Thanks to Nancy Petersen, RN for her invaluable contributions to this article. Visit Nancy’s Nook for Endometriosis Education & Support to connect with others who understand in a supportive, private setting.
No robust effort to champion public health can be complete without addressing the scourge that is endometriosis: an enigmatic disease taking immeasurable toll on every aspect of the health and well-being of approximately 176 million women and girls – and yes, even some men – from every corner of the globe (WERF). One of the most critical challenges facing the endometriosis community is a lack of factual awareness; a challenge which keeps us largely mired in myths, misinformation, lengthy delays in diagnosis, poor treatments, and an incredible lack of support for affected stakeholders. The legacy of misinformation enshrouding this illness is shared in perpetuity from even well-meaning, well-respected providers to patients, from medical educators to next-generation healthcare professionals, from health publishers to the media, from mothers to daughters, from generation to generation. Moreover, unrelenting societal and cultural bias surrounding menstruation and pelvic pain keeps the disease often belittled, ignored and diminished.
If you are not already angry about the state of affairs in endometriosis, you should be.
As a society, we continue to fail those with the disease. Though investigations are being conducted on various aspects of the illness, much of it is redundant in nature and lacks translational benefit, in the sense that it will not prove helpful to patients in the ‘here and now.’ Many of the studies underway are directed solely towards pharmaceutical management and do not provide long-term solutions; still others fail to examine the far-reaching impact of the disease in any meaningful way. “Blame the patient” is still prevalent, and women are still too often told the pain is in their head or normal; others espouse ancient, mythical notions of hysterectomy, drug therapy, incomplete surgery or pregnancy as cures. Such sentiments are a monumental disservice to those suffering.
We must create a far more participatory dialogue in women’s health and put an end to the divisiveness and lack of collaboration among all stakeholders, who should be working together towards solutions for those with the disease; we must continue to lobby policymakers and legislators for robust institutional changes to further benefit those struggling with the illness; we must end the secrecy, isolation and pain of countless sufferers; we must revitalize and create a space for menstrual communications, broaden the gender dialogue, and engage in key conversations. We must allow the endometriosis community’s voice to be heard. Now is the time.
Clinically, endometriosis is characterized by the presence of endometrial-like tissue found outside the uterus, in other areas of the body. This tissue is histologically unlike normal endometrium (Delbandi et. al. 2013), exhibiting significant differences in invasive, adhesive and proliferative behaviors as compared to its eutopic counterpart. In short: endometriosis is not simply normal tissue in an abnormal place, easily treated by hysterectomy, pregnancy or drug therapy, as the persistent myths indicate. The result is a sustained, inflammatory reaction, development of painful endometriomas, marked peritoneal tension and fibrotic scarring, formation of painful adhesions and much more. There is also high likelihood, particularly in advanced stages, of impairment/distortion of anatomy (Kennedy et. al. 2005). Impaired bowel, bladder and reproductive function is common. Lung/diaphragmatic/thoracic and other extrapelvic endometriosis diagnoses are also possible. It is generally accepted there are three distinct types of endometriosis: superficial, ovarian endometriomata and deeply fibrotic [sometimes called infiltrating] (Carneiro et. al. 2013), each with their own particular sequela – and all with the propensity to cause pain and disruption. Often called a “disease of theories,” definitive pathogenesis remains under debate, though endometriosis may be related to a number of hereditary, environmental, epigenetic, and even possible menstrual characteristics and alterations, some sharing certain – though highly limited – common processes with cancer (Kokcu 2011) – however, it is imperative to understand that endometriosis is not cancer.
Symptoms may mimic, and differential diagnoses include, that of interstitial cystitis, ectopic pregnancy, pelvic infection, pelvic congestion syndrome, pelvic floor dysfunction, levator ani muscle myalgia, adenomyosis, leiomyoma, ovarian remnant syndrome, uterine retroflexion, irritable bowel syndrome, acute appendicitis, peritonitis, mechanical trauma or ovarian torsion, among others. Classic signs include severe dysmenorrhea, dyspareunia, pelvic pain at any point in cycle – not just present during menses, gastrointestinal pain (often mistaken for ”IBS”), bladder/bowel dysfunction and more. With some cases, varied symptoms including bowel obstruction, passage of dark/tarry stool, hematuria, dysuria, dyspnea (in pleural and diaphragmatic disease) and swelling in soft tissues may present. Stage, the degree of disease and adhesions present according to rAFS/ASRM criteria, has no correlation with severity of pain or symptomatic impairment. Though infertility is often among chief findings, severe/intractable abdominopelvic pain, anatomic distortion, adhesions and altered inflammatory response are among the vital clinical consequences. Endometriosis is also speculatively linked to a number of environmental, autoimmune and malignant concerns. Read about signs and symptoms of the disease in more detail here. Diagnosis is surgical, though any patient presenting with pelvic pain at any time should have endometriosis considered among the differential diagnoses.
Though receiving little mention in historical medical compendiums, it is without question endometriosis has, for centuries, negatively impacted the social, physical, emotional and sexual quality of life of those living with the disease. The profound economic consequences and significantly impaired quality of life greatly contribute to the urgent need for continued research and improvement in diagnostic and treatment modalities – yet endometriosis remains largely ignored throughout society; dismissed at the public and provider levels alike. Focus on better clarifying pathogenesis, pain mechanisms and potential links to certain morbidities/malignancies remains critically necessary. Prevention continues to be elusive, and many sufferers find themselves isolated and frustrated by the widespread lack of understanding and barriers to quality care they face every day.
Endometriosis remains steeped in menstrual taboos, secrecy and shame, and is epitomized in large part by extremely poor efficacy and safety profiles of commonly proffered therapies. Prevalence corresponds to – and increases with – awareness and training of the diagnosing surgeon, but it is estimated to affect 8.5 million in North America alone (WERF 2010). The annual estimated cost burden – in just the United States – hovers around a staggering $119 billion (D’Hooghe et. al. 2012). Most of the price tag related to the disease is driven by high hospitalization rates, and those who struggle with endometriosis incur almost 65% higher medical costs (Mirkin et. al. 2007).
Nearly a decade ago, it was estimated that total costs of care for women with chronic pelvic pain in general was substantial, with 15% of affected women missing an average of 14.8 hours of work, per month, in the United States alone – accounting for a staggering $14 billion in lost productivity each year. The total costs of potentially unnecessary medical, surgical and psychiatric care or hospitalization were further assessed at $128 million per year (Kuligowska et. al. 2004). Ten years later, very little has changed, with endometriosis specifically accounting for a significant loss of productivity of 11 hours per woman per week, resulting in variable yet considerable costs by country (Nnoaham, Hummelshoj, Webster, D’Hooghe, Nardone, Nardone et al. 2011). The disease remains a top cause of chronic pelvic pain, yet delays in diagnosis across all care settings has not improved. It is imperative that providers become aware of – and better educated on – the clinical characteristics of the disease in order to make accurate diagnoses and facilitate appropriate referrals. The enduring lack of awareness contributes greatly to the average diagnostic delay of more than a decade across multiple consults, and despite its status as a true community health crisis, misinformation remains ubiquitous, continuing to pervade the media, healthcare setting and general public – resulting in continued long delays to effective diagnosis and treatment.
A leading cause of pain, sexual dysfunction, bowel, bladder and/or other organ impairment, infertility and more, endometriosis remains fraught by high treatment failures and consequent recurrence – all of which pose formidable challenges to practitioner and patient alike. The disease remains the third leading cause of gynecologic hospitalization in United States (Missmer et. al. 2004) and is considered a leading contributor to female primary and secondary infertility, prevalent in 0.5% to 5.0% in fertile and 25% to 40% of infertile women (Ozkan et. al. 2008). Not all women with the disease experience pain (Duleba et. al. 1997), but most – particularly those with deeply infiltrating/fibrotic endometriosis – will struggle with painful symptoms (Fauconnier et. al. 2002); some even life-altering. Though classically considered a disease of women, it is important to remember that endometriosis can affect menstruators and non-menstruators alike, as well as those post-hysterectomy and post-menopausal. By and large, we are still not as a society taught what is ‘normal’ and what may be indicative of a problem; ‘period taboos’ stifle the conversations we need to be having about signs and symptoms of the disease that could lead to earlier intervention.
A shocking 72% of those living with endometriosis have reported significant disease-related affects which interfered with their daily lives (Fourquet et. al. 2010). Early intervention and increased, accurate awareness is requisite to reduce morbidity, infertility and progressive symptomatology in patients of all ages, yet in order for those affected to make educated choices about their health pathways, we must provide them with the correct information upon which to base their healthcare decisions and confer the most timely, efficacious interventions – including referrals to tertiary treatment centers as appropriate. Failure to diagnose and treat endometriosis through a judicious, well-timed approach may have multiple tangible and intangible consequences, as pioneering excision surgeon and Founder of the Center for Endometriosis Care, Robert B. Albee, Jr. MD, addresses in his acclaimed editorial, “Is Endometriosis all in Your Head?” Nevertheless, one need only turn to the most recent article on endometriosis to see it referred to merely as ‘killer cramps’ or ‘painful periods,’ routinely treated by one-size-fits-all approaches.
Researchers still can’t even agree on the origins of endometriosis, though popular theories include:
‘Sampson’s Theory’ of retrograde menstruation, 1921 – perhaps the most popular – yet flawed – of theories. Initially, Dr. John Sampson assumed that endometriosis is the result of “seedlings” from the ovaries. Later, he proposed endometriosis results from reflux menstruation, wherein normal endometrium is “showered backwards” onto the peritoneum and ovaries, taking hold. However, endometriosis and normal endometrium are not the same, and retrograde menstruation is a very common phenomenon among most women – yet not all will develop the disease. There are multiple, various issues with Sampson’s ideology, but the continued broadcast of his theory as the root of the disease has led to many cases of poorly treated endometriosis. Unfortunately, this popular notion continues to complicate effective management and understanding of the disease today – a monumental consequence foretold more than two decades ago by excision pioneer David Redwine, MD. Despite the extensive works of Redwine and others who practice modern concepts to dispel Sampson’s Theory over the years, it continues to be at the foundation of many current studies and treatments – even those by well-intentioned thought leaders.
Predating Sampson, the oldest concept assumes that endometriosis may arise in situ – or, in place – from mullerian duct remnants – female genital passages, or from metaplasia of peritoneal or ovarian tissue. Proposed as early as 1870 by anatomist Heinrich von Waldeyer as germinal epithelium of the ovary, this theory continues to be popular today and has the support of pathologists, who often refer to it as the metaplastic theory. Endometriosis routinely found in the cul-de-sac, on the uterosacral and broad ligaments, beneath the ovarian surface, on the peritoneum, on the omentum, and within the retroperitoneal lymph nodes is often referred to as “mullerianosis.” Disease diagnosed in adolescents either prior to or shortly after menarche supports the notion of embryonic mullerian rest pathogenesis (Giudice L, Evers JLH, Healy DL. Endometriosis: Science and Practice. Chichester, West Sussex: Wiley-Blackwell; 2012).
More current research has implicated HOX genes, mesenchymal stem cells and certain immunologic factors in disease origin; there is also data suggesting deep endometriosis may have lymphangiogenic growth factors, which could lead to lymphatic spread in some women (Keichel et. al. 2011). Emerging data has also defined endometriosis as an epigenetic disorder (Guo 2009). Still more recent data is exploring endometriosis from a systems biology perspective (Griffith et. al. 2014).
Still, despite the abundance of theories, no single assumption sufficiently explains the disease. It may be fair to say a composite of several mechanisms are involved; likely, it is present during fetal life and triggered by a number of factors later among those affected.
A number of sources have also asserted over the years that endometriosis is a disease caused by ‘negative emotions’ and various deep-seated “psychological components” (Griffin 2013, et al.). While there are undoubtedly various social, psychological and emotional aspects to any painful, chronic illness such as endometriosis, these are likely consequences of the disease – not the cause. Endometriosis has its origins in very real, very complex genetic and molecular underpinnings – not an abstract ‘rejection of one’s uterus’ or inability to ‘get along’ with one’s parents, as some claim. Contentions that endometriosis is a psychological ailment due to one’s internal failings or otherwise rooted in self-imposed, negative emotions leads only to further delayed diagnosis and ineffective treatment of the disease for countless women and girls. This is not to say that cognitive-behavior-spiritual efforts cannot be helpful to some by perhaps facilitating ways in which they can better temporarily cope with symptoms; indeed, our own patients often feel comforted by the short prayer we offer before they undergo anesthesia and engage in a number of mind-body approaches as part of their self-care. Renowned Nurse, educator, mentor, advocate, excision pioneer – and endometriosis patient – Nancy Petersen shares her experiences and perspective:
“I became a prolific reader of self-care, alternative care, ways of distracting the mind…all that reading, video watching, tape listening, etc. helped move my brain out of the continuous focus on the pain. One of the books I read was Psychologist Mihaly Csikszentmihalyi’s Flow: the Psychology of Optimal Experience. While written in a very scholastic way, I was able to pick out some key ideas, one of which is when you get into something you truly love, your life flows and distractions can be minimized in the moment…I began gardening…I found ways to adapt my life and my garden so I could still do this – without making my life and pain worse. This gave me back some power. During this time, no one was helping me with my pain…so as my joy at digging my hands into the soil, particularly in an extremely difficult climate, began to emerge, I found that I could forget the pain for minutes, sometimes, even a half hour. Even today…I can put the pain aside for hours at a time by finding joy. This is NOT to say the pain goes away, but rather, the brain is trained to look elsewhere for periods of time. I do not believe I would have had the strength to persist if my endometriosis had not been resolved through excision…so I am grateful for the success of [the disease] removal.”
Importantly, she maintains: “You cannot just ‘muscle through the pain.’ Sometimes that will make things worse, because you work physically beyond your tolerance, but you can distract the mind from paying attention for periods of time. Is it easy? Not at all! It is hard work, requiring self-education, focus, practice – and sometimes, you will fail. In some cases, you may always fail! BUT trying to improve your ability to cope with pain until you can find more effective care can be empowering, and give you a sense of purpose. Please do not interpret this to mean you can do ‘mind over matter’ where your pain is concerned. Rather, you can build short respites, sometimes even longer. For me, it was at least something I could try. That alone was empowering.”
In our own clinical setting, we are contacted by more than a thousand patients annually from every corner of the world, many of whom relate to us that their caregivers and loved ones feel they are embellishing their accounts of pain and symptoms – yet most have previously diagnosed endometriosis. “Individuals with endometriosis generally do not make up – or cause – their symptoms of pelvic pain, nor do they exaggerate about the severity of pain experienced,“ says Petersen of her experiences. In fact, she noted, 75% of the women who came to the excision treatment program she founded with Dr. Redwine had been dismissed in the past by their doctors as being neurotic – yet, as in our own patient population, also had biopsy proven disease.
En précis, a number of various emotional, mental, social, spiritual and behavioral factors can somewhat influence our health, but endometriosis is not caused by “being excessively self-critical” (Northrup 2009), nor by “insecurities, disappointment and frustrations,” or as a result of “disappointments from dad” (Weaver 2013). While various psychoimmune interactions are present in women with endometriosis, including pronounced immunological shifts manifested by imbalanced production of anti-inflammatory cytokines (among other biologic responses), these are part of the network of adaptive reactions associated with and perhaps because of the disease – not the origin of it.
In general, no particular demographic, personality trait or ethnic predilections exist in accordance with endometriosis, though family history cannot be undervalued, with studies indicating a near 10-fold increased risk in women with first-degree relatives who have the disease (Matalliotakis et al. 2008). Endometriosis often creates a constellation of symptoms, each patient with their own unique combination of various indications. Thus, it can be difficult isolate a diagnosis if we are not listening to the patient – particularly when we live in a culture of menstrual misinformation. This is especially true among younger women and adolescents with the disease, who are often turned away with their pain dismissed as normal.
Still often mistakenly believed to only impact older women, in reality nearly 70% of teens with pelvic pain go on to later be diagnosed with endometriosis (Yeung, Sinervo, Winer, Albee 2011). Yet in Karen Ballard’s landmark paper from 2006, she powerfully described the stigma given to girls with menstrual pain who were mistakenly believed to simply be unable to ‘handle’ their periods. “The harsh reality is that unless they have a parent or a healthcare professional who believes in them and stays on course determined to understand the reason for the pain, young women [with endometriosis] often face dramatic changes in their lives once the symptoms become severe,” states Dr. Albee. “Somewhere along this journey, a careless doctor or healthcare provider will suggest that ‘it is all in her head’. Over time many will begin asking themselves whether or not they are somehow making this up. Sadly, parents do not know what to think and may begin doubting their daughters as well.” Yet in the largest prospective study of excision in teenagers to date, we demonstrated in contrast that complete excision is an important part of the management plan for pain and even eradicate the disease (Yeung, Sinervo, Winer, Albee 2011).
Still even more isolated are the few men struggling to access endometriosis diagnosis and treatment in a traditionally female-identified space, as well as LGBT patients who face additional, unique considerations in healthcare settings that fail to be inclusive – leading to additional stressors and impaired treatments. There are also cases of male endometriosis in the literature, lending to further confusion about disease origins.
Early diagnosis is fundamental in all settings to effectively manage the disease, and the Endometriosis Research Center encourages adolescents in particular to know when it’s time to seek help. “Periods – or symptoms at any time during a girl’s cycle – that are so painful they get in the way of school, work, sports, extracurricular or social life are an indication something is wrong. Don’t suffer in silence; talk to your nurses and doctors about getting diagnosed and treated,” the organization highlights in their Girl Talk® materials. Girl Talk®, launched in 2003, was the first program in the country designed to educate students along with school nurses, doctors and adolescent healthcare providers about the disease. Still, signs of endometriosis go frequently overlooked and under-diagnosed, resulting in inappropriate referrals and deficient treatment; lack of awareness and bias may result in delayed, mistaken and dismissive diagnoses i.e. sexually transmitted infection, conversion disorder, etc. Many clinicians, even well-meaning, remain naïve as to the potentially damaging effects endometriosis can impose on quality of life, sexual function and overall well-being of those suffering.
Indeed, data reflect that many practitioners’ knowledge is sorely limited, with direct consequences on diagnosis and care. In one investigation, 63% of GPs indicated they felt “ill at ease” in the diagnosis and follow-up of patients with endometriosis. One-half could not cite three main symptoms of the disease out of dysmenorrhea, dyspareunia, chronic pelvic pain and infertility. Only 38% indicated that they perform a clinical gynecologic examination for suspected endometriosis, and 28% recommended MRI to confirm the diagnosis (Quibel et. al. 2013). Among nurse graduates administered a pre-test by the CEC to determine their perceived and actual disease knowledge, 100% failed to correctly identify the correct definition of endometriosis, opting instead for “cysts on the ovaries accompanied by elevated CA-125” and “an infection of the endometrium.” 60% of respondents also erroneously believed that endometriosis only affects older, menstruating women (CEC professional education course data). These brief examples illustrate significant knowledge deficits in the healthcare setting, and further demonstrate the crucial need for improved education with a specific emphasis on disease recognition among all age groups.
In that endometriosis requires surgical diagnosis, a lack of valid markers contributes in part to the long delays in timely intervention, though proteomics and genomics are establishing the basis for future study related to such biomarker development (Giudice L, Evers JLH, Healy DL. Endometriosis: Science and Practice. Chichester, West Sussex: Wiley-Blackwell; 2012). Physical examination and diagnostic imaging also have poor sensitivity, specificity and predictive value. While a thorough combination of history, physical examination, laboratory and diagnostic studies as indicated may be done to rule out non-endometriosis causes of pelvic pain, surgical confirmation of both endometrial glands and stroma in biopsy specimen(s) is required for diagnosis, though surgical findings of fibrosis in combination with hemosiderin-laden macrophages may be sufficient for a presumptive diagnosis in some cases (Kim, Adamson et. al. 2008). Accurate diagnosis, nevertheless, requires an experienced surgeon as varied appearances of disease may allow less obvious manifestations to be overlooked (Carneiro et. al. 2013), leading to continued under-diagnosis and/or poor outcome. Due to the subtle appearance of some forms of endometriosis, accuracy of diagnosis is ‘operator dependent’ – that is to say, depends in large part on the ability of the surgeon to adequately identify the disease. A thorough and systematic examination of the pelvis and abdomen is essential in all patients to identify and document all lesions, with care taken not to overlook peritoneal pockets and ovarian fossae. It is simply not possible to triage women with chronic pelvic pain effectively on history alone; many will benefit from referral to a specialist center for careful clinical assessment and appropriate investigation (Ballard et. al. 2010).
Despite attention brought to endometriosis in recent years by various celebrities who came forth to share their experiences (yet also often share misinformation and inaccuracies about the disease), it continues to remain a diagnostic challenge despite patients presenting with hallmark symptoms, often very early on in life. Often told their pain is normal, part of being female, or in their head, an estimated 80% have symptoms of endometriosis from their very first few periods or even before. Ken Sinervo, MD MSc FRCSC ACGE, world-renowned excision surgeon and Medical Director of the Center for Endometriosis Care, discusses this failed scenario playing out time and again in healthcare settings across the globe:
“A girl mentions her symptoms year after year and is placed on different birth control after different birth control to “manage” them – yet failure of one type of birth control should indicate that her pain and symptoms are not normal…if there is failure of one birth control and/or NSAID, it should suggest the possibility of endometriosis. But instead, these patients are dismissed, ignored and marginalized. It takes years before they finally get their diagnosis and are pariahs – labeled as having endometriosis – a medical dead end.”
Nonetheless, even upon surgical diagnosis, the person with endometriosis may only be offered ineffective (and potentially harmful) drug therapy that only temporarily quells the symptoms, incomplete surgery which leaves disease behind, or worse still, counseled to undergo unnecessary hysterectomy. Though hysterectomy has a place in treatment for select cases, endometriosis is not “cured” by the procedure. Yet, nearly half of the 600,000 hysterectomies performed in just the United States alone annually are the result of endometriosis (Centers for Disease Control, Hysterectomy Surveillance data). An ongoing, dangerous myth responsible for many needless hysterectomies, we must put an end to this misguided “treatment.” Still others are simply told nothing can be done for them, leaving them in utter physical and emotional torment. Tragically – some even lose all hope.
There is a better way. Most patients will indeed need complex, multidisciplinary surgery combined with adaptation of lifestyle changes – yet few are guided towards excisional surgery by their providers and remain unaware of non-invasive, adjunct options such as physical therapy, nutritional approaches and alternative approaches that may help when combined with quality surgical treatment.
When endometriosis is diagnosed at the time of the surgery, surgical destruction is indicated with the objective to remove all lesions, preserve uterus and ovarian tissue and restore normal anatomy. Rarely in today’s minimally invasive surgical environs is open surgery necessary. However, although excisional surgery offers a higher success rate in treating the disease, it also requires a higher level of surgical skill and presents an increased degree of technical difficulty. To that end, surgery to debulk and excise endometriosis may be “more difficult than for cancer” (Reich, 2011). As a result, many patients receive incomplete treatment by less-experienced surgeons, which in turn may lead to persistent symptoms and recurrent disease. It should be noted that women who have undergone repeated surgeries and had a hysterectomy still suffer. The need to improve surgical approach and/or engage in timely referrals to dedicated treatment centers – indeed, even out of their home country if necessary – is unquestionable.
Despite the increased challenges presented by meticulous and thorough dissection of disease, complete excision of endometriosis is entirely possible – including vaginal resection – and offers a significant improvement in sexual functioning, quality of life and pain, including in those symptomatic patients with deeply infiltrating nodules in the posterior fornix of the vagina. Laparoscopic Excision restores normal anatomic relationships and can treat pain, infertility or both by sharply dissecting deep fibrotic nodules which may be causing partial or complete cul-de-sac obliteration. The C02 laser can be successfully used as a precise cutting tool to excise to the roots of disease, from all areas including bowel, rectovaginal septum and other complex regions.
Conversely, superficially burning the disease with the laser – which is what most commonly occurs in typical ob/gyn surgical settings – destroys tissue, making microscopic evaluation impossible and does not remove all disease (Albee, Sinervo). Simply “shining a light” (Redwine) at the disease does not eradicate it. It is important to understand the difference between tool and method; for additional reading on this topic please visit this article. For information specific to the robotic/da Vinci® approach to endometriosis, please visit this article by Dr. Albee. Again: in that this kind of surgery requires uncommon surgical skills and anatomical knowledge, it should be performed only in selected reference centers by those focused on treating the disease. You can find referrals within various support groups such as Nancy’s Nook and The World Endometriosis Research Foundation.
In general, true LAPEX significantly improves general health and psycho-emotional status. Data reflect pain, sexual function, fertility rate and quality of life are improved and associated with low complication and recurrence rates after a CO2 laser laparoscopic radical excision of endometriosis. Complete excision “prevents persistent disease” (Koh 2012); only 7-12% of the time can we document endometriosis after complete excision (Albee, Sinervo 1990-2014 data). Thus, LAPEX remains the most minimally invasive, highly cost-effective option, provided early diagnosis is conferred (Mabrouk et. al. 2011). Left un- or inadequately treated, however, endometriosis can lead to continued pain, infertility or pregnancy loss, dysfunction, in-patient stays and post-operative morbidity, reduced productivity, and ultimately increased costs and poor outcomes. This contributes to highly unnecessary increased financial burdens on patient, hospital provider, practitioner and society alike.
Sadly, even well-meaning clinicians – not just lay society and media – remain ignorant of the damaging effects the disease imposes on girl’s and women’s physical well-being, sexual function, fertility and general welfare, creating a vicious cycle of ineffective treatment. Often, this results in limited treatment access and opportunity. Says Dr. Sinervo: “We have seen patients with more than 20 procedures, who would have had a fighting chance of pain relief had they been offered excision of their endometriosis at an early age. Despite this, our average patient has been on 2-3 medical treatments (birth control, GnRH agonist/antagonist, Depo-provera, Nuvaring, progesterone, esterase inhibitors, etc. etc, etc.) and undergone 2-3 surgeries.” He continues: “Typically, patients are told they have few options: we can try one surgery and if you don’t get relief you are offered GnRH agonists (i.e. Lupron®) or other suppressive medication which has long-term side effects; suck it up and live with pain; get pregnant (who plans on getting pregnant as a teen?? A few, but most are not ready for this!); have an early hysterectomy; or worse, undergo useless surgery after useless surgery treating the disease superficially – which causes more chronic pain and leads to retroperitoneal fibrosis [scarring below the normal pelvic tissues, which may be more damaging than the endometriosis was originally. These patients are damaged much more than their original disease may have harmed them by these ineffectual treatments.”
The good news? Following excision in the hands of a skilled endoscopist, says Dr. Sinervo, “between 80-85% will have significant improvement in their pain for years; some do need hysterectomy due to other painful conditions, most likely adenomyosis. BUT, much of this could be avoided by EARLY (within a few years of symptom onset) DIAGNOSIS and EXCISION.” In our own experiences at our COEMIG-designated Center of Excellence, we have treated thousands of patients from nearly 50 countries around the world. We believe that the key to success is removing disease, not organs. True disease recurrence is actually quite low if all endometriosis is thoroughly excised from all locations – including the bowel, bladder and beyond. Our experiences with patients of all ages from virtually every region of the world reflect a stark contrast to the general recurrence rates; as high as 67% in some settings (Selcuk, Bozdag 2013). Others with dedicated excision-focused practices experience similar results in efficacy among their own patients. An essential prerequisite to proper management, however, is timely recognition and referral to a tertiary care practitioner who can intervene with dedicated, specialized care.
Still, even those directed towards effective resources for quality treatment may find themselves faced with insurmountable barriers. Failure to provide patients with timely, cross-border referrals, lack of authoritative disease education and roadblocks to effective intervention remain significant obstacles – often leading to heartbreaking consequences. Ours remains a healthcare system broken from the inside out, with policy advocating for hysterectomy, which may be needless, and expensive, ineffective medical therapy that has never been proven to confer long-term relief – yet in many settings remains first-line approach (even diagnostic) by many insurance carriers and providers alike. There are no incentives to improve quality of – or perform – specialized treatment for endometriosis; complex, complete excision is reimbursed at lower or same rate as simplistic vaporization or not covered at all. Similarly, referrals are routinely, injudiciously withheld from patients. Often, these decisions come from bureaucrats who do not even understand endometriosis, let alone the need for precise treatments. Our system further encourages superficial surgery by reimbursing and rewarding incomplete operative measures and fails to support proper surgical intervention, leading to untreated disease – which in turn leads to certain failure and need for repeated reoperation, thus incurring additional costs. Moreover, there is no support towards the creation of “disciples” due to lack of incentives, red tape restrictions and medicolegal fears; if this current climate continues, there will be no next generation of endometriosis surgeons to carry out the legacy and teachings of our surgical pioneers.
Says Petersen, “Endometriosis pain is on par with acute appendicitis. Patients develop peritoneal signs and symptoms (bloating, acute abdominal pain, nausea, quiet bowel, sweating, paleness, sometimes fever, etc. etc.), something every medical and nursing student has been well educated to look for in patients. But in endometriosis patients, [it is dismissed as] “oh, it’s just her period!” If you think about the degree of pain associated with peritoneal inflammation, the LEAST we can do is be sure that the patient has adequate pain relief until disease can be resolved. What we fail to recognize in untreated endometriosis is that this disease restricts potential, sexuality, childbearing, ability to work in many cases, and generally constricts life…the lane to quality endometriosis care is cobbled with failure.”
Living with endometriosis truly exemplifies and embodies the social implications of negative attitudes towards menstruation and women’s health. This disease is so much more than ‘painful periods.’ It has the propensity to take away so many of an individual’s choices – when and whether to engage in a fruitful, enjoyable sex life with the partner of her choosing, when or if to pursue fertility options, whether or not to undergo invasive procedures, to choose ineffective menstrual suppression and medications which alter her cycle, and more. Truly, it is a public health crisis – but it is also a key women’s health initiative needing further promotion, understanding, research and empathy.
“We aren’t encouraged to talk about painful sex, debilitating cramps and bleeding, bowel issues, bladder problems, intractable pelvic pain and the like in ‘polite’ company…in fact, we’re often silenced when attempting to do so,” the CEC’s Surgical Program Director, Heather Guidone, remarked recently. “Not much has changed in the past two decades where the conversations about endometriosis are concerned. So patient frustration, significant diagnostic delays, high treatment failures and extremely deficient health literacy continues to obscure the stark realities of this disease. Likewise, endometriosis is consistently sidetracked by and mired in the fertility aspect – when what we should be focusing on is not a woman’s procreative potential, but the impact which pain has on an individual’s entire life and their resulting ability to make and enjoy their own choices – whether sexual or career or socially oriented,“ said Guidone, who suffered for decades from stage 4 disease herself and struggled with countless failed treatments and infertility. “There is no shortage of endometriosis stories…but the public, the medical profession, and society at large must start listening. We have to hear the voices if we are ever to improve the state of affairs in this disease.”
Dr. Sinervo’s call to arms:
“Do all that you can to help other women and endometriosis sufferers to put pressure on health care providers to realize the horrific impact this disease has on women’s health, professional lives, social interactions and so many other aspects of life; adolescents in particular can be quite literally scarred for years if their disease is not recognized and treated effectively early on. Some spiral down such a negative path that it may not be reparable. I would rather treat all women at an early stage and avoid bowel resections, or bladder resections or hysterectomy – something I really think is attainable. More doctors should not be scared to be brave and take the chance that a young patient may have endometriosis and save them years of suffering. I pray for early diagnosis and effective treatment for all women struggling with this disease.”
We plead for an urgent shift in priorities if we are to realize improved time to diagnosis and increased access to efficient treatment. Those focused on the disease would agree that treating early and effectively is the cornerstone to living well in the long-term – in spite of endometriosis. The conversation about the physical, conceptual and political facets of our disease is limitless – but making the difference starts with us. In our work, in our conversations, in our presence in society at large. The endometriosis community deserves nothing less.
-Date of publication: Oct 15, 2013. Minor updates: Feb 18, 2015.