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Category Archives: What is Endometriosis

6 months ago What is Endometriosis No comment

The Role of Estrogen Receptor-β in Endometriosis

Endometriosis is a complex and often painful condition characterized by the presence of tissue similar to the uterine lining (endometrium) outside the uterus. This study delves into the molecular differences between endometriosis lesions and normal uterine tissue, particularly focusing on hormonal receptors and their role in treatment resistance.

Differences in Hormonal Receptors and Treatment Resistance

Endometriosis lesions differ fundamentally from eutopic endometrium in their response to hormones. Estrogen is a key driver of endometriosis, fueling the growth and persistence of lesions. Unlike normal uterine tissue, endometriosis lesions have a unique hormonal receptor profile, notably with higher levels of estrogen receptor-β (ERβ) and lower levels of estrogen receptor-α (ERα) and progesterone receptors (PRs).

This hormonal imbalance contributes to the resistance seen in conventional hormonal treatments such as synthetic progestins, oral contraceptives, and gonadotropin-releasing hormone (GnRH) analogs. These treatments often fail in nearly half of patients, leaving a significant gap in effective management strategies. Aromatase inhibitors, in combination with ovulation suppressors, have shown promise for cases resistant to traditional treatments.

Unique Characteristics of Endometriosis Lesions

Endometriosis lesions can produce their own estrogen, exacerbating inflammation and pain. They exhibit high levels of ERβ, which is more than 100 times higher than in normal endometrium. This overexpression is believed to be influenced by defective DNA methylation and other epigenetic mechanisms. Conversely, ERα and PR expression are significantly reduced in endometriosis lesions. The imbalance between ERα and ERβ disrupts normal hormonal responses, including the ability of estradiol to induce PR expression.

The suppression of PR-B, in particular, contributes to progesterone resistance, a hallmark of endometriosis. Progesterone resistance makes it difficult to manage the condition with conventional hormonal therapies, as the body does not respond effectively to progesterone’s regulatory effects.

The Impact of Estrogen and Prostaglandins on Pain and Inflammation

Estradiol, a potent form of estrogen, is a key hormone in endometriosis. It reaches the lesions either through circulation or is produced locally via aromatase activity. This local estrogen production promotes inflammation, pain, and growth of the lesions. ERβ overexpression stimulates prostaglandin production by inducing COX2 expression, further amplifying pain and inflammation.

Insights into Molecular Differences

The study highlights several molecular differences between endometriotic and eutopic tissues. Key findings include:

  • ERβ overexpression: This suppresses ERα expression, leading to high ERβ-to-ERα ratios in endometriotic cells.
  • Progesterone resistance: Reduced PR-B levels impair the ability of progesterone to regulate endometriotic growth.
  • Steroidogenic activity: The orphan nuclear receptor SF1 is overexpressed in endometriotic tissue, driving local estrogen production.

A Shift in Hormonal Dynamics

The authors speculate that the high ERβ-to-ERα ratio may shift the hormonal balance in endometriotic stromal cells, inhibiting PR expression and further contributing to progesterone resistance. This dynamic underscores the critical role of ERβ in the pathology of endometriosis, with broad implications for understanding the disease and developing targeted therapies.

Conclusion

High estrogen production and unique receptor profiles are defining features of endometriosis. The overexpression of ERβ and the suppression of PR-B highlight the complexity of the condition and its resistance to conventional treatments. Addressing these molecular differences holds the key to developing more effective management strategies and improving outcomes for women with endometriosis.

Reference:


  • Bulun, S. E., Monsavais, D., Pavone, M. E., Dyson, M., Xue, Q., Attar, E., … & Su, E. J. (2012). Role of estrogen receptor-β in endometriosis.
    Seminars in Reproductive Medicine, 30(01), 39-45.
    Read more.
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9 months ago What is Endometriosis No comment

The Autoimmune Protocol for Endometriosis

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Navigating Nutrition for Symptom Relief

Endometriosis is a challenging condition affecting many women, causing symptoms like painful periods, heavy bleeding, digestive issues, and weight changes. As a registered dietitian specializing in endometriosis and fertility, I understand the importance of finding effective nutrition strategies to alleviate these symptoms. One approach that has gained attention is the Autoimmune Protocol (AIP). Let’s explore what AIP is, which foods are allowed and restricted, how it can impact endometriosis, and its potential impact on food relationships. 

Understanding Endometriosis

It’s important to note that endometriosis is not an autoimmune condition; it’s a chronic inflammatory condition where tissue similar to the lining inside the uterus grows outside of it. While some dietary protocols claim to reverse or cure endometriosis, such claims should be considered red flags. Currently, there is no known cure for endometriosis, and excision surgery is regarded as the gold standard of care. However, nutrition can be supportive of managing symptoms and improving quality of life.

What is the Autoimmune Protocol (AIP)?

The Autoimmune Protocol (AIP) is an elimination diet designed to reduce inflammation, support gut health, and manage autoimmune conditions. Although endometriosis is not an autoimmune condition, the anti-inflammatory principles of the AIP for endometriosis can still be beneficial for symptom management.

Allowed Foods on the Autoimmune Protocol for Endometriosis

Meat and Fish: Grass-fed, pasture-raised, and wild-caught options are preferred. These provide essential amino acids, omega-3 fatty acids, and minerals like zinc and iron.

Nutrients: Omega-3 fatty acids (anti-inflammatory), protein (tissue repair), zinc (immune function), Iron

Vegetables: All non-nightshade vegetables, such as leafy greens, cruciferous, and root vegetables.

Nutrients: Fiber (digestive health), vitamins A, C, and K (antioxidant properties, bone health), folate (cell function).

Fruit: In moderation, focusing on berries and other low-glycemic options.

Nutrients: Vitamin C (immune support), antioxidants (reduce oxidative stress), fiber.

Healthy Fats: Avocado, coconut oil, olive oil, and animal fats from AIP-approved sources.

Nutrients: Monounsaturated fats (heart health), medium-chain triglycerides (energy).

Herbs and Spices: Non-seed-based spices like turmeric, ginger, and garlic.

Nutrients: Curcumin from turmeric (anti-inflammatory), allicin from garlic (antimicrobial).

Fermented Foods: Sauerkraut, kimchi, and kombucha for gut health.

Nutrients: Probiotics (digestive health), vitamins K2 and B12 (bone health, energy metabolism).

Foods Not Allowed on AIP for Endometriosis

Grains: Wheat, rice, oats, and other grains

Dairy: Milk, cheese, yogurt, and butter

Legumes: Beans, lentils, peanuts, and soy

Nightshade Vegetables: Tomatoes, peppers, eggplants, and potatoes

Nuts and Seeds: All types, including nut-based oils

Processed Foods: Any food containing additives, preservatives, and artificial ingredients

Refined Sugars: All forms of processed sugar and artificial sweeteners

Why People with Endometriosis Often Feel Better on AIP

Many people with endometriosis find relief following the Autoimmune Protocol. One way that it may reduce symptoms is by reducing high-FODMAP foods. FODMAPs (Fermentable Oligo-, Di-, Mono-saccharides, and Polyols) are short-chain carbohydrates that can be poorly absorbed in the gut, leading to bloating, gas, and abdominal pain. By removing these foods, AIP can improve gut health and reduce digestive discomfort. Additionally, the AIP diet is rich in omega-3 fatty acids and vitamins A, C, D, and E, all of which have been associated in research with reduced endometriosis pain due to their anti-inflammatory and immune-supporting properties. 

The Challenges of Restrictive Nutrition Plans

While the autoimmune protocol for endometriosis can provide relief for some, it is essential to acknowledge the potential pitfalls of highly restrictive diets:

Sustainability Issues: Long-term adherence to restrictive diets can be difficult. People may struggle with social situations, meal planning, and finding suitable food options.

Feelings of Failure: Not being able to stick to a strict diet can lead to feelings of failure, guilt, and decreased self-esteem.

Disordered Eating: Restrictive diets can contribute to disordered eating patterns, such as orthorexia (an obsession with eating “pure” foods) or binge eating.

Eating Disorders: These are serious mental health conditions characterized by unhealthy eating behaviors and attitudes toward food and body image. Examples include anorexia nervosa, bulimia nervosa, and binge eating disorder. Restrictive diets can exacerbate these conditions, leading to severe physical and psychological consequences.

A Balanced Approach: Combining AIP Foods with Flexibility

Incorporating AIP-approved foods can be beneficial in managing endometriosis symptoms due to their anti-inflammatory and nutrient-dense properties. However, it is crucial to maintain a flexible approach:

Personalization: Tailor the AIP framework to individual needs and preferences. Rather than completely eliminating the “not-allowed” list, consider incorporating whole grains, low-fat dairy (lactose-free may be beneficial), and including the nutrient-dense foods the plan recommends regularly.

Balanced Diet: Ensure a well-rounded endometriosis diet by including a variety of foods. Balance is vital to preventing nutrient deficiencies and maintaining a positive relationship with food.

Mindful Inclusion: To maintain a healthy relationship with food and body, honor your hunger and include foods you enjoy regularly. This includes foods with added sugars and processed foods. We know from research that diets don’t work long-term and are associated with poor health outcomes in the long term, weight gain, and bingeing. Rather than restricting these foods, include them when you are hungry for them without guilt, and focus on nutrient-dense foods most of the time.

Conclusion

The autoimmune protocol for endometriosis can offer temporary relief by reducing inflammation and supporting gut health. However, it is vital to approach any restrictive diet with caution, considering long-term sustainability and mental well-being. By focusing on AIP-approved foods while allowing for flexibility and personalization, individuals can find a balanced path to symptom relief and improved quality of life. Remember, diet is one tool in the endometriosis tool kit, but it is not curative, and symptom management often requires a multidisciplinary approach. As always, consult with a healthcare professional or dietitian to tailor dietary strategies to your unique needs and health goals.

Sources: 

https://www.sarahraerdn.com/endo-and-ic/autoimmune-Protocol-for-endometriosis

Protocol-for-endometriosis

Arab A, Karimi E, Vingrys K, Kelishadi MR, Mehrabani S, Askari G. Food groups and nutrient consumption and risk of endometriosis: a systematic review and meta-analysis of observational studies. Nutr J. 2022 Sep 22;21(1):58. doi: 10.1186/s12937-022-00812-x. PMID: 36138433; PMCID: PMC9503255.

Barnard ND, Holtz DN, Schmidt N, Kolipaka S, Hata E, Sutton M, Znayenko-Miller T, Hazen ND, Cobb C, Kahleova H. Nutrition in the prevention and treatment of endometriosis: A review. Front Nutr. 2023 Feb 17;10:1089891. doi: 10.3389/fnut.2023.1089891. PMID: 36875844; PMCID: PMC9983692.

Influence of diet on the risk of developing endometriosis. Joanna Jurkiewicz-Przondziono, Magdalena Lemm, Anna Kwiatkowska-Pamuła, Ewa Ziółko, Mariusz K. Wójtowicz. DOI: 10.5603/GP.a2017.0017. Ginekol Pol 2017;88(2):96-102.

Marcinkowska, A.; Górnicka, M. The Role of Dietary Fats in the Development and Treatment of Endometriosis. Life 2023, 13, 654. https://doi.org/10.3390/ life13030654

Barnard, N.D., Holtz, D.N., Schmidt, N., Kolipaka, S., Hata, E., Sutton, M., Znayenko-Miller, T., Hazen, N.D., Cobb, C., & Kahleova, H. (2023). Diet associations in endometriosis: a critical narrative assessment with special reference to gluten. Frontiers in Nutrition, 10. https://doi.org/10.3389/fnut.2023.1166929

Yalçın Bahat P, Ayhan I, Üreyen Özdemir E, İnceboz Ü, Oral E. Dietary supplements for treatment of endometriosis: A review. Acta Biomed. 2022 Mar 14;93(1):e2022159. doi: 10.23750/abm.v93i1.11237. PMID: 35315418; PMCID: PMC8972862.

Amini L, Chekini R, Nateghi MR, Haghani H, Jamialahmadi T, Sathyapalan T, Sahebkar A. The Effect of Combined Vitamin C and Vitamin E Supplementation on Oxidative Stress Markers in Women with Endometriosis: A Randomized, Triple-Blind Placebo-Controlled Clinical Trial. Pain Res Manag. 2021 May 26;2021:5529741. doi: 10.1155/2021/5529741. PMID: 34122682; PMCID: PMC8172324.

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1 year ago What is Endometriosis 2 comments

Is Endometriosis an Autoimmune Disease? An In-depth Analysis

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Endometriosis is a chronic and often debilitating condition that affects around 1 in 10 women in the US. It is characterized by the growth of endometrium-like tissue outside the uterus, often resulting in severe pain and fertility issues. Despite extensive research, the root cause of endometriosis remains unclear. Recent studies, however, have pointed to a potential interplay between endometriosis and autoimmunity, prompting questions about whether endometriosis could be an autoimmune disease.

Understanding Endometriosis

Endometriosis is a complex condition with a wide range of symptoms, varying from person to person. The endometriosis tissue, which is similar to the tissue that lines the uterus, can grow in several places outside the uterus, such as the ovaries, abdomen, and bowel. This misplaced tissue can bleed and become inflamed, leading to symptoms such as:

  • Severe cramps
  • Chronic pelvic pain
  • Nausea or vomiting
  • Heavy menstrual flow
  • Pain during sexual intercourse
  • Bowel or urinary problems
  • Infertility

The Immune System and Autoimmunity

To understand the potential link between endometriosis and autoimmunity, it’s crucial to first understand what autoimmunity means. The immune system, which is designed to protect the body against harmful pathogens, can sometimes mistakenly attack its own cells, tissues, or organs. This misguided immune response leads to autoimmune diseases, which can cause a wide array of symptoms depending on the part of the body affected. Examples of autoimmune diseases include Celiac disease, Rheumatoid Arthritis, and Multiple Sclerosis.

Endometriosis and Autoimmunity: The Connection

Although endometriosis is not officially classified as an autoimmune disease, research has suggested a possible link between the condition and problems with the immune system. Endometriosis may cause inflammation and an imbalanced immune response, which could potentially trigger the onset of an autoimmune disease. Alternatively, an existing autoimmune disease could exacerbate the symptoms of endometriosis.

Autoimmune Disorders Linked to Endometriosis

Several autoimmune disorders have been partially linked to endometriosis, including:

  • Multiple Sclerosis (MS)
  • Sjögren’s Syndrome
  • Lupus
  • Inflammatory Bowel Disease (IBD)
  • Celiac Disease
  • Rheumatoid Arthritis
  • Hypothyroidism
  • Addison’s Disease

Endometriosis: Not Officially an Autoimmune Disease

While there are clear links between endometriosis and certain autoimmune diseases, it’s important to note that endometriosis is not officially classified as an autoimmune disease. The exact cause of endometriosis remains unknown, and more research is needed to fully understand the complex interplay between endometriosis and the immune system.

Endometriosis: Immune System Dysfunction and Inflammation

Research has found evidence of immune system dysfunction in individuals with endometriosis. This includes elevated levels of inflammation and disturbances in the function of certain immune cells. This immune dysfunction could potentially contribute to the development and progression of endometriosis.

The Impact of Autoimmunity on Endometriosis Severity

Recent studies suggest that the presence of a co-existing autoimmune disease may be an indicator of more severe stages of endometriosis. This may be due to the additional inflammation and immune system dysfunction caused by the autoimmune disease, which could exacerbate the symptoms and progression of endometriosis.

Autoimmune Treatments for Endometriosis

Current treatments for endometriosis primarily focus on managing symptoms and preventing disease progression, as there is currently no cure. These treatments include hormonal medications, pain relievers, and surgery. While treatments for autoimmune diseases typically involve suppressing the immune system, these treatments have not been found to be effective for endometriosis. However, research is underway to explore potential immunotherapy treatments for the condition.

Endometriosis and Other Health Risks

Endometriosis is associated with several other health risks beyond autoimmune diseases. For instance, endometriosis may also be linked to asthma, allergies, and some cardiovascular diseases.

Endometriosis and Cancer

There is some evidence to suggest that endometriosis may be linked to certain types of cancer. Specifically, endometriosis may increase the risk of developing ovarian cancer and a specific type of breast cancer.

Conclusions and Future Directions

The potential link between endometriosis and autoimmunity presents a complex avenue for future research. While more studies are needed to fully understand this connection, the current findings could have significant implications for the diagnosis and treatment of endometriosis. By better understanding the role of the immune system in endometriosis, researchers may be able to develop more effective treatments and potentially even discover a cure for this debilitating condition.

References

https://www.medicalnewstoday.com/articles/326108

https://pelvicrehabilitation.com/is-endometriosis-an-autoimmune-disease/

https://theconversation.com/endometriosis-how-the-condition-may-be-linked-to-the-immune-system-203305

https://autoimmune.org/disease-information/endometriosis/

https://www.nature.com/articles/s41598-021-94877-z

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1 year ago What is Endometriosis 3 comments

Ureteral Endometriosis : Can Endometriosis Spread to the Ureter

Endometriosis is a chronic condition that affects approximately 10-15% of women between 15-50 and other genders as well. This medical condition, characterized by endometrial-like tissue outside the uterus, can impact various body parts. One of the lesser-known facts about endometriosis is its potential to spread to the urinary system, specifically the ureter. This article aims to shed light on the question: “Can endometriosis spread to the ureter?” and delve into the intricacies of this complex issue.

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Prevalence of Ureteral Endometriosis

Ureteral endometriosis is a form of urinary tract endometriosis (UTE), which is a rare manifestation of deep infiltrating endometriosis (DIE). Ureteral endometriosis can be either extrinsic, where endometriosis lesions occur outside the ureter causing it to compress, or intrinsic, which happens within the muscular, inner layers of the ureter.

While UTE affects between 0.3% and 12% of endometriosis cases and between 20% and 52.6% of those diagnosed with DIE, ureteral endometriosis is even rarer. Within the entire urinary system endometriosis, the prevalence of ureteral endometriosis is approximately 10%.

Causes of Ureteral Endometriosis

As the exact cause of endometriosis itself is not fully understood, pinpointing the cause of ureteral endometriosis is even more complex. Theories that attempt to explain the origin of ureteral endometriosis include stem cells, immune factors, and retrograde menstruation. In some women, UTE might also be iatrogenic, resulting from previous Caesarean sections.

Read More: Can Endometriosis on Ureter Cause Kidney Shooting Back Pain?

Symptoms Linked to Ureteral Endometriosis

Symptoms of UTE often overlap with those of peritoneal endometriosis. Women with UTE typically experience pelvic pain and dysuria (pain with urination). They may also suffer from frequent urinary tract infections, changes to urination frequency, and hematuria (blood in the urine). However, distinguishing this pain from the one that arises as a result of other forms of pelvic endometriosis is difficult.

Ureteral endometriosis is very rare, with an estimated prevalence of 0.1%. Up to 50% of women with ureteral endometriosis are asymptomatic, 25% have colicky pain, and 15% have gross hematuria. Tissue biopsy and histopathological examination are the gold standard methods for the diagnosis of ureteral endometriosis.

Read More: Can Endometriosis Cause Bowel Issues?

Diagnosing Ureteral Endometriosis

Diagnosing ureteral endometriosis can be quite challenging. It is, therefore, important to consult a specialist who can listen to and understand your symptoms. The initial stages of diagnosis of endometriosis affecting any area include taking the patient’s medical history, followed by pelvic examination and imaging techniques such as ultrasound, sonohysterography, or magnetic resonance imaging (MRI).

Intravenous pyelogram (IVP) is a good imaging technique to predict intrinsic forms of ureteral endometriosis. IVP also helps to evaluate ureter structure after treatment. MRI and Transabdominal ultrasonography can help visualize ureter structure and obstruction in the pelvic region.

Laparoscopic excision surgery followed by histological examination is the gold standard for confirming endometriosis in the urinary tract.

Read More: Can Minimal Endometriosis Cause Infertility

Treating Ureteral Endometriosis

The aim of ureteral endometriosis treatment is to remove endometriosis lesions in the urinary tract and preserve renal function. In cases of mild ureteral endometriosis, medical management, such as combined oral contraceptives, progestin, and aromatase inhibitors, may help with symptoms. However, this is not a permanent solution, and disease progression is expected, so surgical methods are the best option.

The primary treatment for ureteral endometriosis is excision surgery. Although successful medical treatment outcomes have been reported in the literature, medical treatment alone cannot revert the fibrosis resulting from ureteral endometriosis that leads to ureter obstruction.

Conclusion

Ureteral endometriosis, though rare, can cause serious complications, including the potential loss of renal function. Clinical suspicion and preoperative assessment may assist in diagnosis and allow for a multidisciplinary pre-consultation. The laparoscopic surgical approach is based on the extent of the disease and its localization and can be carried out successfully by a highly skilled surgeon.

In conclusion, if there is no other obvious etiology for the presence of unilateral hydroureteronephrosis in women in their reproductive age, the diagnosis of endometriosis should be considered. Early detection and treatment of ureteral endometriosis are essential to prevent severe complications, including the potential loss of kidney function.

References:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7595017/

https://www.cureus.com/articles/74383-isolated-intrinsic-ureteral-endometriosis-a-rare-presentation-of-ureteral-obstruction

Ureteral Endometriosis

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1 year ago What is Endometriosis No comment

Diaphragmatic Endometriosis: An In-Depth Analysis

Diaphragmatic endometriosis is a chronic health condition that manifests when tissues akin to the endometrial lining start to grow outside the uterus. This exogenous growth of endometrial-like tissue can be found in various areas such as the ovaries, fallopian tubes, and bladder. However, endometriosis can also occur in less common areas like the diaphragm, organs in the upper abdomen, like the stomach, in the retroperitoneum like the lymph nodes and kidneys, and so on.  Of these uncommon findings, finding some amount of endo on the diaphragm is perhaps most common. 

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Understanding the Diaphragm

The diaphragm is a large, dome-shaped muscle located beneath the lungs, responsible for the crucial function of respiration. Acting as a separation between the abdominal and thoracic (chest) cavities, its involuntary contraction and relaxation facilitate the breathing process. The diaphragm also has openings that allow important structures such as the esophagus and major blood vessels to pass through.

What is Diaphragmatic Endometriosis?

In most cases, diaphragmatic endometriosis affects the right side of the diaphragm. The endometrium-like tissue that builds up on the peritoneal surface of the diaphragm reacts to the menstrual cycle’s hormones in the same way it does in the uterus, which can cause a range of symptoms in the affected individuals.

Read More: Understanding How Endometriosis Can Cause

Symptoms of Diaphragmatic Endometriosis

The most common symptoms of diaphragmatic endometriosis include pain in the chest, upper abdomen, right shoulder, and arm. This pain typically occurs around the time of your period and may get worse when you take deep breaths or cough. In rare cases, if it grows through the diaphragm and involves the lungs, it can lead to a collapsed lung.  This is known as catamenial pneumothorax. However, diaphragmatic endometriosis can often be asymptomatic while only small superficial implants are present.  Hence, surgery usually involves at least looking at the diaphragms to document if there are any endo implants even if there are no symptoms in that area. 

Causes of Diaphragmatic Endometriosis

The exact causes of diaphragmatic or other types of endometriosis remain unknown.  However, it is plausible that endo cells from the pelvis can travel throughout the abdomen and up into the diaphragm. What makes them implant and grow there is unknown.  Alternatively, there are other possible etiologies, such as lymphatic or blood stream spread to this area or direct transformation of stem cells or growth of embryologic remnants into endometriosis implants.  This is all likely facilitated or repressed by genetic and genomic molecular signalling that is only now coming to be appreciated and unraveled.  

Read More: What Does Bowel Endometriosis Feel Like? Understanding the Pain and Symptoms

Diagnosis of Diaphragmatic Endometriosis

Diagnosing diaphragmatic endometriosis can be challenging. Diagnosis often involves a combination of medical history, physical examination, and imaging tests such as a CT (computed tomography) scan or MRI (magnetic resonance imaging).

The most reliable way to diagnose diaphragmatic endometriosis is via minimally invasive laparoscopic or robotic surgery. Ideally, the surgeon who is excising endo in the pelvis can also remove diaphragmatic implants or have a surgeon available as part of the team, who can do so. In the much rarer event that endo is suspected to be inside the chest and/or growing on or in the lungs, a thoracic surgeon should be consulted.

Treatment of Diaphragmatic Endometriosis

Surgery is the main treatment for diaphragmatic endometriosis and this can usually be accomplished using minimally invasive laparoscopic or robotic surgery.  Again, the excision surgeon or surgical team should be capable of removing endo from the diaphragms.  

In some cases, endo is not suspected to be growing on the diaphragm.  In that case, if the surgery cannot be safely accomplished by the surgeon or surgeons on the team, it is best to back out and not cause more harm than good.  The diaphragm is very thin and it is rather easy to enter the chest as part of the excision.  In expert hands, that is not a problem. However, going one step beyond diaphragmatic endo, if it is unclear whether or not the endo may be crossing into the chest cavity it is best to back out, re-evaluate with proper imaging and consultation and perform the surgery with a thoracic surgeon at a later date.  

Complications of Diaphragmatic Endometriosis

In relatively rare cases, endometriosis of the diaphragm can lead to defects or holes forming in the diaphragm. Endo can then grow into the chest cavity and possibly involve the lungs. This can lead to life-threatening complications such as a collapsed lung during your period (catamenial pneumothorax) or significant bleeding into the chest, also compressing the lung.  

Read More: Can Endometriosis on Ureter Cause Kidney Shooting Back Pain?

Conclusion

In conclusion, while it is relatively uncommon, endometriosis can indeed spread to your diaphragm. Under more rare circumstances it can even grow into the chest and lungs.  Expert endometriosis consultation and care is always prudent.  But if you are experiencing upper abdominal or chest symptoms as discussed this this article, it become crucial.  

References

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6018178/

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1 year ago What is Endometriosis No comment

Colon Chronicles: Delving into Bowel Endometriosis

In our recent blog, we highlighted the significance of addressing bowel endometriosis, a condition prone to misdiagnosis. Whether individuals have struggled with lifelong bowel issues or are suddenly facing disruptions, determining what’s considered normal can be perplexing. The “normal” range spans anywhere from three times a day to as infrequent as three times per week. In many sources, the focus is typically limited to frequency and to some degree consistency; however, there’s an overall scarcity of information on what defines normalcy. 

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ICYMI: Understanding Bowel Endometriosis

This ambiguity is particularly challenging for those with endometriosis, where gastrointestinal symptoms vary widely, making it tough to discern what’s amiss. About 90% of endometriosis cases involve some form of gastrointestinal symptoms, often leading to an IBS (irritable bowel syndrome) diagnosis, which essentially offers a label for persistent symptoms without an identifiable cause. The usual next step in diagnostics is often a colonoscopy, a key tool for identifying or ruling out certain diseases. This article explores the nuances of bowel endometriosis, with a primary focus on the role and precision of colonoscopy in diagnosing this condition.

Bowel endometriosis is considered to be deep infiltrating endometriosis and can lead to a variety of symptoms which we discussed in the previous blog, but is often concerning if not diagnosed timely and may risk more complex surgeries including resection if the disease is not properly addressed. 

Related Reading: How to Get an Endometriosis Diagnosis

The Role of Colonoscopy – Is it helpful?

A colonoscopy is a diagnostic procedure commonly used to examine the inner lining of the large intestine (colon and rectum). It involves the use of a long, flexible tube called a colonoscope, which has a small camera attached to its end. This tool allows physicians to visualize the interior of the colon to identify any abnormal conditions or changes.

In the context of bowel endometriosis, a colonoscopy can potentially detect signs of endometrial tissue growth within the bowel. However, its effectiveness and accuracy in diagnosing this condition have been subjects of ongoing research and debate. Aside from its ability to detect endometriosis, there is also consideration of the provider performing the procedure and their level of knowledge of endometriosis. 

The use of colonoscopy in diagnosing bowel endometriosis has been a topic of considerable discussion among medical professionals. Given the invasive nature of the procedure and the often non-specific symptoms of bowel endometriosis, the role and necessity of colonoscopy in its diagnostic process have been questioned.

However, several case studies and research findings suggest that colonoscopy can indeed play a crucial role in identifying bowel endometriosis. In particular, it has been found to be effective in detecting endometriosis growth in the bowel, with certain colonoscopic findings such as eccentric wall thickening, polypoid lesions, and surface nodularities often being associated with endometriosis.

Evaluating the Accuracy of Colonoscopy for Diagnosing Bowel Endometriosis

While the potential of colonoscopy in detecting bowel endometriosis has been recognized, its accuracy in doing so has been the subject of extensive research. A number of studies have sought to evaluate the sensitivity, specificity, and predictive values of colonoscopy in diagnosing this condition.

One such study was conducted by Milone M et al., who performed a prospective observational study that included women diagnosed with deep pelvic endometriosis. The study aimed to evaluate the accuracy of colonoscopy in predicting intestinal involvement in deep pelvic endometriosis.

The results of the study suggested that colonoscopy did have the potential to detect bowel endometriosis, with a number of cases accurately diagnosed through the procedure. However, the overall sensitivity, specificity, and predictive values of colonoscopy were found to be variable, indicating room for improvement in its diagnostic accuracy.

In another study conducted by Marco Milone and his team, the researchers also found that while colonoscopy could indeed identify bowel endometriosis, its accuracy was not optimal. The study elucidated that the presence of colonoscopic findings of intestinal endometriosis in deep pelvic endometriosis was quite low, indicating that routine colonoscopy may not be justified for all women with deep pelvic endometriosis.

A Case Study: Bowel Endometriosis and Colonoscopy

To illustrate the potential role of colonoscopy in diagnosing bowel endometriosis, let’s consider a case study involving a 45-year-old woman who presented with abdominal pain in her left lower quadrant. This woman underwent a colonoscopy, which revealed a submucosal tumor-like lesion in her sigmoid colon.

Upon further examination using magnifying endoscopy, the lesion was found to contain sparsely distributed round pits – a finding that was suggestive of endometrial glands and stroma (the histological definition of endometriosis). This discovery led to a biopsy of the lesion, the results of which confirmed the presence of intestinal endometriosis.

This case study serves to highlight how colonoscopy, when combined with other diagnostic methods like magnifying endoscopy and biopsy, can aid in the detection and diagnosis of bowel endometriosis.

The Future of Bowel Endometriosis Diagnosis

While the role and accuracy of colonoscopy in diagnosing bowel endometriosis have been explored, research in this area is ongoing. The development and refinement of diagnostic methods are crucial for improving the detection and treatment of bowel endometriosis.

In parallel with the innovations in medical technology, new diagnostic methods such as magnifying chromoendoscopy, target biopsy, and virtual colonoscopy are being explored and studied for their potential to improve the accuracy of bowel endometriosis diagnosis. These advancements, coupled with a deeper understanding of the condition, may pave the way for more accurate and less invasive diagnostic options in the future.

Bowel endometriosis is a complex condition that can significantly impact the quality of life of those affected. While colonoscopy can play a role in its diagnosis, its effectiveness and accuracy are subject to continuous research and improvement. Exploring new diagnostic methods and refining existing ones are crucial steps toward enhancing the detection and treatment of this condition. As we continue to learn more about bowel endometriosis and its nuances, we can hope for more efficient and accurate diagnostic tools in the future.

Related Reading:

  1. Endo-Fighting Microbiome Optimization: Research-based Tips
  2. Endometriosis and the Microbiome: Insights and Emerging Research

References:

  1. Walter SA, Kjellström L, Nyhlin H, Talley NJ, Agréus L. Assessment of normal bowel habits in the general adult population: the Popcol study. Scand J Gastroenterol. 2010;45(5):556-566. doi:10.3109/00365520903551332
  2. Habib, N., Centini, G., Lazzeri, L., Amoruso, N., El Khoury, L., Zupi, E., & Afors, K. (2020). Bowel Endometriosis: Current Perspectives on Diagnosis and Treatment. Int J Womens Health, 12, 35-47. https://doi.org/10.2147/IJWH.S190326 
  3. Milone, M., Mollo, A., Musella, M., Maietta, P., Sosa Fernandez, L. M., Shatalova, O., Conforti, A., Barone, G., De Placido, G., & Milone, F. (2015). Role of colonoscopy in the diagnostic work-up of bowel endometriosis. World J Gastroenterol, 21(16), 4997-5001. https://doi.org/10.3748/wjg.v21.i16.4997 
  4. Tomiguchi, J., Miyamoto, H., Ozono, K., Gushima, R., Shono, T., Naoe, H., Tanaka, M., Baba, H., Katabuchi, H., & Sasaki, Y. (2017). Preoperative Diagnosis of Intestinal Endometriosis by Magnifying Colonoscopy and Target Biopsy. Case Rep Gastroenterol, 11(2), 494-499. https://doi.org/10.1159/000475751 

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1 year ago What is Endometriosis No comment

Understanding Bowel Endometriosis

Bowel Endometriosis is a debilitating chronic health condition that affects a significant number of women worldwide. This disease is characterized by the growth of endometrial-like tissue outside the uterus, specifically on or inside the bowel walls. The condition often presents with varying gastrointestinal symptoms like painful bowel movements, constipation, and diarrhea, making it difficult to diagnose.

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What is Bowel Endometriosis?

Bowel Endometriosis is a specific form of endometriosis that involves the intestines. In this condition, cells similar to those that line the uterus start growing on the bowel or even penetrate into the bowel wall. This growth can lead to painful and uncomfortable symptoms, particularly during a woman’s menstrual cycle.

Prevalence and Affected Areas

Bowel Endometriosis is a subset of a larger condition, endometriosis, affecting 1 in 5 endo patients. The most common sites for bowel involvement are the rectum, appendix, sigmoid, cecum, and distal ileum. It’s also worth noting that bowel endometriosis frequently co-exists with endometriosis in other areas, making it a multifaceted disease that requires comprehensive treatment.

Symptoms of Bowel Endometriosis

Understanding the symptoms of bowel endometriosis can help in early diagnosis and treatment. It’s essential to note that these symptoms often overlap with other gastrointestinal conditions, making it a challenging disorder to diagnose.

Common Symptoms of Endometriosis

  • Painful bowel movements: This is one of the most common symptoms of bowel endometriosis. The pain is often described as sharp or cramping and may worsen during menstruation.
  • Constipation and Diarrhea: Changes in bowel habits are another common symptom. Some women may experience constipation, while others may have diarrhea. These symptoms may also worsen during menstruation.
  • Rectal Bleeding: While not as common, some women may experience rectal bleeding, particularly during their menstrual period. A healthcare professional should always evaluate this symptom as it can also be a sign of other serious conditions.
  • Abdominal Pain: Abdominal pain, often worsening during the menstrual cycle, is another common symptom. The pain can range from mild to severe and may be constant or intermittent.
  • Dyspareunia: Dyspareunia, or painful sex, is another symptom that may indicate the presence of bowel endometriosis. This pain often stems from endometriosis lesions in the posterior pelvic compartment peritoneum, an area around the rectum that includes the surface peritoneum, commonly called the pouch of Douglas.

Diagnosing Bowel Endometriosis

Diagnosing bowel endometriosis can be challenging due to the overlap of symptoms with other gastrointestinal disorders. However, several diagnostic tools can aid in the identification of this condition.

Physical Examination and Patient History

A detailed patient history and a thorough physical examination are crucial first steps in diagnosing bowel endometriosis. The doctor will ask about the symptoms, their severity, and if they worsen during menstruation. A pelvic exam may also be performed to check for any abnormalities.

Imaging Tests

Imaging tests, such as transvaginal sonography (TVS) and magnetic resonance imaging (MRI), are commonly used to identify and characterize endometriosis lesions.

TVS is a first-line imaging technique providing detailed dynamic images of the pelvis with minimal patient discomfort. It helps identify all of the bowel’s layers and any potential endometriosis nodules.

MRI, on the other hand, is typically used as a second-line diagnostic tool. It excels in evaluating the extent of the disease and identifying any specific organ involvement and depth of infiltration.

Endoscopy and Biopsy

An endoscopy may also be performed to examine the bowel for any abnormalities. A biopsy can be taken during this procedure to check for the presence of endometriosis cells. However, this method has its limitations as it only provides a superficial sample, and endometriosis usually involves deeper layers of the bowel wall.

Laparoscopy

Laparoscopy is the gold standard for diagnosing endometriosis. This surgical procedure allows for visual inspection of the peritoneal cavity and can provide a definitive diagnosis. The surgeon can also assess the extent of the disease and its impact on other organs.

Misdiagnosis of Bowel Endometriosis

Bowel endometriosis is often misdiagnosed due to its similar symptoms to other gastrointestinal disorders. This condition is frequently mistaken for irritable bowel syndrome (IBS), Crohn’s disease, and even colon cancer.

It’s crucial for healthcare providers to consider a possible diagnosis of bowel endometriosis in women presenting with gastrointestinal symptoms, especially if these symptoms worsen around the menstrual cycle.

Treatment of Bowel Endometriosis

Treating bowel endometriosis is typically multidisciplinary, involving a team of specialists. It generally involves a combination of medical and surgical therapies.

Medical Therapy

Medical treatments aim to control the symptoms of bowel endometriosis and may include pain relievers, hormonal therapies like oral contraceptives or progestins, and gonadotropin-releasing hormone analogs. These treatments work by reducing inflammation and suppressing the growth of endometrial tissue.

Surgical Therapy

In more severe cases, or when medical therapy is ineffective, surgery may be necessary. The type of surgery will depend on the extent and location of the endometriosis. In some cases, a conservative approach may be used, where the surgeon attempts to remove the endometriosis while preserving as much of the bowel as possible. In other cases, a segment of the bowel may need to be removed.

Laparoscopic Surgery

Laparoscopic surgery is often the preferred method for treating bowel endometriosis. This minimally invasive procedure allows for precise removal of the endometriosis with less damage to surrounding tissue and quicker recovery times. However, it requires a skilled surgeon and may only be an option in some cases.

Read More: Why It’s Important Your OB-GYN Specializes in Endometriosis?

Bowel Endometriosis and Fertility

Research indicates that bowel endometriosis may have an impact on a woman’s fertility. This could be due to the inflammation and scarring caused by the disease, which can interfere with the normal function of the reproductive organs.

In cases where infertility is an issue, assisted reproductive technologies may be considered. However, surgery to remove the endometriosis is often recommended first to increase the chances of a successful pregnancy.

Read More: Does Endometriosis Cause Infertility?

Conclusion

Bowel endometriosis is a complex condition that can significantly impact a woman’s quality of life and fertility. Early diagnosis and effective treatment are crucial to managing this condition and minimizing its effects. Suppose you’re experiencing symptoms of bowel endometriosis. In that case, it’s important to consult with a healthcare provider who is knowledgeable about this condition and can guide you through the diagnosis and treatment process.

References:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6996110/

https://drseckin.com/bowel-endometriosis/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6397811/

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1 year ago What is Endometriosis No comment

Endometriosis: Is it a Disability?

Endometriosis, a debilitating condition affecting millions of women globally, often prompts questions about its influence on daily life and work ability. This article provides an in-depth analysis of endometriosis, how it affects women’s work ability, and the possibility of qualifying for disability benefits.

Endometriosis is a medical condition that primarily affects women during their reproductive years, and is very prevalent, with over 80 million women diagnosed worldwide, typically between the ages of 20 and 40. Treatments such as surgery and medical management as well as physical therapy can alleviate some symptoms, but there is currently no definitive cure for the disease.

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Endometriosis and Disability: An Intricate Relationship

The symptoms of endometriosis vary greatly among individuals. The most common symptom is pelvic pain, particularly during menstruation, sexual intercourse, bowel movements, or urination. Other symptoms include abdominal bloating, nausea, as well as infertility, among other symptoms. 

Endometriosis can significantly disrupt daily functioning due to associated symptoms such as pain, fatigue, and psychological distress especially during one’s menses (period) but is not always confined to that time of the month. Consequently, the disease might qualify as a disability under the Americans with Disabilities Act (ADA) in certain cases. However, it is important to know that the Social Security Administration (SSA) does not automatically classify endometriosis as a disability in endometriosis disability act.

Endometriosis and Social Security Disability Benefits

Qualifying for Social Security disability benefits due to endometriosis is not straightforward. The SSA considers two primary factors when determining if an individual qualifies for SSDI (Social Security disability insurance) or SSI (Supplemental Security Income) disability benefits:

1. Does the individual’s condition meet (or equal) the requirements of a listed impairment?

2. If not, do the symptoms of endometriosis significantly interfere with the individual’s ability to function, to the point where they cannot perform any type of job safely?

Since endometriosis is not listed as a qualifying condition, sufferers cannot automatically meet the first criterion. However, they might still qualify for Social Security disability if their symptoms significantly impede their ability to work, what the SSA calls “substantial gainful activity,” or SGA.

How to Qualify for Social Security Disability for Endometriosis

To qualify for Social Security disability due to endometriosis, it must be demonstrated that the symptoms of the disease prevent the afflicted individual from performing their job. The SSA will then assess if there is any type of job that the individual can safely perform. This evaluation considers medical records, age, work experience and job skills, education, and residual functional capacity (the minimum work that can be expected from an individual).

Applying for Social Security Disability for Endometriosis

Applications for Social Security disability benefits can be made online, through a phone call to the Social Security’s national office, or in person at a local Social Security field office. Winning a disability claim for endometriosis can be challenging, but applicants can seek assistance from an experienced disability attorney or non-attorney representative.

Endometriosis and Employment: A Complex Scenario

While endometriosis can significantly impact an individual’s ability to work, it does not automatically lead to unemployment or early retirement. In fact, many women suffering from endometriosis are able to maintain their employment status, albeit with certain adjustments to accommodate their symptoms.

Work Ability and Endometriosis

A woman’s ability to work can be severely compromised by endometriosis, with the disease often linked to poor work ability at age 46. This decreased work ability can lead to increased absence from work due to health issues. However, despite the increased absenteeism, women with endometriosis often maintain an employment rate comparable to women without the disease. It makes you question why? 

Over the past few years, emphasis has been put on staying home if you are sick, as a safety measure for spreading disease, though many with endometriosis may not be able to afford days off of work either because financially they are unable, or there is worry about saying PTO for an unexpected turn of event such as a necessary surgery, or increased symptoms causing debilitating pain. So we suffer through expecting there to be worse days. Women in general, tend to minimize their own symptoms or question if they are “really that bad” as a result of societal influences.

Endometriosis Disability Act and Retirement

The emergence of disability retirement due to endometriosis is not common. Despite the debilitating symptoms of the disease, the risk of early retirement is not significantly higher for women with endometriosis compared to those without the condition. This finding is encouraging and demonstrates the resilience and determination of women battling this condition. Or, is it that those with endometriosis stay working longer because of the financial need and medical bills?

Conclusion

Endometriosis is a complex and debilitating condition that can significantly impact a woman’s ability to work. However, it does not inevitably lead to unemployment or early retirement per the literature, though that does not mean that those living with the condition are able to work feeling well or without worry about consequences of not working.  With appropriate medical treatment and workplace accommodations, we hope that not only can those with endometriosis keep working, but with a higher quality of life while working. 

References:

  1. The Americans with Disabilities Act www.ada.gov
  2. Rossi, H., Uimari, O., Arffman, R., Vaaramo, E., Kujanpää, L., Ala‐Mursula, L., Piltonen, T.T., 2021. The association of endometriosis with work ability and work life participation in late forties and lifelong disability retirement up till age 52: A Northern Finland Birth Cohort 1966 study. Acta Obstetricia et Gynecologica Scandinavica 100, 1822–1829. 

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1 year ago What is Endometriosis No comment

Endometriosis and Painful Intercourse: Is it Really Just Endometriosis?

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Those with endometriosis oftentimes will experience pain and discomfort with intercourse, especially pain with deep thrusting, also known as deep dyspareunia. However, many people also experience a different type of pain that extends beyond intercourse – superficial dyspareunia or pain upon entrance. Many people will have been diagnosed with ‘vaginismus’ and oftentimes given dilators, told to “just relax” or “have a glass of wine,” which is terrible advice. While some may have vaginismus, or pelvic floor dysfunction, for many the culprit could be that birth control pill that was given to you and advertised as a treatment for your endometriosis.  It is a mixed bag on how many people benefit from the use of oral contraceptive pills (OCPs), and they can be a helpful tool for many. That being said, one thing is certain: medications always have consequences – sometimes good, sometimes not good. 

In today’s blog, we will discuss a condition called vestibulodynia, and we will specifically cover hormonally associated vestibulodynia which is a prevalent health concern that results in pain in the vestibule, the tissue within the vulva at the opening of the vagina which also surrounds the urethra. It’s a subcategory of a broader term, vulvodynia, which refers to chronic pain in the vulva. This article aims to provide an in-depth understanding of vestibulodynia, its causes, symptoms, and effective treatment methods.

Vestibulodynia vs Vulvodynia vs Vaginismus?

Vestibulodynia is a general term used to describe discomfort in the vestibule, a part of the vulva that sits at the entrance of the vagina. The vestibule is the transition point between external and internal, similar to the entrance of a building. Vulvodynia is the broader category that includes vestibulodynia but can be pain anywhere in the vulva and typically is present for longer than three months and has specific causes and associated factors. Vaginismus lies within these and often is a misdiagnosis, the term refers to a chronic muscle spasm upon penetration or attempted penetration. This is one of the oldest terms used and while some may have true vaginismus, in the case of endometriosis there are much more likely causes, such as the birth control pill and other hormonal suppressive agents. 

Think about it – if you touch a hot stove, the muscles in your shoulder and arm reflexively pull you away. If a penis, speculum, finger, or tampon hit tissue that is painful and irritated, the surrounding muscles will tense reflexively because it is painful. So yes, there is a muscle spasm, but the cause of the spasm is the inflamed and painful vestibule, possibly due to consequences from the birth control pill. There are other causes of pain here, which we will cover in future blogs. 

Subtypes of Vestibulodynia

Recent research has led to the identification of a few subtypes of vestibulodynia based on the root cause of the discomfort:

·   Neuroproliferative vestibulodynia

·   Hormonally-mediated vestibulodynia

·   Inflammatory vestibulodynia

The vestibule tissue is fundamentally different from the skin around it, developing from a different part of the embryo. This biological difference is crucial to understanding the causes of pain specifically in the vestibule. In this post, we will be reviewing hormonally mediated vestibulodynia, and in upcoming posts we will discuss neuroproliferative vestibulodynia as there are some interesting new research in the connection between neuroproliferative vestibulodynia and endometriosis.

Causes of Vestibulodynia

The reason why some individuals develop vestibulodynia while others do not, is still under investigation. However, a 2014 study suggests that there may be a genetic risk factor for developing vestibulodynia when taking anti-androgen medication.

Hormonally-mediated vestibulodynia can be caused by several factors, times in life or medications that alter hormones and result in a suboptimal state. This could be during periods of amenorrhea (lack of a period) in young adults, medications including combined oral contraceptive pills, aromatase inhibitors used in breast cancer, and other hormonal suppressive medications as well as acne medications (Accutane and Spironolactone). Periods in life that result in reduced hormones including breastfeeding (lactational amenorrhea) and perimenopause through menopause which we describe as GSM (genitourinary syndrome of menopause). The vestibule tissue is particularly sensitive to a lack of hormone signals, so for those with endometriosis, while your birth control may be helping your painful periods, it maybe causing you to have painful intercourse. 

Symptoms of Vestibulodynia

Pain

Individuals with vestibulodynia typically experience discomfort at the entrance of the vagina, known as the vestibule. The pain in the vestibule can be described in many ways. People with hormonally-mediated vestibulodynia may describe their discomfort as burning, stinging, or tearing. 

Provoked vestibulodynia refers to vestibular pain that occurs with touch or pressure, while unprovoked pain occurs spontaneously. Sometimes, it can be challenging to distinguish provoked from unprovoked pain before all triggers are recognized, especially when they are seemingly simple things like sitting or wearing tight clothing.

People often feel discomfort any time there is contact or pressure on the vestibule. This includes during vaginal penetration (dyspareunia), tampon use, and speculum exams. Day-to-day activities that put pressure on the vestibule, such as wearing tight clothing, sitting for long periods, or wiping with toilet paper, can also cause discomfort. 

Urinary

Because this tissue also impacts the urethra, for some, the primary symptoms are urinary in nature. Urinary urgency, frequency, or UTI-like feelings without an infection are common and some will even receive a diagnosis of interstitial cystitis/painful bladder syndrome, also very common to see in those with endometriosis. 

Pelvic Floor Tightness

It is believed that pelvic floor dysfunction may develop in people with vestibulodynia due to a subconscious guarding response against discomfort (remember the stove analogy). However, chronic tightening of the pelvic floor muscles can create more discomfort. The muscles can accumulate knots (trigger points) and become shortened and weak. The weakness is because the muscles are not functioning optimally, please do not go and do kegels! 

Additional symptoms of pelvic floor dysfunction can include feeling tension, discomfort, and burning in the hips, legs, lower back, and vulva, especially the vestibule. One can also experience urinary symptoms like frequency, urgency, and leakage, as well as bowel symptoms like constipation or discomfort with bowel movements.

Diagnosis of Vestibulodynia

The first step towards diagnosing vestibulodynia is a thorough history of your story by a knowledgeable provider. Your story holds crucial clues to your diagnosis. People with hormonally-mediated vestibulodynia may have discomfort that developed later in life after any of the associated factors discussed above, including starting a medication, surgery, breastfeeding, or menopause.

Then there should be a very specific examination of the pelvis, vulva, and vagina. In patients with hormonally-mediated vestibulodynia, the vestibule usually appears very red and irritated (erythema), but also pale (mucosal pallor). The provider should manually examine the pelvic floor muscles to determine if there is excess tension in the muscles.

A process called a Q-tip test is essential for mapping discomfort in the vulva. The provider will gently press a cotton swab to each part of the vulva while the patient reports their degree of discomfort at each spot. It is important that the provider touch each region of the vestibule, all the way around the vaginal opening. The physical exam is extremely important prior to using dilators as this may cause more irritation because the cause (or one cause) of the muscle tension is the vestibule and needs attention before dilators come into treatment. 

Some specialists will check labs including total testosterone, free testosterone, and SHBG (sex hormone binding globulin), and many with hormonally mediated vestibulodynia show altered levels; though you do not need labs to confirm this diagnosis. 

Treatment of Vestibulodynia

Fortunately, in the case of hormonally-mediated vestibulodynia, the standard treatment has a very high success rate. If vestibulodynia developed after starting a medication that is known to affect hormone levels, then patients should stop taking that medication. Stopping the medication is often not enough to help the vestibule tissue heal quickly because hormone levels might stay low for a long time after taking birth control pills.

Providers should prescribe a topical hormone gel to apply directly to the vestibule to restore the hormone signals to the tissue. The standard is 0.01-0.03% estrogen and 0.1% testosterone gel. The hormone gel is usually made by a compounding pharmacy. Custom compounded medications are especially helpful if someone is sensitive to a medication’s base, the inactive ingredients, and needs a different base.

Patients typically use the gel 1 to 2 times daily and start to notice improvement in 6 to 12 weeks. Some patients stop using the hormone gel once the offending medication has been stopped for a while, but many women choose to stay on this therapy.

Support for Vestibulodynia Patients

There are many societies with interests in female sexual dysfunctions in addition to ISSWSH. The National Vulvodynia Association (NVA) is a US-based association founded by patient advocates that focuses specifically on vulvodynia. They provide some educational materials for the public and fund research of vulvodynia. Tight Lipped is also a patient facing, grass-roots, advocacy group helping to change medical education around this condition. 

There are many online support groups and communities of patients who support each other on social media. To find fellow patients locally, ask a provider if they know of another patient seeking community or any local groups to join.

Conclusion

Understanding and effectively managing vestibulodynia necessitates a comprehensive understanding of its causes, symptoms, and treatments. The information in this article seeks to bridge the gap between scientific research and the general public, providing evidence-based insights into this prevalent health concern. If you are experiencing symptoms of vestibulodynia, seek advice from a healthcare professional. There is a broad range of treatment options available, and you are not alone in your journey towards healing and managing this condition.

While this article provides a comprehensive overview of vestibulodynia, it is essential to remember that each individual’s experience with the condition can vary. Therefore, it’s crucial to consult with healthcare professionals and consider personal circumstances when making decisions regarding management and treatment.

Find a specialist: www.isswsh.org

Additional reading:

References:

  1. Rubin, R. W. C. (2022). Hormonally mediated vestibulodynia. Accessed from https://www.prosayla.com/articles/hormonally-mediated-vestibulodynia
  2. Burrows LJ, Goldstein AT. The treatment of vestibulodynia with topical estradiol and testosterone. Sex Med. 2013 Aug;1(1):30-3. doi: 10.1002/sm2.4. PMID: 25356284; PMCID: PMC4184715.
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1 year ago What is Endometriosis No comment

Endometriosis Guidelines: A Closer Look at a Potential Source of Confusion in Treatment (Part 2)

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Understanding Endometriosis Treatment Confusion

Endometriosis affects millions of women worldwide, presenting with pain, irregular menstruation, and infertility. To shed light on the most effective treatment methods, this article is Part 2 in our series on this topic.  It summarizes and comments on the findings from a recent 2021 review which provided a detailed analysis of various endometriosis treatment global guidelines as of September 2020. 

There are often some discrepancies between guidelines for any disease.  However, for endometriosis, a prior review in 2018 revealed that only about 7% of recommendations were comparable between international guidelines.  Up to 28% of the recommendations were not supported by good research evidence at all.  This helps explain why there is such a wide variation between doctors’ recommendations in clinical practice.  

Key Guidelines reviewed in the most recent publication were:

  • American College of Obstetricians and Gynecologists (ACOG)–reviewed in our last post, which you can read HERE
  • Society of Obstetricians and Gynaecologists of Canada (SOGC)
  • European Society of Human Reproduction and Embryology (ESHRE)
  • Australian National Endometriosis Clinical and Scientific Trials (ACCESS)
  • Royal College of Obstetricians and Gynaecologists (RCOG)
  • French National College of Gynecologists and Obstetricians (CNGOF)
  • American Association of Gynecologic Laparoscopists (AAGL)
  • German Society for Gynecology and Obstetrics (DGGG)

Summary Review of Treatment Recommendations

  • Non-Hormonal Medical Pain Management
    • Nonsteroidal anti-inflammatory drugs (NSAIDs): While this is considered by all guidelines to be first-line therapy for dysmenorrhea and acyclic pelvic pain, it is not specific for endometriosis.  A diagnosis and targeted therapy is more prudent since a large review showed no difference in effectiveness between NSAIDs and placebo. 
  • Hormonal Treatment Options:
    • Progestins and Combined Oral Contraceptives (COCs): Widely recommended for initial pain management. Specific formulations and dosages vary across guidelines. Of interest, there is little mention of compounded micronized progesterone which is hard to study but may deserve a place in the conversation. The Levonorgestrel Intrauterine System (LNG-IUS) is particularly noted for its localized progestin delivery, reducing systemic side effects and effectively managing pain.
    • Megace (Megestrol Acetate): A potent progestin recommended by several guidelines but varies as a first-line vs second-line option. The additional benefit is less bone loss than that seen with GnRH agonist therapy.  
    • GnRH Agonists: Uniformly recommended in all guidelines for severe symptoms after first-line therapy; potential side effects, which can be long-lasting, include decreased bone density and menopausal-like symptoms.  Add-back low-dose estrogen therapy can reduce symptoms. Most guidelines, and the FDA, recommend durations of 6 months or less.  
    • Emerging Hormonal Therapies: GnRH antagonists are gaining attention for their rapid onset of action and fewer side effects compared to agonists. The evidence is not conclusive. 
    • Danazol and Gestrinone: Older treatments with androgenic effects, are less commonly used today due to side effects. Gestrinone is not currently available in the United States. 
    • Selective Estrogen Receptor Modulators (SERMs) and Selective Progesterone Receptor Modulators (SPRMs) are emerging options being explored for their targeted action and potential benefits.
    • Aromatase Inhibitors: Considered in some cases, especially for pain unresponsive to other treatments.  Most guidelines agree that this is a possible second-line option, but the evidence is not conclusive.  A possible niche for effective use may be in post-menopausal patients who have endo. 
  • Surgical Approaches: Navigating the Complexities
    • Laparoscopic Surgery: Endorsed for its efficacy and reduced recovery time, compared to big incision (laparotomy) surgery. However, the extent of surgery (complete vs. partial removal of lesions) varies among guidelines. Studies are likely hampered by different skill sets between participating surgeons.  
    • Robotic Surgery: AAGL and others highlight its benefits in complex cases, but its cost and accessibility limit widespread use. Specialized training is required. 
    • Ablation vs. Excision: The choice between these two methods remains a contentious topic, for some reason. Ablation is simpler and requires much less technical skill but is only applicable for treating superficial lesions.  It may not be as effective in the long term as excision, which is more comprehensive and accurate in terms of removing all of the visible disease.  Again, the skill base of surgeons is critical, and high variability in this regard may be affecting the ability to prove or disprove the effectiveness and safety of each.  
    • Endometrioma: Cystectomy or excision of endometriomas is superior to drainage in terms of lower recurrence.  Excision also provides the opportunity for pathologic confirmation, and this may be important where it is not clear whether or not there is also a tumor present.  Where fertility is a major concern, the more atraumatic the approach to surgery, the less ovarian reserve is affected, and this is another area where surgeon expertise is critical. 
    • Deep Infiltrating Endometriosis: Highly specialized excisional surgeries are recommended because ablation simply does not work with these lesions. There is an even stronger emphasis on the surgeon’s expertise and patient selection.  Intuitively, the best outcomes probably rest with selecting the best possible technology in a master surgeon’s hands.  Some strongly believe that this means robotic surgery for advanced cases with highly distorted anatomy. 
    • Hysterectomy:  This is considered a “definitive” or last resort surgery but may be helpful for complete excision of endo at any point.  It also allows the removal of any co-existing pain-producing adenomyosis, which is embedded in the wall of the uterus. 
    • LUNA (laparoscopic uterine nerve ablation) and PSN (presacral neurectomy):  Guidelines reflect multiple reviews that suggest no benefit to LUNA but a possible benefit for PSN in selected cases.  PSN is technically very challenging and treatment should be individualized.  As far as LUNA is concerned, studies include a mix of ablation and excision, which means a lack of precision in many of them and, again, surgeon skill level may be a factor.  Thus a definitive conclusion may be elusive until a better methodology to accurately study this is employed. 
  • Complementary and Alternative Therapies: Exploring Additional Avenues
    • Acupuncture and Electrotherapy (TENS): Mentioned in some guidelines as adjunct therapies, with some encouraging results.  More research is needed to fully validate their effectiveness.  However, these are low-risk options. 
    • Nutritional Supplements: Some guidelines suggest that dietary changes and supplements might play a role in symptom management.  This includes microbiome management for optimal estrogen metabolism.  There will likely never be large randomized studies for any of these variables because they would have to be huge and thus impractical to conduct.  But in today’s emerging world of personalized molecular medicine, other study methodologies are being explored to determine which of these approaches to diet and lifestyle may be more effective than others. 
  • Infertility and Endometriosis: A Delicate Balance
    • Surgical vs. Non-Surgical Approaches: The decision to opt for surgery in infertility cases is complex and depends on individual factors like age, severity of endometriosis, and previous treatments.  Reducing inflammation appears to be beneficial to effective intrauterine implantation and gestation. 
  • Emerging Treatments and Research
    • Future Directions: Ongoing research into immunotherapies, new hormonal agents, and gene/molecular therapy offer promising avenues for more personalized treatment strategies. 

Endometriosis management is a highly dynamic field with evolving guidelines and currently very discrepant recommendations due to incomplete or low-quality scientific evidence. Understanding current options is crucial for women to make informed decisions about their health. Regular consultations with endometriosis experts, staying informed about new research, and considering a multi-disciplinary holistic approach to treatment can significantly improve quality of life.

Additional Reading:

References:

  1. Kalaitzopoulos, D. R., Samartzis, N., Kolovos, G. N., Mareti, E., Samartzis, E. P., Eberhard, M., Dinas, K., & Daniilidis, A. (2021). Treatment of endometriosis: a review with comparison of 8 guidelines. BMC Womens Health, 21(1), 397. https://doi.org/10.1186/s12905-021-01545-5 
  2. Hirsch M, Begum MR, Paniz É, Barker C, Davis CJ, Duffy J. Diagnosis and management of endometriosis: a systematic review of international and national guidelines. BJOG. 2018;125(5):556–64.
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1 year ago What is Endometriosis No comment

Endometriosis Guidelines: A Closer Look at a Potential Source of Confusion in Treatment Debates

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Treatment strategies for endometriosis vary widely, with the primary objective being to alleviate pain and enhance fertility where necessary. However, the confusion and inconsistency in recommendations is alarming.  This article reviews and comments on some of the key current management strategies supported by the American College of Obstetrics and Gynecologists (ACOG), by way of Bulletin #114 (2010 and reaffirmed in 2022) and Bulletin #760 concerning adolescents (2018 and reaffirmed 2022). In the following posts, we will review other guidelines to give a more in-depth look at these inconsistencies and what you may face as you navigate your journey with endometriosis. 

Other internationally recognized bodies have published various guidelines seeking to help clinicians with the diagnosis and treatment of endometriosis. Unfortunately, there is significant discrepancy between some of the recommendations due to the complex nature of the disease and limitations of research to date. Many patients will look to online resources and forums after seeing providers and not seeing results. What they may be surprised to find is that information on sites dedicated to endometriosis are often inconsistent with what is proffered by different guideline resources. 

Surgery

Surgery is considered a cornerstone in the management of pain and infertility associated with endometriosis. The timing of surgery and the type of surgery recommended varies between guidelines. However, it is illuminating to note that ACOG guideline Bulletin #114 states that “definitive diagnosis of endometriosis only can be made by histology of lesions removed at surgery.”

Minimally invasive surgery is highly preferred over open surgery (laparotomy) due to less pain, shorter hospital stay, quicker recovery, and better cosmetic results. However, a high level of skill and expertise is required to perform these procedures, whether it be laparoscopic or robotically assisted surgery. Despite better technology inherent in robotic surgery, outcomes research does not clearly show which modality is better overall.  However, the skill of the surgeon likely trumps the surgical tools used. Robotic surgery may be better suited for particularly difficult cases involving severely distorted anatomy due to advanced endo or scarring from repeat surgeries.  

The excision of endometriosis is widely recommended for patients with endometriosis-associated pain. However, there is ongoing debate on the preferred surgical technique (ablation versus excision) due to lack of conclusive evidence. Currently, the studies that look at excision surgery vs. ablation have significant limitations, potentially due to variation in the skill and training of the surgeons involved in these studies.  Meaning, studies to date may not have been done by true excision specialists and resulted in incomplete removal thereby skewing the research results.  This variation in surgeon expertise is a common plight affecting surgical procedure outcomes research. 

In ovarian endometriosis (endometriomas or chocolate cysts), minimally invasive excision of endometriomas is superior to drainage and ablation in terms of reducing recurrence of dysmenorrhoea, dyspareunia, cyst recurrence, and the need for further surgical interventions. 

In cases where women have completed their family planning and failed to respond to conservative treatments, hysterectomy with simultaneous excision of endometriotic lesions is considered the last resort. However, except for cases in which there is coexisting adenomyosis, hysterectomy is not necessarily required for pain relief purposes.  Each situation should be highly individualized. 

Medical Management of Endometriosis

While surgery is an effective treatment strategy and helps many patients, medical management currently plays a crucial role in managing symptoms and preserving fertility. These treatments primarily focus on pain management, hormonal suppression, and birth control.

Pain management is a critical aspect of endometriosis treatment. Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used for symptomatic treatment of dysmenorrhea and acyclic pelvic pain. In fact, in their article discussing dysmenorrhea and endometriosis in adolescents, without any workup, ACOG believes that the majority of adolescents have primary dysmenorrhea which is defined as painful menstruation in the absence of pelvic pathology and recommends first line-therapies such as NSAIDs and birth control. The question is: without undergoing a definitive workup and assessment (surgery) for endometriosis and knowing that imaging is insufficient for diagnosis – how is it determined they do not have pelvic pathology? Furthermore, ACOG considers those that respond symptomatically to birth control pills and NSAIDs as a confirmation of primary dysmenorrhea, though some people with endometriosis also respond symptomatically to birth control pills and NSAIDs. 

Hormonal suppression, through the use of progestins, combined oral contraceptives, micronized progesterone, or Gonadotropin-releasing hormone (GnRH) analogues, is a common treatment strategy. This recommendation assumes that estrogen is responsible for endometriosis, but this is based on an incomplete understanding of endometriosis genesis and progression. Hormones are clearly involved but, based on increasing molecular evidence, this is not the sole factor in promoting growth of endometriosis. 

Birth control pills, specifically combined oral contraceptives, are often used as a first-line therapy for endometriosis-associated pain. This works by suppressing ovulation, which may help slow the growth of endometriotic tissue but has not been proven to induce regression or resolution. 


GnRH analogues are recommended as second-line treatment options for endometriosis-associated pain. They work by suppressing the production of estrogen, thereby theroretically reducing the growth of endometriotic tissue. Along these lines, ACOG states that “there is no data that support the use of preoperative medical suppressive therapy,” yet in clinical practice, many individuals are offered these medications inconsistently related to consideration or timing of surgery. Additionally, their level B evidence (second level) recommendations state “After an appropriate pretreatment evaluation (to exclude other causes of chronic pelvic pain) and failure of initial treatment with OCs (oral contraceptives) and NSAIDS, empiric therapy with a 3-month course of a GnRH agonist is appropriate.” It can be argued that this is extremely problematic given that there is no conclusive data to support the use of these medications prior to surgery. Finally, there is a significant  risk of short and potentially long term side effects and complications. 

Complementary Therapies

Complementary therapies such as dietary interventions, acupuncture, and electrotherapy are increasingly being recognized as potential adjunctive treatments for endometriosis. Quite a bit is evidence supported, but more research is needed to fully establish their efficacy and safety. Thus guidelines do not routinely address such options, leaving patients to their own devices and trial and error.  

In conclusion, the management of endometriosis requires a multi-faceted approach, incorporating both surgical and medical treatments which will be variable from patient to patient. In the past few years, there have been some improvements in the amount of research as well as advocacy. Finding a knowledgeable specialized surgeon and care team is of utmost importance.  The majority of OBGYNs do not focus on endo, have not undergone further specialized training and generally align with the guidelines set forth by ACOG, largely driven by perceived medico-legal concerns related to standard of practice.. Furthermore, other guidelines seem to differ in their opinions and recommendations regarding medical management and surgery, so stay tuned for more information.

Related reading:

  1. Find an Endometriosis Specialist for Diagnosis, Treatment, & Surgery
  2. Why was iCareBetter built? 
  3. What You Need to Know About Endometriosis Excision Surgery

References:

  1. Bulletins–Gynecology, A. C. o. P. (2000). ACOG practice bulletin. Medical management of endometriosis. Number 11, December 1999 (replaces Technical Bulletin Number 184, September 1993). Clinical management guidelines for obstetrician-gynecologists. Int J Gynaecol Obstet, 71(2), 183-196. https://doi.org/10.1016/s0020-7292(00)80034-x 
  2. ACOG Committee Opinion No. 760: Dysmenorrhea and Endometriosis in the Adolescent. (2018). Obstet Gynecol, 132(6), e249-e258. https://doi.org/10.1097/AOG.0000000000002978 
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2 years ago What is Endometriosis No comment

History of Endometriosis: Unraveling the Theories and Advances

Table of contents

Endometriosis is a complex condition that affects a significant number of women (XX) and on average takes 7-10 years for a diagnosis. The majority of people date their symptoms back to adolescence though go years seeking answers. Throughout their journey, many people  receive either a wrong diagnosis or were simply dismissed altogether.  In recent years, there has been a marked improvement in the recognition of the word ‘endometriosis’ but why does this disease remain such an enigma to so many healthcare professionals? Furthermore, endometriosis has been a subject of medical investigation for over a century with debates about how to approach treatment, understanding of the pathogenesis, clinical manifestations, and treatment methods.

Research in this field has evolved over time, but are we really that much further along than we were a century ago? One of the most frustrating concepts for those of us who truly understand endo, is the regurgitation of the theory of retrograde menstruation postulated in the 1920’s by Dr. John A. Sampson. The theory that endometriosis is derived from retrograde menstruation is an incomplete understanding of this original theory, that has perpetuated misinformation and our current recommended treatments – hormonal suppression and hysterectomies. Sampon’s original theory was more involved, but future research into alternative theories seems much more promising. Even so, our current “validated or trusted treatments” are still rooted in early understanding. This article delves into the intricate history of endometriosis, tracing its theories and advances, or lack thereof, to provide a comprehensive overview of this complex condition.

The Early Recognition of Endometriosis

Initial Observations and Descriptions

The first description of a disease resembling endometriosis can be attributed to Thomas Cullen in the early 20th century.1 Cullen identified endometriosis and adenomyosis as a single disease, characterized by the presence of endometrium-like tissue outside the uterine cavity.2 This breakthrough laid the foundation for future research and understanding of endometriosis.

Sampson’s Theory of Retrograde Menstruation

The term “endometriosis” was coined by John A. Sampson in the late 1920s.3 Sampson proposed the theory of retrograde menstruation as the primary cause of endometriosis, due to the observation during surgery of the similarity in endometriosis lesions and the endometrium, suggesting that endometrial cells are transported to ectopic locations via menstrual flow. This theory gained widespread acceptance and significantly influenced the direction of endometriosis research. Though he did note early on that there were additional factors to allow the growth of these lesions to transform, similar to more current theories and the immune system involvement.

Advances in Diagnosing Endometriosis

The Advent of Laparoscopy

The introduction of laparoscopy in the 1960s revolutionized the diagnosis of endometriosis.4 This minimally invasive surgical procedure allowed physicians to visually identify and classify endometriosis lesions, leading to a significant increase in the diagnosis of the disease.

Differentiating Clinical Presentations

With the advent of laparoscopy, three distinct clinical presentations of endometriosis were identified: peritoneal, deep adenomyotic, and cystic ovarian.5 These classifications, along with advances in imaging techniques such as ultrasound and magnetic resonance imaging (MRI), have improved the precision of endometriosis diagnosis.

Development of Medical Therapies for Endometriosis

Early Interventions

The first attempts at treating endometriosis with synthetic steroids began in the 1940s.6 Initially, androgenic substances were used, but their side effects led to a search for more effective and tolerable treatments. Fun fact: testosterone was actually the first hormone used in attempts to “treat” the disease. 

The Pseudo-pregnancy Regimen

The 1950s saw the advent of the “pseudo-pregnancy” regimen, where hormones were used to mimic the hormonal environment of pregnancy, thereby suppressing ovulation and endometrial growth.7 During this time, there were limited options and this suggestions came from the observation that symptoms were improved when pregnancy occurred. This approach utilized a combination of estrogen and progestin medications and marked a significant advance in the medical management of endometriosis. At this time, birth control was becoming more widespread and more options were being developed. The myth that is still perpetuated today by uninformed practitioners and society of “just get pregnant, it will cure your endo” or “just have a baby” stems from this belief. In 1953 a physician legitimized the limited options and made recommendations suggesting that frequent and often pregnancy was one of the only options and “subsidize your children” was the solution for the increased financial burden. There are so many infuriating suggestions at this recommendation, but the 50’s were a different time, with limited research and options. 

Gonadotropin-Releasing Hormone (GnRH) Agonists

Gonadotropin-releasing hormone (GnRH) agonists emerged as a primary medical therapy for endometriosis in the late 20th century.8 These drugs work by reducing the production of estrogen, thereby limiting the growth of endometriotic tissue, at least in theory. However, the side effects of hypoestrogenism led to the development of ‘add-back’ therapies to mitigate these effects.Not to mention poor regulation and research practices present in the 1990’s including falsified data on the true impact of these drugs. 

Evolution of Surgical Treatments

Conservative Surgery & Advancements in Endoscopic Surgery

The development of laparoscopy also transformed the surgical management of endometriosis. Conservative surgical techniques, including the excision of visible endometriosis lesions and adhesion lysis, became feasible.9 These procedures aimed to preserve fertility while effectively managing the disease. The late 20th century saw further advancements (again, in theory) in laparoscopic surgery for endometriosis. Techniques such as CO2 laser vaporization and the use of circular staplers for bowel resection improved the effectiveness and safety of surgery.10

Unraveling the Pathogenesis of Endometriosis

The Role of the Peritoneal Environment

Research in the 1980s began to focus on the peritoneal environment’s role in endometriosis. Studies found evidence of a local peritoneal inflammatory process, including increased activation of peritoneal macrophages and elevated cytokine and growth factor concentrations.11

Endometrial Dysfunctions

Investigations also revealed biochemical differences between eutopic and ectopic endometrium in women with endometriosis. These differences suggested that endometriosis might be associated with endometrial dysfunction, contributing to both the pathogenesis and sequelae of the disorder.12 While research exists that shows differences in BOTH the endometriosis lesions and the endometrial environment, this is correlational research, and does not imply causation. 

Immunological Factors

The involvement of the immune system in the pathogenesis of endometriosis was another significant discovery. Altered immune responses, including decreased T-cell and natural killer cell cytotoxicities, were observed in those with endometriosis.13

The Connection Between Endometriosis and Adenomyosis

In the late 20th century, researchers revisited the connection between endometriosis and adenomyosis, suggesting that the two conditions might represent different phenotypes of the same disorder.14 This theory proposed that both endometriosis and adenomyosis are primarily diseases of the junctional zone myometrium.

Modern Approaches to Endometriosis Treatment

Use of Gonadotropin-Releasing Hormone Agonist and Levonorgestrel-Releasing Intrauterine System

In more recent years, GnRHa therapy, often combined with ‘add-back’ therapy, has become a popular “treatment” for endometriosis.15 The levonorgestrel-releasing intrauterine system (LNG-IUS), which releases a progestin hormone into the uterus, has also shown promise in the management of endometriosis-associated chronic pelvic pain.16 In reality, this may be more true for adenomyosis and further research is needed. Research with less bias seems to oppose these claims stating that “GnRH drugs show marginal improvement over no active treatment” when compared with other hormonal suppression medications. Thanks to marketing, this is not well known among consumers. 19 Not to mention the significant side effects that further contribute to the various chronic overlapping pain syndromes associated with endometriosis. 

The Future of Endometriosis Research and Treatment

The evolution of endometriosis theories and advances underscores the complexity of this condition. As we continue to unravel the mysteries of endometriosis, there is an ongoing need for research into its pathogenesis, diagnosis, and treatment. The future of endometriosis research and treatment lies in a deeper exploration of its genetic-epigenetic aspects, the role of oxidative stress, and the impact of the peritoneal and upper genital tract microbiomes.18

Conclusion

The history of endometriosis is marked by a continual evolution of theories, advancements in diagnostic and therapeutic approaches, and an expanding understanding of the disease’s complex pathogenesis. From the initial descriptions by Thomas Cullen to the modern laparoscopic techniques and hormonal therapies, the journey of understanding and treating endometriosis has indeed been a frustrating one.

One of the most frustrating aspects is that when we really understand the first observations of endometriosis in the 1800’s into the early 1900’s, it is not far from where we are today. This demonstrates the serious need for more research, better research, and more in depth understanding of the pathogenesis and treatment approaches for endometriosis. While this has improved in the last five years, it is not enough. We need to do more, and we need to do better. Healthcare policy change is an extremely slow process and in my personal observation, decided among individuals who show less understanding than those with the disease. 

10. References

Disclaimer: This article is intended to provide general information on the topic and should not be used as a substitute for professional medical advice. Always consult with your healthcare provider for personal medical advice.

  1. Cullen, T. (1920). Adenomyoma of the Uterus. WB Saunders.
  2. Sampson, J.A. (1927). Metastatic or Embolic Endometriosis, due to the Menstrual Dissemination of Endometrial Tissue into the Venous Circulation. American Journal of Pathology, 3(2), 93–110.
  3. Sampson, J.A. (1927). Peritoneal endometriosis due to menstrual dissemination of endometrial tissue into the peritoneal cavity. American Journal of Obstetrics & Gynecology, 14, 422–469.
  4. Brosens, I., & Benagiano, G. (2011). Endometriosis, a modern syndrome. Indian Journal of Medical Research, 133(6), 581–593.
  5. Amro, B., et al. (2022). New Understanding of Diagnosis, Treatment and Prevention of Endometriosis. International Journal of Environmental Research and Public Health, 19(11), 6725.
  6. Miller, E.J. (1944). The use of testosterone propionate in the treatment of endometriosis. American Journal of Obstetrics & Gynecology, 48(2), 181–184.
  7. Kistner, R.W. (1958). The use of newer progestins in the treatment of endometriosis. American Journal of Obstetrics & Gynecology, 75(2), 264–278.
  8. Hughes, E., et al. (2007). Ovulation suppression for endometriosis for women with subfertility. Cochrane Database of Systematic Reviews, (3), CD000155.
  9. Brosens, I., et al. (2022). New Understanding of Diagnosis, Treatment and Prevention of Endometriosis. International Journal of Environmental Research and Public Health, 19(11), 6725.
  10. Keckstein, J., & Becker, C.M. (2020). Endometriosis and adenomyosis: Clinical implications and challenges. Best Practice & Research Clinical Obstetrics & Gynaecology, 69, 92–104.
  11. Dmowski, W.P., & Braun, D.P. (1997). Immunology of endometriosis. Best Practice & Research Clinical Obstetrics & Gynaecology, 11(3), 365–378.
  12. Lebovic, D.I., et al. (2001). Eutopic endometrium in women with endometriosis: ground zero for the study of implantation defects. Seminars in Reproductive Medicine, 19(2), 105–112.
  13. Dmowski, W.P., & Braun, D.P. (1997). Immunology of endometriosis. Best Practice & Research Clinical Obstetrics & Gynaecology, 11(3), 365–378.
  14. Leyendecker, G., et al. (2009). Endometriosis results from the dislocation of basal endometrium. Human Reproduction, 24(9), 2130–2137.
  15. Surrey, E.S., & Soliman, A.M. (2019). Endometriosis and fertility: A review of the evidence and an approach to management. Journal of the Society of Laparoendoscopic Surgeons, 23(2), e2018.00087.
  16. Vercellini, P., et al. (2003). Endometriosis and pelvic pain: relation to disease stage and localization. Fertility and Sterility, 79(2), 156–160.
  17. Sutton, C.J., et al. (1994). Laser laparoscopy in the treatment of endometriosis: a 5 year study. British Journal of Obstetrics and Gynaecology, 101(3), 216–220.
  18. Brosens, I., & Benagiano, G. (2011). Endometriosis, a modern syndrome. Indian Journal of Medical Research, 133(6), 581–593.
  19. Johnson, N. P., Hummelshoj, L., & World Endometriosis Society Montpellier, C. (2013). Consensus on current management of endometriosis. Hum Reprod, 28(6), 1552-1568. 

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