Maria Victoria Vargas, M.D., Gynecologist, Minimally Invasive Gynecologic Surgeon
City: Washington DC, USA
Philosophy: Endometriosis is a complex disease and its etiology appears to be multifactorial. Currently, Mulleriosis seems to be the most accepted theory of origin. Unfortunately, we still lack understanding about the full spectrum of the disease, which includes a self-sustaining, highly inflammatory environment with the capacity to promote its own nerve and blood supply. There seems to be a hereditary component, and increasingly, we are defining somatic mutations common to endometriosis lesions. Given the many unknowns regarding endometriosis, I focus my practice on ensuring patients understand the complexity of the disease and try to develop an individualized approach based on each patient’s preferences and circumstances.
Medication: Depending on my patient’s preferences and needs, I offer hormonal suppressive therapy including combined oral contraception, oral progestin medication, and the levonorgestrel-releasing IUD. I typically recommend extended cycle dosing or continuous dosing of oral medications to achieve amenorrhea. In some cases when patients don’t have sufficient improvement with hormonal suppression or when they don’t tolerate or are opposed to hormonal suppression, I may also recommend NSAIDs, gabapentin, or SNRIs.
Approach to Persistent Pain After Surgery: I bring up the possibility of residual pain before the surgery takes place so patients understand that there may be ongoing treatment beyond the recovery from surgery. I follow patients closely after surgery to ensure that they are able to achieve a maximal improvement in quality of life. If residual pain is present, I consider the possibility of co-morbidities, such as pelvic floor dysfunction and painful bladder syndrome. When appropriate I refer to my colleagues in pelvic floor physical therapy, pain management, and urology. I do promote a focus on non-narcotic options for residual pain, such as nerve blocks, trigger point injections, acupuncture, and TENS therapy. I also encourage mindfulness and meditative practices. I utilize hormonal suppressive therapy when appropriate as well. Rarely, I discuss second look surgery as an option. I find that the vast majority of my patients achieve a positive outcome with this approach.