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Center for Endometriosis - Endometriosis & Pain

Endometriosis and Pain

Written by Patrick Yeung Jr. MD

Director, Saint Louis University Center for Endometriosis

Endometriosis-  U.S. National Library of Medicine - The World's Largest Medical Library

Endometriosis Treated with C02 Dr Yeung

What is endometriosis?

Endometriosis is a condition where endometrial tissue, normally found in the uterus’ lining and shed during a menstrual period, is found elsewhere in the body.

Endometriosis lesions can be found anywhere in the pelvic cavity -- on or in the ovaries, the fallopian tubes, and on the pelvic sidewall. Other common sites include the uterosacral ligaments, the cul-de-sac behind the uterus, and in the recto-vaginal septum.

In addition, these lesions can be found in other places within the pelvis including on the bladder, large or small bowel, and appendix.

What are the symptoms of endometriosis?

The main manifestations of endometriosis are pelvic pain, adhesions, and infertility. Endometriosis is found in 15-80 percent of women with chronic pelvic pain, and in 21-65 percent of women investigated for infertility.  The most common symptom of endometriosis is pelvic pain. For many women, the pain of endometriosis is so severe and debilitating that it impacts their lives in significant ways. For other women, the pain of endometriosis is somewhat more mild.

The pain often occurs with the menstrual period, but a woman with endometriosis may also experience pain at other times in her cycle, such as with intercourse and bowel movements.  Other symptoms of endometriosis include diarrhea, constipation, abdominal bloating, irregular bleeding, and fatigue.  

Endometriosis can also cause scar tissue and adhesions to develop that can distort a woman’s internal anatomy. In advanced stages, this can be severe, and internal organs such as the uterus, ovaries, and bowel may be stuck together.

How is it diagnosed?

There is no easy test to diagnose endometriosis. In one study, the average time from the onset of symptoms to the surgical diagnosis of endometriosis was 12 years. The best way to definitively diagnose endometriosis is to perform laparoscopic (“keyhole”) surgery and to take a biopsy of the tissue.

Surgery is an expensive, invasive procedure. Further, if the surgeon is not a specialist or experienced in recognizing endometriosis, he or she may not accurately diagnose whether endometriosis is present or not. It has been recommended that, when possible, “see and treat” laparoscopy is performed so that endometriosis is both diagnosed and treated during the same surgery.

Other tests the gynecologist may perform include ultrasounds, MRI scans, and gynecological examinations. While none of these tests can definitively rule out the presence of endometriosis, they can suggest when the disease is present.

How is it treated?

In general, treatment for endometriosis includes pain medications, hormonal suppression, or surgery.
Pain medications and hormonal suppression treat the symptoms of endometriosis. An example of hormonal suppression is when a doctor prescribes a combination of birth control pills that create a sort of “chemical pregnancy,” or, alternately, when he or she prescribes gonadotropin agonists or antagonists that create a “chemical menopause.” These medications are used to suppress the endometriosis, which can alleviate symptoms, but they do not treat infertility.

Surgery is the only treatment that can remove the disease and restore normal anatomy, which is potentially curative for women who suffer from endometriosis.

What are the benefits of surgical excision versus ablation?

The goal of surgical excision is to completely cut out all visible endometriotic implants. Excision can be performed using any number of modalities including monopolar scissors, harmonic energy, and the carbon dioxide (CO2) laser.  The surgeon will select the modality that gives the greatest confidence in removing all the endometriotic implants wherever they are found -- even over vital organs including the bladder, parts of the bowel, and the ureters.

The aim of ablation is to destroy the endometriotic implants by burning or coagulating them. The concern with ablation is that only the easily visible signs of endometriosis are treated, potentially leaving deeper areas of endometriosis untreated.

At the Saint Louis University Center for Endometriosis, the surgical approach to endometriosis is to try to achieve complete excision of all areas suggestive of endometriosis - both typical and atypical.  While excision is not 'proven' to be superior to ablation, excision of areas thought to have endometriosis has a number of advantages -- the lesion is excised down to normal tissue ensuring its complete removal, less charred areas are produced which can lead to adhesions, and the specimen removed is sent to pathology for a definitive diagnosis.

Is there a benefit to early excision?

A recent article published by Dr. Yeung in Fertility & Sterility 2011:  (1) demonstrates that
complete excision (even in teenagers) by an expert is potentially curative, and can eradicate disease; (2) implies the importance of early excision, to prevent progression and preserve fertility, and (3) indicates that these results do not require long-term hormonal suppression.

Is there a "definitive therapy" for endometriosis?

“Definitive therapy” for endometriosis is considered by most to be removal of the uterus (so that the woman no longer has the pain associated with her periods) and removal of both ovaries (to remove the hormonal stimulation of endometriosis). However, removing the uterus and ovaries does not eliminate the disease itself, and removes hormonal production of the ovaries which may be beneficial.

Some have proposed that complete excision of endometriosis itself be considered a form of definitive therapy since the goal is to remove all areas of endometriosis.  Sometimes this requires removal of the uterus (if child-bearing is complete), since the uterus itself can have disease called adenomyosis.

If I have had complete excision of endometriosis, but I still have painful periods, are there any other treatments available?

There is a procedure that has shown benefit for patients who have central pelvic pain caused by endometriosis but are resistant to surgical treatment. The procedure is called presacral neurectomy and it can be performed by laparoscopy.
This procedure is not for everyone, so you will need to research the procedure and talk with your doctor to determine if it is right for you.

Are there ways to prevent adhesions during laparoscopic surgery for endometriosis?

Good surgical technique that minimizes blood loss and charring is the best way to prevent adhesions.  In addition, there are fluids or barriers that can be used to prevent the development or recurrence of adhesions.  These include a fluid called Adept (a clear fluid left in the abdomen after the procedure which is then absorbed in a few days), Goretex (a non-absorbable barrier which has to be removed in a second procedure), and a compound called Seprafilm (made up of chemically modified sugars, some of which occur naturally in the human body).