Shanti Mohling, M.D., Endometriosis Specialist, Minimally Invasive Gynecologic Surgeon
City: Portland, OR, USA
Philosophy: I believe endometriosis has multifactorial origins. Regarding surgical management, I treat it as though its origin begins with development during embryogenesis as the müllerian system is migrating. I believe most patients with endometriosis are born with it and that it flourishes during menarche with advent of hormonal changes. I also believe that there is a component of environmental impact such that a patient with genetic predisposition (and abnormal cells from embryogenesis) may do worse with an inflammatory environment (foods, pollution, stress, etc.). However, I believe that complete excision should mostly arrest disease and my treatment is based on mullerianosis as the genesis.
Medication: I work with patients in a collaborative fashion to arrive at the best option for each individual.
Hormonal therapies: Progestin-only contraceptives, combination oral contraceptives, Levonorgestrel IUD, Nexplanon occasionally. I almost never offer Depo Medroxyprogesterone acetate (due to side-effects) or GnRH analogs (due to side-effect profile and long-term negative effects). I have worked with bioidentical hormone therapy for over 20 years and also incorporate that when appropriate, such as in patients who have undergone surgical menopause or patients who do not tolerate synthetic hormonal therapy.
For pain: NSAIDS, occasionally narcotics, naltrexone and occasionally Medical Marijuana when appropriate. Sometimes neuromodulators such as gabapentin and pregabalin. I often recommend amitriptyline, especially in the case of interstitial cystitis. Finally, I sometimes prescribe compounded vaginal suppositories which may include valium, baclofen or ketamine.
I also use Botox for pelvic floor myalgia on a routine basis.
Approach to Persistent Pain After Surgery: I believe most pelvic pain is multifactorial: endometriosis, interstitial cystitis, bowel dysfunction (to include IBS, SIBO, Intestinal Permeability, gastroparesis), myofascial pain and neuropathic pain. At the initial work-up, I attempt to identify each of these contributors. Yesterday, I saw a postop patient who had had extensive endometriosis excised and confirmed by pathology. She had persistent pain. We reviewed her history of bowel symptoms, history of schistosomiasis and giardia (she had worked in Africa) as well as an exam suggesting pelvic floor myalgia. She will now work with a functional medicine specialist and pelvic floor physical therapist. We also discussed hormonal options (progesterone has a distinct effect on gastric function). This is very typical of my approach.