In my office, patients with surgically proven endometriosis range in age from 13 years old to 78 years old. Once believed to only affect adult women in their 30’s and 40’s, we now know better. The most common cause of pelvic pain in teenage girls is endometriosis. You also do not need periods to suffer from endometriosis – it can occur before the onset of menses, after menopause, and even if you’ve had your uterus and ovaries removed. Abnormally painful periods are the most common early sign of endometriosis. Women will frequently call out sick from work or school every month because of period pain – it is important to know this is not normal! Other warning signs include painful bowel movements, painful urination, pelvic pain outside of the monthly period, painful intercourse, fatigue and brain fog, nausea, bloating, and infertility. Some patients with endometriosis don’t have these symptoms and are only diagnosed after they are unable to conceive on their own – 25 to 50% of patients with infertility have underlying endometriosis. Endometriosis causes infertility in different ways, affecting nearly every step from the egg in an ovary to a pregnancy growing in the uterus. Endometriosis can lead to reduced ovarian reserve (the quantity or remaining number of eggs), poor egg quality, impaired function or even blockage of the fallopian tubes, as well as problems with embryo implantation. Medications are not a cure – they may provide temporary relief from pain but do not improve fertility nor treat advanced disease. Research suggests medicines do nothing to slow the progression of endometriosis. The gold standard for diagnosis is laparoscopic surgery, where I make small incisions to look for endometriosis with a slim camera. As endometriosis progresses over time, causing worsening pain, scarring, and possibly infertility, laparoscopic surgery should be considered the moment endometriosis is suspected. Indeed, 75 to 95% of adolescent girls who fail initial medications will be surgically diagnosed with endometriosis. I perform laparoscopic excision of endometriosis – removal of this abnormal tissue from the body – as opposed to burning or ablation of endometriosis (also called cautery, coagulation, or fulguration). Ablation of the part of endometriosis that is visible, like the tip of an iceberg, cannot treat the whole of the disease. After ablation women are more likely to experience continued pain due to a 70 to 80% risk of recurrence. Alternatively, up to 80% of women who undergo excision surgery note sustained improvement in their symptoms. Every woman’s future plans for fertility should be discussed before surgery, and surgery should be tailored
Symptoms of endometriosis include: • Painful periods • Painful bowel movements • Painful urination • Painful intercourse • Fatigue and brain fog • Bloating and nausea • Diarrhea/constipation • Infertility to meet her goals. Studies show long-term pregnancy rates after excision surgery are excellent among young women, who are more likely to have early-stage disease (61% are stage 1 and 29% are stage 2). Excision surgery for early-stage disease often restores fertility – approximately 80% of previously infertile women will successfully conceive, with the highest fertility within the 6 months after surgery. Some women with endometriosis will require fertility treatments or assisted reproductive technology (ART). Although excision surgery improves pregnancy rates for both natural conception and conception through ART, only 1/3 of women who undergo ART for endometriosis related infertility give birth. Fertility in women with advanced-stage endometriosis is a complicated issue that depends on the presence of endometriomas (ovarian cysts filled with endometriosis). Endometriomas cause inflammation in the surrounding ovary such that normal tissue is replaced by nonfunctioning tissue. This directly decreases the number of high-quality eggs. In some cases, it is best to consider fertility preservation, such as freezing eggs, embryos, or ovarian tissue, prior to surgical removal of an endometrioma. Studies show pregnancy rates are better after excision of an endometrioma versus drainage and coagulation of the cyst, but it is imperative that the surgeon be experienced in endometrioma excision to limit damage to the ovary. We probably all have a family member or friend with endometriosis, but she might not know it yet. Recognizing the symptoms of endometriosis will hopefully lead women to seek care and get a diagnosis sooner than the 8 to 10 years it has taken in the past – when it comes to fertility, those are wasted years. My goal is to get women the treatment they need as early in the disease process as possible, to prevent ongoing pain and to provide women the ability to start their families when they want to. Endometriosis and fertility go hand in hand – early treatment of one will help preserve the other. w northidahowellness.com 19