Dr. Paul Tyan, M.D., Endometriosis Specialist, Gynecologist, Minimally Invasive Gynecologic Surgeon
City: Arlington, VA, USA
Philosophy: In its most basic definition, endometriosis is the presence of endometrial cells (that form the inner lining of the uterus) outside the uterus. In some patients, those ectopic cells can produce an inflammatory response that is at the origin of various cascades that can lead to pain or scarring. There are multiple proposed theories about the origin of endometriosis. The only certainty is that the origin of endometriosis is multifactorial.
The retrograde menstruation or implantation theory is one of the initial principles of the pathogenesis of endometriosis;however, it has been challenged as the single cause for several years, as evidenced by the occurrence of symptomatic endometriosis in premenarchal and postmenopausal women. Also, by the fact that nearly all patients will have retrograde menstruation, but not everyone has endometriosis.
Most recently, we have had significant advances in the genetic and epigenetic theory of endometriosis. The clonality of endometriosis lesions and the cancer-driver genes that have been identified in deeply infiltrative endometriosis lesions shed light on the genetic component of the disease. Recent work on the epigenetic factors linked to external conditions affecting pluripotent cell behavior in the setting of endometriosis is a promising field set to unveil exciting information.
Keeping up to date with the intricacies of the pathogenesis of endometriosis is crucial to my clinical practice. Many patients will be counseled over the years that surgery is unnecessary at that blocking the menstrual cycle or hormonal suppression is sufficient for “curing” endometriosis. Explaining to patients the complex nature of the disease and the necessity of early intervention, especially in the deeply infiltrative endometriosis subtype, could be a crucial factor in decreasing morbidity and improving the quality of life of my patients.
What type of surgery do you perform for endometriosis?:
Excision
Medication: I recommend a combination hormonal contraceptive (birth control) for post-surgical suppression. In cases where a combination option is contraindicated, I recommend a progesterone-only option.
I recommend treatment with an SSRI, SNRI, or GABA-Analog for patients with central sensitization due to chronic pain secondary to endometriosis.
For patients with pelvic floor tension myalgia, I recommend physical therapy, various muscle relaxers, and trigger point injections or nerve blocks in warranted conditions.
Treatment plans tend to be individualized based on the patients’ presenting symptoms, surgical management, and postoperative course.
Approach to Persistent Pain After Surgery: For some patients, endometriosis excision is sufficient for complete symptomatic relief. However, some patients will still have symptoms after surgery. It is crucial to counsel patients before surgery that endometriosis excision is only one aspect of a comprehensive management plan that should involve central and peripheral pain management, pelvic floor physical therapy, and dietary modification.