Rachael Haverland, M.D., Endometriosis Specialist, Gynecologist, Minimally Invasive Gynecologic Surgeon
City: Dallas, TX, USA
Philosophy: The etiology of endometriosis is complex. I do not agree with retrograde menstruation as I have seen premenstrual as well as postmenopausal patients with endometriosis. This also leads to the idea if you stop menstruation, you stop the pain which is not always the case. While more research on endometriosis needs to be done, I do believe the endometriotic implants are likely genetically present consistent with the Mullerianosis theory. They may additionally spread by lymphatic or blood systems ( how we get cardiac and pulmonary endometriosis). Endometriosis for gold standard treatment must be excised completely. Once appropriate excision surgery has been completed, a dynamic team approach with pelvic floor PT, injections by physiatrists and frequent postoperative visits to ensure no other additional diagnosis was missed is important. Frequently IBS, IC, or other chronic conditions are found in patients with endometriosis.
Medication: Endometriosis treatment is multifaceted and must start with a holistic approach to not only management of the endometriosis but also the other disease processes. I reserve/restrict the use medications such as Lupron, Orlissa, or other GnRH agonists or antagonists due to significant physical and mental side effects. Medications can be used to help symptoms if a patient does not desire excision surgery and options such as progesterone IUD or birth control pills are offered if desiring contraception. I also discuss after surgery, the first 2-3 cycles may be irregular and or more painful due to acute inflammation. Frequently, I use other non-opioid mediations such as NSAIDs, duloxetine, gabapentin, other SNRIs and compounded medications in adjunct depending on the patient’s pain generators.
Approach to Persistent Pain After Surgery: Multidisciplinary approach is the key to success! After patients have been in prolonged pain, the central sensitization of pain cycle can be important to address. Using compounded vaginal suppositories, pelvic floor PT, pelvic floor Botox and also targeted nerve injection series with physiatrist can be beneficial to address pain after surgery. If persistent pain continues, my approach is individualized. First, I closely evaluate each organ system to ensure we are addressing each area in a holistic approach at the initial visit to identify potential coexisting pain generators. At the initial consultation visit I also identify other compounding potential etiologies of pain. Sometimes a second look is necessary or discussion of other forms of hormonal suppression. I always follow my patients until their symptoms are improved.