If you have come to our website, most likely you are here because you are struggling with endometriosis and related symptoms. Our practice is a national level referral center of endometriosis care, offering expert level excision surgery for all types of endometriosis, including rare conditions such as thoracic, diaphragmatic, urinary tract, and abdominal wall endometriosis.
So What is Endometriosis?
In simple terms, endometriosis is the presence of endometrial tissue (the tissue that normally lines the uterus) outside of the uterus. In more complex terms, it is the ectopic presence of abnormal tissue that looks like endometrium but behaves quite differently, leading to a variety fo symptoms.
What are the symptoms of endometriosis?
Pelvic Pain, either with cycles or at other times
Painful menstrual cycles, sometimes severe
Pain with intercourse, usually with deep penetration
Infertility (difficulty getting pregnant)
Painful bowel movements
Painful urination / urgency to urinate
Pain that may radiate into back, down the legs, sometimes into chest
Pain in shoulder / neck (diaphragm endometriosis)
Dizziness with cycle
Cyclic diarreah / constipation
What is the treatment for endometriosis?
Treatment for endometriosis focuses either on surgical resection or destruction of the endometriosis tissue or on using medications to hormonally suppress the endometriosis tissue and reduce symptoms.
In our practice, we offer excision of endometriosis, the optimal surgical technique for removing endometriosis. This type of surgery aims to completely remove endometriosis tissue from the body. The surgical techniques for doing this are very similar to the techniques that would be use to remove a widely spread cancer. That is, very technical and painstaking surgery that attempts to remove all disease. In some practices (not ours), physicians may attempt to remove endometriosis by burning it away (ablation). This technique may have some effectiveness for very superficial disease, but has no lasting effectiveness for deep endometriotic lesions, and in these cases rarely leads to lasting improvement.
Medical therapy usually is focused of two pathways: Either one uses progesterone to suppress the metabolic activity of the endometriosis tissue (eg birth control pills, oral progestins, progesterone IUD), or one uses some kind of estrogen blocker that starves the endometriosis of the estrogen it needs to grow (eg Lupron, Elagolix). Many women experience a decrease in their symptoms with one of these pathways of medical therapies. Neither of these techniques works for all women, and in some cases the endometriosis tissue itself has ways to defeat these techniques (for example, some deep infiltrating endometriosis lesions express aromatase, a way a making estrogen, and thus they can grow and become inflamed even in the absence of external estrogen). Many women on medical therapy experience some improvement but continue to have some symptoms, particularly in cases of deep infiltrating endometriosis. Simple medical therapies such as birth control pills and progestins have moderate effectiveness and generally have few side effects, and those that are there are reversible after discontinuation. Strong hormonal modulators like Lupron (leuprolide) and Orilissa (elagolix) reliably create side effects associated with the low estrogen state (hot flashes, osteoporosis). Some women have reported experiencing permanent side effects from the use of Lupron, though this is relatively rare.
Most patients seek our care because they have tried various medical therapies with their physician, and potentially ablative surgical therapy, without adequate relief. For this reason, the bulk of our work in in excisional surgery for endometriosis.
Are there other treatments for endometriosis?
There are a variety of interventions that may have an adjunctive benefit for women with endometriosis
Pelvic Floor Physiotherapy
Pelvic Floor Botox
Acupuncture / Chinese Medicine
Avoiding environmental triggers
In our experience, the best outcomes come with surgical excision along with pelvic floor PT, with or without additional adjunctive therapies.
Who benefits the most from excision surgery?
In short, the more severe the case of endometriosis, the more it benefits from surgery. The most highly successful surgeries are for women with severe deep infiltrating endometriosis (large nodules of disease) that is highly painful to pressure on pelvic exam or intercourse. This type of disease often is entirely resolvable with surgery. Women with severe disease in the bowel or urinary tract also experience dramatic positive impact from successful surgery. Women who have low grade but widespread disease often benefit from surgery, but in our experience have a less dramatic improvement from surgery, and likely a higher chance or recurrence of pain.
Does endometriosis come back after excision surgery?
The million dollar question, that we can never truly answer reliably. After all, the only way to really know would be to re-operate on every woman at some point after her first surgery and confirm or deny whether there is any more endometriosis, which would be neither feasible nor ethical. That said, we have enough experience with re-operation on women with previous excision to suggest that endometriosis is usually not found at repeat surgery. When it is found, we also never know if this was truly recurrent or if it was left behind in a previous surgery. If the previous surgery was ablative in nature, we can be fairly certain that it was never removed, as ablation in general is only capable of removing the most superficial of lesions. If the previous surgery was excisional, lesions found at a previous surgery may be residual (not removed in the first surgery) or possibly recurrent.
Endometriosis is a heterogenous disease, meaning that not all people have exactly the same disease state. Some women seem to have complete elimination of endometriosis with substantial and persistent resolution of symptoms after their first surgery, and others do go on to have recurrence. At repeat surgery in women who have some level of recurrent pain, we often find only scar tissue and not recurrent endometriosis.
I have endometriosis that was previously ablated. Should I have excision surgery?
We cannot fix what is not broken - meaning that if you are not having a problem we cannot make you better. If instead you are having recurrent or persistent pain and you know that endometriosis was previously ablated, excision surgery has a good chance of improving things for you. In some cases, there can be an argument for excising endometriosis for the purpose of preventing progression of the disease and potential loss of fertility potential. Each case is different, and only after evaluating your specific case can we make a specific recommendation on this issue.
What does endometriosis look like?
These are just a few images of different ways endometriosis can present.