C., El Nakadi, I., De Moor, V., Simonart, T., & Noël, J. C. (2006). Pain, mast cells, and nerves in peritoneal, ovarian, and deep infiltrating endometriosis. Fertility and sterility, 86(5), 1336-1343. Retrieved from https://doi.org/10.1016/j.fertnstert.2006.03.057 

“The presence of increased activated and degranulating mast cells in deeply infiltrating endometriosis, which are the most painful lesions, and the close histological relationship between mast cells and nerves strongly suggest that mast cells could contribute to the development of pain and hyperalgesia in endometriosis, possibly by a direct effect on nerve structures.” 

“The objective of this study was to evaluate the significance of severe preoperative pain for patients presenting with ovarian endometrioma (OMA)…. After multiple logistic regression analysis, uterosacral ligaments involvement was related with a high severity of chronic pelvic pain [odds ratios (OR) = 2.1; 95% confidence interval (CI): 1.1–4.3] and deep dyspareunia (OR = 2.0; 95% CI: 1.1–3.5); vaginal involvement was related with a higher intensity of lower urinary symptoms (OR = 13.4; 95% CI: 3.2–55.8); intestinal involvement was related with an increased severity of dysmenorrhoea (OR = 5.2; 95% CI: 2.7–10.3) and gastro-intestinal symptoms (OR = 7.1; 95% CI: 3.3–15.3). CONCLUSIONS: In case of OMA, severe pelvic pain is significantly associated with deeply infiltrating lesions. In this situation, the practitioner should perform an appropriate preoperative imaging work-up in order to evaluate the existence of associated deep nodules and inform the patient in order to plan the surgical intervention strategy.”

“In the brain stem, the neurotransmitters serotonin and norepinephrine modulate pain transmission through ascending and descending neural pathways. Both serotonin and norepinephrine are also key neurotransmitters involved with the pathophysiology of depression. Tricyclic antidepressants are effective treatments for pain and depression; selective serotonin reuptake inhibitors provide less benefit. Duloxetine and venlafaxine, which are serotonin and norepinephrine reuptake inhibitors, were shown in clinical trials to alleviate pain and depressive symptoms. Diabetic neuropathy and other chronic pain syndromes were also shown to benefit from duloxetine and venlafaxine. Antidepressants remain fundamental therapeutic agents for depression and anxiety disorders. Their extended use into chronic pain, depression with physical pain, physical pain with or without depression, and other potential medical conditions should be recognized.”

  • Grundström, H., Gerdle, B., Alehagen, S., Berterö, C., Arendt‐Nielsen, L., & Kjølhede, P. (2019). Reduced pain thresholds and signs of sensitization in women with persistent pelvic pain and suspected endometriosis. Acta obstetricia et gynecologica Scandinavica, 98(3), 327-336. Retrieved from https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/aogs.13508

“Women with pelvic pain and suspicion of endometriosis should probably be treated more thoroughly to prevent or at least minimize the concomitant development of central sensitization.”

Links:

  • “Hormones and chemicals released by endometriosis tissue also may irritate nearby tissue and cause the release of other chemicals known to cause pain….Some endometriosis lesions have nerves in them, tying the patches directly into the central nervous system. These nerves may be more sensitive to pain-causing chemicals released in the lesions and surrounding areas. Over time, they may be more easily activated by the chemicals than normal nerve cells are. Patches of endometriosis might also press against nearby nerve cells to cause pain.” https://www.nichd.nih.gov/health/topics/endometri/conditioninfo/Pages/symptoms.aspx

Reference

Bloski, T., & Pierson, R. (2008). Endometriosis and chronic pelvic pain: unraveling the mystery behind this complex condition. Nursing for women’s health, 12(5), 382-395. doi: 10.1111/j.1751-486X.2008.00362.x

Ferrero, S., Vellone, V. G., & Barra, F. (2019). Pathophysiology of pain in patients with peritoneal endometriosis. Annals of translational medicine, 7(Suppl 1). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6462618/

4 years ago Symptoms No comment

Introduction: Pain

What a Pain!

  • Pain can be experienced as mild to severe.
  • Pain can occur at any time during the menstrual cycle. 
  • Pain may not be confined to the pelvic area. 
  • Pain can be experienced as inflammatory (due to inflammation), peritoneal quality (irritation of surrounding tissue in the abdomen), musculoskeletal (muscles and ligaments affected), and/or neuropathic (irritated nerves).

Pain greatly affects quality of life, sleep patterns, fatigue, ability to work or go to school, and the ability to perform normal daily tasks. It is important to identify what it causing pain. Other related conditions can contribute to pain. Removing endometriosis is a significant step in pain relief, but it is often not the only step. Identifying other conditions, such adenomyosis or interstitial cystitis, which may be contributing to symptoms is important as well. In addition, pain and other conditions can have an effect on muscles, ligaments, and nerves. Years of pain and untreated disease cannot be undone in a day. Medications, physical therapy, and other therapies can help (see “Treatments“). 

4 years ago Symptoms No comment

Symptoms Based on Endometriosis Locations

Symptoms based on location of endometriosis lesions:

  • Foti, P. V., Farina, R., Palmucci, S., Vizzini, I. A. A., Libertini, N., Coronella, M., … & Milone, P. (2018). Endometriosis: clinical features, MR imaging findings and pathologic correlation. Insights into imaging, 9(2), 149-172.

           “Clinical manifestations depend on the anatomic locations of the disease.

  • Bladder: dysuria, gross hematuria during menses, irritative voiding symptoms, urgency, frequent urination, urinary storage symptoms, tenesmus, burning sensation, suprapubic discomfort and pain, urinary incontinence [2, 3, 15].
  • Ureters: dysmenorrhea, dyspareunia, urinary symptoms, hydronephrosis, flank pain, decline of renal function [2, 3].
  • Round ligaments: painful, palpable inguinal mass (extra-pelvic portion of the ligaments); nonspecific pelvic pain (intra-pelvic portion) [11].
  • Retrocervical region and uterosacral ligaments: severe and painful symptoms, dyspareunia [3].
  • Vagina: dysmenorrhea, dyspareunia, postcoital spotting, prolonged menstruation not responding to medical therapy leading to anaemia [3, 16].
  • Rectosigmoid colon: cyclic pain during defecation, dyschezia, cyclic hematochezia, bloating, constipation, bowel cramping, catamenial diarrhoea, pencil-like stools, bowel obstruction [2, 3, 12, 17].
  • When unusual locations outside the pelvis occur, the pain may be site specific.
  • Thoracic-diaphragmatic endometriosis: chest pain (diffuse or basithoracic) with right-sided predominance, scapular or cervical pain associated with menses, sometimes radiating to the arm, pneumothorax, dyspnea, hemoptysis [18,19,20].
  • Sciatic nerve: cyclic sciatica, back pain, gluteal pain radiating to the dorsal thigh and lateral lower leg, positive Lasègue’s sign, sensory loss, reflex alterations, muscle weakness, paresis [2, 21,22,23].”
4 years ago Symptoms No comment

Endometriosis symptoms

Endometriosis symptoms

Endometriosis symptoms can vary widely in both presentation and severity. While endometriosis can present with “typical” symptoms such as chronic pelvic pain during menstruation, it can also present with symptoms not readily attributed to endometriosis. One example is sciatica type symptoms- pain running along the lines of the sciatic nerve (from the low back down the back of the leg). For some, infertility rather than pain is the first sign that they note.

Pelvic Endometriosis:

The following study performed a literature review on pelvic endometriosis in order to identify signs and symptoms (hoping to lead to more timely investigation into the possibility of endometriosis).

Riazi, H., Tehranian, N., Ziaei, S., Mohammadi, E., Hajizadeh, E., & Montazeri, A. (2015). Clinical diagnosis of pelvic endometriosis: a scoping review. BMC women’s health, 15(1), 39. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4450847/pdf/12905_2015_Article_196.pdf

  • Pain:
    • Pain with periods (dysmenorrhea)- during and at the end of menstruation
    • Pelvic pain before and during menstruation
    • Pain during sexual intercourse or after sex (dyspareunia)
    • Lower abdominal pain or suprapubic pain
    • Lower back pain and loin pain
    • Chronic pelvic pain (lasting ≥6 months)
    • Pain between periods (intermenstrual pain)
    • Ovulation pain
    • Rectal pain (throbbing, dull or sharp, exacerbated by physical activity)
    • Pain often worsened over time and changed in character
  • Menstrual symptoms:
    • Heavy or prolonged periods (hypermenorrhea or menorrhagia)
    • Premenstrual spotting for 2–4 days
    • Mid cycle bleeding
    • Irregular bleeding
    • Irregular periods
  • Urinary problems:
    • Pain with urination (dysuria)
    • Blood in urine (hematuria)
    • Urinary frequency
    • Urinary tract infection
    • Inflammation of the bladder (cystitis)
  • Digestive symptoms:
    • Abdominal bloating
    • Diarrhea with period
    • Painful bowel movements
    • Painful defecation (dyschezia) during periods
    • Blood in stool (hematochezia)
    • Nausea and stomach upset around periods
    • Constipation
    • Irritable bowel syndrome (IBS)
    • Early satiety
  • Gynecologic comorbidities:
    • Gynecological infections and low resistance to infection
    • Candidiasis
    • Infertility
    • Pelvic inflammatory disease
    • Ovarian cysts
    • Bleeding after sex (postcoital bleeding)
  • Comorbidities:
    • wide range of allergies and allergic disease
    • dizziness
    • migraines and headaches at the time of period or before
    • mitral valve prolapse
  • Social life symptoms:
    • Inability to carry on normal activities including work or school
    • Depressed and anxious feelings
    • Irritability or premenstrual tension syndrome
    • Psychoemotional distress
  • Musculoskeletal symptoms:
    • muscle/bone pain
    • joint pain
    • leg pain
  • Other symptoms:
    • Chronic fatigue, exhaustion, low energy
    • Low-grade fever
    • Burning or hypersensitivity- suggestive of a neuropathic component
    • Mictalgia (pain with urination)

Some signs of endometriosis in other places/specific places might include:

  • Bowel:
    • Abdominal pain
    • Disordered defecation (dyschezia)
    • Having to strain harder to have a bowel movement or having cramp like pain in the rectum (tenesmus)
    • Bloating, abdominal discomfort (meteorism)
    • Constipation
    • Diarrhea
    • Alternating constipation/diarrhea
    • Painful defecation
    • Dark feces containing blood (melena) or fresh blood with bowel movements (hematochezia) (Charatsi et al., 2018)
    • “The gastrointestinal tract is the most common location of extrapelvic endometriosis (and extragenital pelvic endometriosis when referring to rectum, sigmoid, and bladder)… Symptoms, in general, include crampy abdominal pain, dyschezia, tenesmus, meteorism, constipation, melena, diarrhea, vomiting, hematochezia, pain on defecation, and after meals. The traditional cyclical pattern of symptomatology has not been confirmed by recent studies which postulate a rather noncyclical chronic pelvic pain as a more persistent symptom [32]. Cyclical symptoms that aggravate during menses, however, have also been reported in a small number of patients [33, 34]. Since intestinal mucosa is rarely affected, rectal bleeding is also an unusual symptom, reported in 0 to 15% to 30% of patients [15, 35, 36]. Bleeding can also occur due to severe bowel obstruction and ischemia [32, 37]. Acute bowel obstruction due to stenosis is a scarce complication reported only in cases when severe small bowel involvement is present or in the presence of dense pelvic adhesions.” (Charatsi et al., 2018)
  • Bladder and Ureters:
    • “feeling the need to urinate urgently,
    • frequent urination,
    • pain when the bladder is full,
    • burning or painful sensations when passing urine,
    • blood in the urine,
    • pelvic pain,
    • lower back pain (on one side)” (Medical News Today, 2018)
    • None (if endometriosis is close to the ureters there may be no presenting symptoms)
    • “Vesical endometriosis is usually presented with suprapubic and back pain or with irritative voiding symptoms [96]. These symptoms generally occur on a cyclic basis and are exaggerated during menstruation. Less than 20% of patients however report cyclical menstrual hematuria, which is considered a pathognomic sign for bladder endometriosis [97–99]. Bladder detrusor endometriosis symptoms may cause symptoms similar to painful bladder syndrome; therefore, diagnosis of bladder endometriosis should be considered in patients with recurrent dysuria and suprapubic pain [100]. Clinical symptoms of ureteral endometriosis are often silent [76, 101, 102]. Since the extrinsic form of the disease is more common resulting from endometriosis affecting the rectovaginal septum or uterosacral ligaments and surrounding tissues, patients present with dyspareunia, dysmenorrhea, and pelvic pain [103]. Abdominal pain is the predominant symptom, occurring in 45% of symptomatic patients [93, 104–106]. Symptoms are often cyclical when the ureter is involved, and cyclic microscopic hematuria is a hallmark of intrinsic ureteral disease [95, 107, 108]. There is a limited correlation between severity of symptoms and the degree of obstruction of the ureter. High degree of obstruction may proceed for a long time without symptoms, leading to deterioration of renal function [76]. Unfortunately, ureteral endometriosis is often asymptomatic leading to silent obstructive uropathy and renal failure [109].” (Charatsi et al., 2018)
  • Thoracic (Diaphragm and Lung):
    • “…many patients being asymptomatic. Symptomatic patients often experience a constellation of temporal symptoms and radiologic findings with menstruation, including catamenial pneumothorax (80%), catamenial hemothorax (14%), catamenial hemoptysis (5%), and, rarely, pulmonary nodules.However, symptoms have been reported before menstruation, during the periovulatory period, and following intercourse.Symptoms of thoracic endometriosis are largely related to the anatomic location of the lesions. Pleural TES typically presents with symptoms of catamenial pneumothorax and chest or shoulder pain. Catamenial pneumothorax is defined as recurrent pneumothorax occurring within 72 h of the onset of menstruation. The symptoms experienced by patients are comparable to those of spontaneous pneumothorax and include pleuritic chest pain, cough, and shortness of breath. Furthermore, diaphragmatic irritation may produce referred pain to the periscapular region or radiation to the neck (most often right-sided). The right hemithorax is involved in up to 92% of cases, with 5% of cases involving the left hemithorax and 3% experiencing bilateral involvement. Catamenial hemothorax is a less common manifestation of pleural TES. Similar to catamenial pneumothorax, it presents with nonspecific symptoms of cough, shortness of breath, and pleuritic chest pain. It is predominantly right-sided, although rare cases of left-sided hemothorax have been reported.Less common bronchopulmonary TES presents as mild to moderate catamenial hemoptysis or as rare lung nodules identified on imaging. Massive, life-threatening hemoptysis is rare. Pulmonary nodules can be an incidental finding at the time of imaging or can occur in symptomatic patients. They can vary in size from 0.5 to 3 cm. Outside of the well-established clinical manifestations of TES, cases of isolated diaphragmatic endometriosis are typically asymptomatic but can result in irritation of the phrenic nerve. This can produce a syndrome of only catamenial pain, presenting as cyclic neck, shoulder, right upper quadrant, or epigastric pain.” (Nezhat et al., 2019)

(catamenial refers to menstruation; pneumothorax is air leaking into the space between the lung lining; hemothorax is blood leaking into the space between the lung lining; hemoptysis is coughing up blood)

  • Sciatic: pain in the buttock or hip area; pain, numbness, and/or weakness going down the leg; symptoms may initially occur with ovulation or menses (Sarr  et al., 2018)
  • Scar: “Symptoms at presentation included the presence of a palpable mass at the level of the scar (78.57%), non-cyclic and cyclic abdominal pain (50%, 42.85% respectively), bleeding form mass (7.14%) and swelling of the affected area (7.14%).” (Malutan et al., 2017)

This qualitative study describes symptoms as experienced by individuals with endometriosis:

“All women had suffered severe and progressive pain during menstrual and non-menstrual phases in different areas such as the lower abdomen, bowel, bladder, lower back and legs that significantly affected their lives. Other symptoms were fatigue, tiredness, bloating, bladder urgency, bowel symptoms (diarrhoea), bladder symptoms and sleep disturbances due to pain….

“The women described the pain as ‘sharp’, ‘stabbing’, ‘horrendous’, ‘tearing’, ‘debilitating’ and ‘breath-catching’. Severe pain was accompanied by vomiting and nausea and was made worse by moving or going to the toilet. The frequency of pain differed between the women with some reporting pain every day, some lasting for three weeks out of each menstrual cycle, and another for one year…

“Most of the women complained of dyspareunia during and/or after sex….

“Heavy and/or irregular bleeding was another symptom experienced but in some women, it was a side effect of endometriosis treatment. Bleeding when exercising and after sex were experienced by only a few women. Women and their partners were particularly worried when bleeding occurred after sex….

“Most women reported that endometriosis had significant impacts as they lived through it every day of their lives…. The physical impact was associated with symptoms, treatment side-effects and changes in physical appearance. Pain in particular was reported to limit their normal daily physical activity like, walking and exercise. Women who had small children mentioned that they were not able to care for them as they would like…Fatigue and limited energy were also among reported physical impacts of endometriosis. Although infertility was primarily a physical impact of endometriosis, it had a negative impact on the psychological health, relationship, and financial status of the women….

“Most women reported a reduction in social activity, and opted to stay home, and missed events because of severe symptoms especially pain, bleeding and fatigue. They resorted to using up their annual leave after exhausting their sick leave because of their disease. Some women also decreased their sport or leisure activities and some gave up their routine sport including water ski, horse-riding, swimming and snow skiing….”

References

Charatsi, D., Koukoura, O., Ntavela, I. G., Chintziou, F., Gkorila, G., Tsagkoulis, M., … & Daponte, A. (2018). Gastrointestinal and urinary tract endometriosis: a review on the commonest locations of extrapelvic endometriosis. Advances in medicine, 2018. Retrieved from https://www.hindawi.com/journals/amed/2018/3461209/

Malutan, A. M., Simon, I., Ciortea, R., Mocan-Hognogi, R. F., Dudea, M., & Mihu, D. (2017). Surgical scar endometriosis: a series of 14 patients and brief review of literature. Clujul Medical, 90(4), 411. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5683831/

Medical News Today. (2018). Can endometriosis cause bladder pain?. Retrieved from https://www.medicalnewstoday.com/articles/321439

Nezhat, C., Lindheim, S. R., Backhus, L., Vu, M., Vang, N., Nezhat, A., & Nezhat, C. (2019). Thoracic endometriosis syndrome: a review of diagnosis and management. JSLS: Journal of the Society of Laparoendoscopic Surgeons, 23(3). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6684338/

Saar, T. D., Pacquée, S., Conrad, D. H., Sarofim, M., De Rosnay, P., Rosen, D., … & Chou, D. (2018). Endometriosis involving the sciatic nerve: a case report of isolated endometriosis of the sciatic nerve and review of the literature. Gynecology and minimally invasive therapy, 7(2), 81. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6113996/

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4 years ago Symptoms No comment

How Do I Know If I Have Endometriosis? Endometriosis Signs

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Learn Endometriosis Signs & Symptoms & What to Tell Your Doctor

Pelvic pain is common for most women during their period. However, for some – this time of the month comes with excruciating pain due to the medical condition – endometriosis (also known as endo for short). Believe it or not, endometriosis signs extend beyond just the debilitating pain, although, that’s the hallmark symptom of this inflammatory disorder.

If you think you might have endometriosis, it’s important to have a solid foundation of information before you see your doctor for a possible endo diagnosis. Keep reading to learn what endometriosis is and what are the most common signs and symptoms of this condition.

What Is Endometriosis?

Pronounced (en-doe-me-tree-O-sis), endometriosis is a chronic inflammatory disorder of the pelvis where tissue similar to that normally grows inside your uterus, grows elsewhere instead, usually on the outside of it. The endometriosis tissue can block fallopian tubes, cover your ovaries, and even line the organs of your pelvis. 

Endometriosis can cause intense pain and fatigue, which makes it a disabling inflammatory condition for many women. Pain from endometriosis can be so intense that sometimes even medication cannot touch it. Other organs commonly involved include the fallopian tubes, bowels, cervix, ovaries, vagina, and pelvic tissue. Rarely, endo may also affect distant organs. Learn more about the disorder in our previous article, “Endometriosis 101: Covering the Basics”.

What Are Endometriosis Signs and Symptoms?

Sadly, endometriosis is an inflammatory disorder that often goes undiagnosed for years because the hallmark symptoms are things that some women take for granted as “normal”: heavy bleeding and pain during periods. If you think you might have endometriosis, it’s important that you know what to look for and when you should notify a doctor. The following are seven common signs of endometriosis:

Dysmenorrhea (Painful Periods): 

Intense pelvic or abdominal pain is one of the most common symptoms of endometriosis. Endometriosis pain is often described as a sharp or stabbing sensation. During menstruation, women with endo may experience very painful periods because the endometrial tissue swells and bleeds every month, just like the uterine lining would. However, because this process is occurring outside the uterus, blood is not easily shed, and this pressure can cause extreme cramping that is much more intense than typical period cramps. Period pain should not disrupt your daily life, so if it does, you need to let your doctor know or find a qualified endo specialist.

Menorrhagia (Heavy Menstrual Bleeding): 

While many women bleed heavily during their period, endometriosis can cause significant blood loss. How do you know if your amount of bleeding is excessive? Watch for these signs:

  1. Passing large clots
  2. Period goes on longer than a week
  3. Bleeding through a pad or tampon in an hour
  4. Too fatigued to carry out daily activities

If you have these symptoms, you may have menorrhagia and should contact a gynecologist. Menorrhagia is sometimes caused by endometriosis, and it can cause anemia and severe fatigue.

Dyspareunia (Pain During or After Intercourse): 

When endometriosis is the cause of painful intercourse, the woman may not experience the pain upon entry, only upon deep penetration. There can be physical and psychological causes of this condition, and endometriosis may be the culprit, as tissue builds up on the other side of the lower uterus or vagina – and sexual intercourse can stretch the tissue. You should talk to an experienced physician if you have pain during or after intercourse.

Chronic Pelvic Pain: 

While the inflammatory condition usually involves pain during menstruation, endometriosis pain can occur at any time of the month. Endometriosis causes an increase in pressure due to the excessive tissue in the pelvic cavity. This can cause a chronic pain condition that might be felt exclusively in the pelvis or manifest as abdominal or back pain. 

Ovarian Cysts: 

There is a type of endometriosis that causes endometriomas (also known as chocolate cysts) to grow on your ovaries. These cysts are non-cancerous but may become large and painful. Also, women who have these may also have other endometrial growths in the abdominal or pelvic areas. 

Infertility: 

Up to about half of women who have problems with fertility also have endometriosis. Furthermore, up to 50 percent of women who have endometriosis are unable to get or stay pregnant. The relationship between these conditions isn’t always clear as many factors can impact fertility. However, in the event that the endometriosis tissue blocks the reproductive organs, there is a clear connection. Treating the condition can increase your odds of having a baby. If these fertility issues are affecting you, contact an endometriosis specialist. 

Bowel/Bladder Problems: 

Bathroom visits may be problematic if you have endometriosis lesions growing near your bladder or bowels. And if you are experiencing difficulty with urination or bowel movements or bleeding in the bowel – these may be signs of endometriosis. Also, if you have painful urination, blood in your stool, nausea, or hyper urgency to urinate – you should tell your medical provider immediately. 

When to Call Your Healthcare Provider

Share with your healthcare provider any of the following endometriosis signs and symptoms:

  • Pain. Pain is the most common sign of endometriosis, and it can be present:
    • During or after sex
    • With bowel movements
    • When urinating during your period
    • As chronic abdominal, lower back, or intestinal pain
    • Similar to menstrual cramps that get worse gradually
  • Bleeding or spotting between periods
  • Difficulty getting pregnant or infertility
  • Digestive issues or stomach problems such as diarrhea, constipation, bloating, or nausea—especially during your periods
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4 years ago Symptoms No comment

What are the First Signs and Symptoms of Endometriosis: Everything You Need to Know

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Sharp. Stabbing. Burning. Throbbing. Aching. All these adjectives have been used to describe endometriosis pain. Endometriosis is a condition that, for some women, can cause excruciating uterus pain. Some describe it as feeling like their insides are being pulled out of their bodies. Even worse – endometriosis pain medication doesn’t cut through or provide relief for many patients with this condition. Therefore, an endometriosis diagnosis can be very serious and life-changing news.

Our commitment to our patients runs deep, and our mission is to help patients with endometriosis pain and other complications find the skilled doctors they need.

As our first introduction to the disorder, we will give you a brief overview of the signs and symptoms of endometriosis, its causes, complications, and treatment options (or, as we like to call it – hope). First, we will give you general information on the disease and cover what endometriosis is.

What is the Endometrium?

The endometrium, also known as the endometrial lining, is the tissue that comprises the “wallpaper”, or lining of the uterus. The uterus is the pear-shaped organ that houses a growing baby. During pregnancy and menstruation, the endometrium plays vital functions.

What is Endometriosis Pain?

Endometriosis is pronounced (en-doe-me-tree-O-sis). Endometriosis is a medical condition in which tissue similar to what normally lines the inner walls of the uterus, also known as the endometrium, grows outside the uterus. It is often a very painful, even debilitating disorder. It may involve the ovaries, fallopian tubes, bowels, vagina, cervix, and the tissues that line the pelvis. In rare cases, it can also affect other organs, such as the bladder, kidneys, or lungs.

Signs and Symptoms of Endometriosis Pain

Signs and Symptoms of Endometriosis
signs of endometriosis
endometriosis symptoms

Not all women will experience the same symptoms of endometriosis or degree of intensity/severity. Some women may not experience any symptoms at all. 

endometriosis does not always have symptoms. It can show itself by complications such as infertility.

It is also important to keep in mind that the severity of symptoms is not a solid indicator of the progress of the disease. There are women with advanced stages of endometriosis who experience no symptoms at all and others with mild cases who endure many. Common endometriosis pain symptoms include: 

  • Painful periods, or dysmenorrhea
  • Infertility
  • Diarrhea during period
  • Pain during intercourse
  • Heavy or abnormal menstrual flow
  • Abdominal or pelvic pain after vaginal sex
  • Painful urination during or between menstrual periods
  • Painful bowel movements during or between menstrual periods
  • Gastrointestinal problems, including bloating, diarrhea, constipation, and/or nausea

Mechanisms of Signs and Symptoms of Endometriosis:

Painful Periods (dysmenorrhea)

Cyclic release of multiple inflammatory factors activates nerve fiber growth, leads to cell damage and fibrosis, and exacerbates pain during periods. 

Infertility

The overall mechanisms can include tubal blockage, local inflammation, uterine muscle dysfunction, local hormonal alterations, and much more.

Diarrhea During Menstrual Periods

Diarrhea may result from endometriosis growing directly on the rectal muscle or endometriosis inflammatory substances. Local production of inflammatory molecules can lead to hyper-motility of the sigmoid and rectum muscles, which can manifest as cramping and diarrhea.

Pain During Intercourse (Dyspareunia)

Endometriosis implants have more nerve endings than usual (hyperinnervated) and can produce pain with pressure. The act of intercourse can apply this pressure on the upper vaginal area and uterosacral ligaments, which are common locations of endo implants. Once this pain occurs and local inflammation further causes tension in the pelvic floor, the muscles surrounding the vagina can contract, which worsens the problem.

Heavy or abnormal menstrual flow

Endometriosis can impact your bleeding by increasing stress from pain or damage to the ovaries, which can change local hormonal function.

Abdominal or Pelvic Pain After Vaginal Sex

Uterine and pelvic floor spasms are part of regular orgasms. When these areas are hypersensitive due to endometriosis, spasms lead to continued contractions and pain that lasts for a while. In addition, rectal fusion to the posterior vaginal wall will also cause more direct pain and inflammation by the vaginal area pulling on the rectal wall. Also, as you probably recognize, any event that stirs up the pelvis and causes some trauma leads to increased molecular signaling, further amplifying the problem. 

Painful Urination During or Between Menstrual Periods (Dysuria)

Painful and frequent urination is a prevalent symptom of endometriosis. Endo cells and responding inflammatory cells produce inflammatory molecular signals that aggregate in the area of injury. These molecular signals affect all pelvic organs, including the bladder, leading to bladder wall spasms. Moreover, interstitial cystitis is common in endometriosis patients and can also be a factor. In the worst-case scenario, endo lesions implant inside the bladder, which can also cause cyclic bleeding from the bladder (hematuria). 

Painful Bowel Movements During or Between Menstrual Periods (Dyschezia)

Endometriosis causes inflammation and fibrosis or scarring as your body attempts to heal. This inflammation and fibrosis can severely alter the anatomy in the pelvis and distort the rectal course, gluing it to the uterus, cervix, and posterior vaginal wall. This angulation can cause constipation and trouble evacuating stool, while the inflammatory signals cause the rectal muscles to hyper-contract. These mechanisms lead to painful bowel movements, which worsen during the cyclic increases in inflammatory molecules. In the worst-case scenario, the endo will grow through the rectum wall over time, causing cyclic rectal bleeding.

Gastrointestinal Problems, Including Bloating, Diarrhea, Constipation, and Nausea

Generally, intestinal symptoms of endometriosis can be direct or indirect or related to conditions like small intestinal bacterial overgrowth (SIBO). Even if there are no direct implants on the bowel, the endo inside the abdomen and pelvis can cause enough inflammation to irritate the intestine and cause symptoms. In addition, endometriosis implants directly on the bowel can worsen the symptoms.

Causes of Endometriosis

One cause of endometriosis is the direct transplantation of endometrial cells into the abdominal wall during a medical procedure, such as a cesarean section. Besides this known cause of endometriosis, other theories exist as to how it develops:

1. One theory is that during the menstrual cycle, a reverse process takes place where the tissue backs up through the fallopian tubes and into the abdominal cavity, where it attaches and grows.

2. Another theory is a genetic link. This is based on studies that show if someone has a family member with endometriosis, they are more likely to have it as well.

3. Some also suggest that the endometrial tissues travel and implant in other body parts via blood or lymphatic channels, like cancer cells spread.

4. A fourth theory suggests that all cells throughout the body have the ability to transform into endometrial cells. 

Complications of Endometriosis

The following are complications of endometriosis if left untreated or in advanced stages of the disorder:

  • Infertility/subfertility
  • Chronic pelvic pain that can result in disability
  • Anatomic disruption of involved organ systems (i.e., adhesions, ruptured cysts, renal failure)

Diagnosis of Endometriosis

The diagnosis starts with assessing signs and symptoms and then performing imaging studies such as MRI and ultrasonography. But the confirmation or exclusion of the endometriosis diagnosis is only possible with surgical biopsy and histopathology. Laparoscopy is the gold-standard surgical modality for diagnosis in all cases.

Treatment for Endometriosis

Endometriosis needs a multidisciplinary team approach for effective and holistic treatment. This team should include the following medical professionals:

  • Nutritionist
  • Physical therapist
  • Endometriosis surgeon
  • Mental health therapist
  • Pain management specialist

Pain is often the biggest complaint from patients with endometriosis. Therefore, many treatment options are aimed at pain control. So first, here are some options for women to help temporarily ease the pain of endometriosis:

  • Exercise
  • Meditation
  • Breath work
  • Heating pads
  • Rest and relaxation
  • Prevention of constipation

These therapies may be used in combination with medical and/or surgical options to lessen the pelvic pain associated with this disorder. Furthermore, alternative therapies exist that may be used in conjunction with other interventions, and those include but are not limited to:

  • Homeopathy
  • Immune therapy
  • Allergy management
  • Nutritional approached
  • Traditional Chinese medicine

*Be sure to discuss any of these treatment options with a physician before implementing them.

The Right Medical Treatment For You:

Options for medical and/or surgical treatments for endometriosis are going to depend on several factors, including: 

  • Desire for pregnancy
  • The extent of the disease
  • Type and severity of symptoms
  • Patient opinions and preferences
  • Overall health and medical history
  • Expectations of the course of the disease
  • Patients’ tolerance level for medications, therapies, and/or procedures

In some cases, management of pain might be the only treatment. In others, medical options may be considered. The following are typical non-surgical, medical treatments for endometriosis:

  • “Watch and Wait” approach, where the course of the disease is monitored and treated accordingly
  • Pain medication (anything from non-steroidal anti-inflammatory drugs [NSAIDs] to other over-the-counter and/or prescription analgesics)
  • Hormonal therapy, such as:
    • Progestins
    • Oral contraceptives with both estrogen and progestin to reduce menstrual flow and block ovulation
    • Danazol (a synthetic derivative of the male hormone testosterone)
  • Gonadotropin-releasing hormone antagonist, which stops ovarian hormone production

Surgical Treatment Options for Endometriosis:

Despite their effectiveness in symptom control, pain medications can have significant side effects. Moreover, these medications do not stop the progression of the disease, and symptoms might return once stopped. But on the other side, surgery can lead to long-term relief and can prevent further damage to tissues. Your treatment plan should be a shared decision based on your desires, goals, and abilities. 

Almost all endometriosis surgical procedures are laparoscopic or robotic. These are minimally invasive surgeries in which small tubes with lights and cameras are inserted into the abdominal wall. It allows the doctor to see the internal organs and remove endometriosis.

Excision of Endometriosis

In this technique, a surgeon cuts out much or all of the endometriosis lesions from the body. Therefore, surgeons avoid leaving any endometriosis lesions behind while preserving normal tissues. This technique is widely adopted by highly skilled endometriosis surgeons who are world leaders.

Ablation of Endometriosis

In this technique, a surgeon burns the surface of the endometriosis lesions and leaves them in the body. Most top experts highly criticize this ablation method. Ablation is most popular with surgeons who have not received enough training to do excision. As a result, these surgeons are not comfortable performing excision, and they do the ablation.

Hysterectomy

this is a surgery in which surgeons remove the uterus and sometimes ovaries. But, many surgeons consider hysterectomy an outdated and ineffective treatment for endometriosis. Almost all top endometriosis surgeons reject doing it unless there is a clear indication for hysterectomy such as adenomyosis.

Laparotomy

this surgical procedure cuts and opens the abdomen and does not use thin tubes. Therefore it is more extensive than a laparoscopy. Very few surgeons still do laparotomy because of its complications. Almost none of the top endometriosis surgeons do laparotomy for endometriosis.

Multidisciplinary Care

Along with effective surgical treatment, the patient should start working with endometriosis experts in physical therapy, mental health, nutrition, and pain management to achieve the best possible outcome.

Get in touch with Dr. Steve Vasilev

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