Dr. Jill Ingenito, Endometriosis Specialist
City: Centennial, Colorado, USA
Philosophy of Endometriosis Care: Endometriosis is a complex condition with multiple proposed theories of origin, and I approach its treatment with this multifaceted nature in mind. Here are the key theories I consider and how they influence my approach:
1. Retrograde Menstruation Theory: Endometrial-like tissue flows backward through the fallopian tubes into the peritoneal cavity during menstruation, where it implants and grows.
Influence on Treatment: This theory underscores the importance of hormonal suppression to reduce menstrual flow and mitigate disease progression. Treatments like hormonal contraceptives, progestins, and GnRH modulators can help control symptoms and prevent recurrence.
2. Coelomic Metaplasia Theory: The peritoneal lining transforms into endometrial-like tissue due to genetic or environmental factors.
Influence on Treatment: This theory supports the need for a holistic approach, including addressing potential environmental triggers and reducing inflammation through lifestyle modifications, diet, and anti-inflammatory therapies.
3. Stem Cell Theory: Stem cells from the bone marrow or endometrium migrate to ectopic locations and differentiate into endometrial-like tissue.
Influence on Treatment: This theory emphasizes the potential role of immune system modulation and ongoing research into regenerative therapies.
4. Immune Dysfunction Theory: Impaired immune surveillance allows ectopic endometrial-like tissue to implant and persist.
Influence on Treatment: I focus on optimizing the immune environment through anti-inflammatory strategies, adjunctive therapies (e.g., low-dose naltrexone), and encouraging overall immune health.
5. Genetic and Epigenetic Theories: A genetic predisposition and epigenetic modifications may make certain individuals more susceptible to developing endometriosis.
Influence on Treatment: Understanding that endometriosis is likely influenced by heritable factors helps me counsel patients on recurrence risk and tailor long-term management strategies.
6. Lymphatic and Hematogenous Spread Theory: Endometrial-like cells spread through the lymphatic system or bloodstream, explaining distant lesions.
Influence on Treatment: This theory highlights the importance of a systemic approach to the disease, particularly in cases with extra pelvic manifestations.
My Approach:
Excision Surgery: Recognizing that excision addresses the visible and tangible lesions of endometriosis regardless of origin, I prioritize this approach for definitive treatment.
Multidisciplinary Care: I integrate pelvic floor physical therapy, dietary interventions, pain management strategies, and psychological support to address the systemic impact of the disease.
Patient-Centered Care: I emphasize shared decision-making, tailoring treatment plans based on the severity of symptoms, goals, and individual patient needs.
Ongoing Education and Research: Staying updated on emerging theories and treatments is critical to providing the most effective care.
By addressing endometriosis as a multifactorial condition, I aim to provide comprehensive and compassionate care that not only alleviates symptoms but also improves the overall quality of life for my patients.
What type of surgery do you perform for endometriosis: Excision
Medication: In my practice, I incorporate a range of medications tailored to the individual needs of patients with endometriosis, always balancing symptom relief with long-term management goals. Here’s an overview of the medications I use and how I recommend them:
I frequently use hormonal therapies. Combined oral contraceptives (COCs) are a first-line option for mild to moderate symptoms or as a trial before more invasive interventions. These are used continuously or cyclically to suppress ovulation and reduce menstrual flow, which helps decrease inflammation and pain by reducing hormonal cycling. Progestins, such as norethindrone acetate, dienogest, or medroxyprogesterone acetate, are another option, particularly for patients who cannot tolerate estrogen or prefer non-estrogen approaches. These can be delivered orally, via injection (Depo-Provera), or intrauterine (e.g., Mirena IUD), thinning endometrial tissue and suppressing ovulation to reduce lesion activity and pain. GnRH agonists and antagonists, such as leuprolide (Lupron) or elagolix (Orilissa), are often used for moderate to severe symptoms or as an adjunct to surgery. These induce a hypoestrogenic state and are used short-term due to side effects like bone density loss, often combined with add-back therapy to mitigate these side effects. For long-term management, especially for those seeking contraception, levonorgestrel-releasing IUDs (e.g., Mirena or Kyleena) provide localized progestin release, reducing heavy bleeding and pelvic pain with minimal systemic effects.
Approach to Persistent Pain After Surgery: I often recommend NSAIDs, such as ibuprofen or naproxen, for acute pain or in combination with other therapies. These are most effective when taken around the clock during symptom flares to reduce prostaglandin-mediated inflammation and pain. Neuromodulators like gabapentin or amitriptyline are used for neuropathic or chronic pelvic pain that persists despite hormonal or surgical management, typically initiated at low doses and titrated as needed. Low-dose naltrexone is another option for chronic pain and inflammation, taken nightly with patient education about its gradual onset. For bowel-related symptoms, I may use antispasmodics like dicyclomine as needed during symptom flares to reduce smooth muscle spasms.