Dr. Hebert Enrique Quintero Fajardo
Dr. Hebert Enrique Quintero Fajardo, Endometriosis Specialist
City: Barranquilla, Colombia
Philosophy of Endometriosis Care: The epigenetic theory
What type of surgery do you perform for endometriosis: Excision
Medication: Dienogest is used continuously in patients with superficial, ovarian, or deep endometriosis, with a reassessment of symptoms 12 weeks after starting treatment. Depending on the identification of other pain generators, additional medications may be incorporated, such as neuromodulators, muscle relaxants, antidepressants, and others.
Approach to Persistent Pain After Surgery: Given that patients with endometriosis experience multiple sources of pain, I conduct a thorough reassessment using a comprehensive, multi- and interdisciplinary approach. This approach addresses physical, nutritional, hormonal, and emotional aspects. Additionally, we evaluate pain centralization, assess potential recurrences, and review the recorded surgical footage to verify the complete excision of the affected tissue.
Dr. Agustina Larrea
Dr. Agustina Larrea, Endometriosis Specialist
City: Ciudad Autonoma de Buenos Aires, Argentina
Philosophy of Endometriosis Care:
-Retrograde Menstruation Theory
-Genetics: as it often runs in families and also is linked to nutrition habits in families.
-Nutrition: inflamed intestines because of flour, sugar, alcohol, and dairy, among others, lead to an an inflamated body and trigger an autoimmune system. It fails to recognize and eliminate endometrial cells growing outside the uterus, allowing the disease to progress. Besides, the metabolism of sugar is linked to the metabolism of estrogen. And we know this disease is estrogen-dependent.
I believe all these theories work together and are the key factors of treatment.
What type of surgery do you perform for endometriosis: Excision
Medication: I first apply together an anti-inflammatory diet + supplements such as magnesium and dienogest. If the patient can´t afford dienogest (I live in a low-income country), then I can rotate dienogest to drospirenone 4 mg without using placebos. I met the patient after 4 months to see how she was doing.
NSAIDs can complement treatment to manage pain. If I believe the patient has a Central Sensitization Syndrome, because of chronic pelvic pain, despite of all treatments applied, I work with a pain treatment team that usually gives amitriptiline to modulate central pain.
Approach to Persistent Pain After Surgery: I explain to the patient that surgery can not always relieve pain in 100%. Definitely, we should continue with an anti-inflammatory diet and dienogest (if the patient does not desire pregnancy), regardless of the surgical treatment.
Depending on the pain, I can work with pelvic floor physiotherapists, a pain treatment team to treat central sensitization syndrome, and a psychologist in order to give emotional support and, if needed, antidepressants.
Dr. Alberto Jose De Abate Julio
Dr. Alberto Jose De Abate Julio, Endometriosis Specialist
City: Panama City, Panama
Philosophy of Endometriosis Care: Epigenetic theory
What type of surgery do you perform for endometriosis: Excision
Medication: Dienogest; Oral Contraceptive; Mirena IUDI recommended as a first-line treatment of endometriosis with physical exercise and diet. To all patients for 3-6 months. If the pain does not improve. I am sending the presurgical study to program the Surgery.
Approach to Persistent Pain After Surgery: It depends. Pelvic Physical therapy; pain medications; amitriptiline.
Dr. Carlos Linder Efter
Dr. Carlos Linder Efter, Endometriosis Specialist
City: Mexico City, Mexico
Philosophy of Endometriosis Care: Celomic metaplasia
What type of surgery do you perform for endometriosis: Excision
Medication: I include progestins (Mirena) in my practice to assess the response to medication. In some special cases, I like to include GnRH analogs.
Approach to Persistent Pain After Surgery: Physical therapy and nutritional changes
Dr. Alberto Maya Epelstein
Dr. Alberto Maya Epelstein, Endometriosis Specialist
City: San Nicolás de los Garza, Mexico
Dr. Hugo Ruano
Dr. Hugo Ruano, Endometriosis Specialist
City: Guatemala, Guatemala
Philosophy of Endometriosis Care: Embriologic Theory. Endometriosis has a mesodermic origin. It starts as early as embryologic life when the three layers (endoderm, mesoderm, and ectoderm) are different(iating)
What type of surgery do you perform for endometriosis: Excision
Medication: Non-steroidal anti-inflammatory medications. I also use oral contraceptives such as ethinyl estradiol plus dienogest or dienogest alone and IUD of levonorgestrel.
Approach to Persistent Pain After Surgery: We usually carry on an evaluation with a neuropelviologist for initial and persistent symptoms. We also have an anesthesiologist specializing in pain management.
Dr. Jill Ingenito
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.
Dr. Amanda Chu
Dr. Amanda Chu, Endometriosis Specialist
City: New York City, USA
Philosophy of Endometriosis Care: No single theory adequately explains all presentations of endometriosis, but I believe that certain theories play more of a role in individual patients.Older theories have merit, e.g., retrograde menstruation and coelomic metaplasia, but we are constantly increasing our knowledge of endometriosis, & I think that epigenetics and immune dysregulation will become increasingly important.
What type of surgery do you perform for endometriosis?: Excision
Medication: Currently, hormonal medications are a useful and, at times, necessary adjunctive for cyclic symptoms and ovarian cyst prevention. Typically, I utilize continuous progesterone-only medications with the goal of amenorrhea/anovulation. I prefer to avoid GnRH agonists/antagonists for long-term use given their severe side effect profile.
Approach to Persistent Pain After Surgery: Postoperatively, I prefer to focus on finding less invasive ways to decrease inflammatory, musculoskeletal, & neuropathic pain rather than repetitive procedures. I believe in treating all etiologies of pain, including often coexisting comorbidities, and well as being receptive to approaches that expand beyond traditional Western medicine. Finally, the mental & social impact of endometriosis cannot be overstated, and a multidisciplinary team is essential.
Dr. Jurgis Vitols
Dr. Jurgis Vitols, Endometriosis Specialist
City: Riga, Latvia
Philosophy of Endometriosis Care: Genetic – epigenetic theory.
What type of surgery do you perform for endometriosis: Excision; Both. I may use ablation only for ovarian cysts. For ovarian endometriosis, I may use laser vaporization on the hilum of the capsule or for all of the cyst capsules in case the cyst enucleates badly and there is a high risk of damage to normal ovarian tissue. My preferred approach for ovarian cysts is cystectomy.
Medication: Depends on the patients wishes and complains. For patients who doesn’t want to have surgery, I recommend use of combined oral contraceptive pills or progesterone pills. If symptoms persist, I recommend surgical treatment. After surgery, I recommend long-term use of combined oral contraceptive pills or progesterone pills for patients who don’t wish to become pregnant and have had ovarian endometrioma – to reduce recurrence. For patients who wish to become pregnant after surgery, sometimes I recommend short use (maximum for 3-4 months) of GnRH analogs or GnRH antagonists to improve their chance of having a natural conception. I never prescribe long-term use of GnRH medication.
Approach to Persistent Pain After Surgery: Combined oral contraceptive pills or progesterone pills. Suppose this doesn’t help—pregabalin or amitryptiline. Patients with persistent pain symptoms are referred to pain specialists.
Dr. Brooke Winner
Dr. Brooke Winner, Endometriosis Specialist
City: Seattle, Washington, USA
Philosophy of Endometriosis Care: I believe in the embryologic origin theory, which basically says you are born with the endometriosis cells in the wrong place. This would explain why so many endometriosis patients say that their periods have been terrible ever since they started.
What type of surgery do you perform for endometriosis: Excision
Medication: Some patients respond well to hormone therapy, and others do not. There is no “one size fits all” approach. We will discuss the options available, the pros and cons given your unique situation, and ultimately the decision is up to you. We typically do not use Lupron or Orlissa to treat endometriosis due to significant side effects, although there are some patients who have found these medications helpful as well.
Approach to Persistent Pain After Surgery: The persistence of symptoms postoperatively is multifaceted and requires a multidisciplinary approach. One common issue is pelvic floor muscle spasms, in which case pelvic floor physical therapy can be helpful. Vaginal suppositories, acupuncture, massage, nutrition and mental health counseling can all be beneficial as well.
Website: https://www.fullspectrumgyn.com/
Instagram: https://www.instagram.com/dr.brookewinner/
Dr. Marco Guzman
Dr. Marco Guzman, Endometriosis Specialist
City: Juarez, Chihuahua, Mexico
Philosophy of Endometriosis Care: Embriology
What type of surgery do you perform for endometriosis: Excision
Medication: Hormonal, anti-inflammatory therapy, in early stages, and after surgery
Approach to Persistent Pain After Surgery:Hormonal therapy (Progestines )
Dr. Gina Ranieri
Dr. Gina Ranieri, Endometriosis Specialist
City: Princeton, New Jersey, USA
Philosophy of Endometriosis Care: The theory of endometriosis that I believe makes the most sense is that endometriosis likely originates during embryologic development either through coelomic metaplasia or embryonic cell remnants. This explains how endometriosis can be seen in non-menstruating patients and areas outside the abdominopelvic cavity.
What type of surgery do you perform for endometriosis: Excision
Medication: I will use hormonal medications such as the levonorgestrel IUD, combined oral contraceptive pills, Depo-Provera, or norethindrone for patients who are not interested in surgical treatment or to prevent recurrence after surgical excision in select patients.
Approach to Persistent Pain After Surgery: For patients who have undergone complete surgical excision of endometriosis and continue to report symptoms, I will often explore other pain generators. I do refer patients to pelvic floor physical therapy and perform pelvic floor trigger point and Botox injections as well as abdominal wall injections to treat myofascial pain. I will also prescribe non-opioid centrally acting pain medications for patients with very challenging to treat pain. If I suspect that the patient’s endometriosis has returned, I will often order imaging in the form of an MRI and potentially offer repeat surgery in appropriate and select patients.
