What Should We do to Treat Endometriosis Pain?Fertility Treatment
Endometriosis refers to the abnormal growth of uterine tissue outside the uterus. Usually, endometriosis grows on the pelvis, ovaries, fallopian tubes, bladder, small and large intestine, appendix, and the dividing wall of the anus and vagina. Endometriosis may also develop in cesarean surgery, laparoscopy, or laparotomy wounds.
The first and most common sign of endometriosis is a pain in the pelvic area during menstrual bleeding. However, endometriosis has also other symptoms such as:
- Abdominal pain during menstruation, urinating, and defecating;
- Pain during or after sexual intercourse;
- Pain in the lower back;
- Diarrhea, constipation, bloating, and nausea;
- Heavy or irregular menstrual bleeding;
- Extreme fatigue;
- Anemia due to severe bleeding; and
The primary and most troublesome consequence of endometriosis is infertility. It is estimated that 30 to 40% of women with this disease are infertile.
Diagnosis of Endometriosis
Diagnosing endometriosis is difficult but can be done by:
- Monitoring the symptoms
- Physical examination
- Transvaginal ultrasound
However, the only reliable ways to diagnose endometriosis are laparoscopy and biopsy.
What are the Ways to Treat Endometriosis?
As the causes of endometriosis are not yet clearly known, no definitive treatment has been found. The treatments currently being offered can only reduce the severity and progression of this disease to some extent.
There are three types of treatment for endometriosis; surgical procedures, taking medications and having a proper diet. Depending on the location, size, and depth of the endometrial tissue, the doctor chooses one of the following cures for endometriosis.
Endometriosis Treatment with NSAIDs
Non-steroidal anti-inflammatory drugs (NSAIDs) are painkillers that prevent the release of prostaglandins (a chemical responsible for pain) in the body. The patient should take NSAIDs a couple of days before menstruation to minimize pain and inflammation. Patients with endometriosis usually take over-the-counter NSAIDs such as Ibuprofen and Naproxen, according to the manufacturer’s instructions. In some cases, the patient should take higher doses under the supervision of her physician.
Based on the stage of endometriosis, the doctor will prescribe the best NSAID for the patient. Keep in mind that taking, discontinuing, and changing the painkillers must be done with a doctor’s opinion. Also, people with aspirin allergy, bronchial asthma, and nasal polyps should choose NSAIDs carefully because their bodies may react to them. Taking NSAIDs with plenty of water is recommended, and if you have digestive problems, you can take them with milk or food.
Patients with endometriosis stage 3 or 4 should take NSAIDs and hormonal medications prescribed by a gynecologist.
Hormonal Treatment for Endometriosis
The goal of hormonal treatment for endometriosis is to suppress the symptoms of the disease by regulating the production of estrogen in the body. In hormone therapy for endometriosis, the following medications are used:
Combined oral contraceptive pill (birth control pill)
This kind of medication contains estrogen and progestin and suppresses the activity of endometriosis. The dose and duration of taking birth control pills depend on the severity of the endometriosis. Still, the patient usually takes these pills for three months to regulate her periods and lessen the pain.
This medication is suitable for people who do not respond to birth control pills or are allergic to them. Progestins can reduce the inflammation in the pelvic cavity and shrink the endometrial tissue by regulating estrogen production in the body. Still, they cannot be used as an infertility treatment. Progestins also have side effects such as acne, bloating, dizziness, headache, nausea, spotting, irregular bleeding, breast tenderness, weight gain, etc.; however, these complications usually disappear soon after treatment.
This medication can also suppress endometrial tissue and stop its growth for a while. Danazol is, in fact, a synthetic androgen, a hormone produced by men’s testicles, so it has some unpleasant side effects such as increased body hair, weight gain, liver injury, and acne.
However, this hormonal medication can highly eliminate the symptoms of endometriosis and reduce your pain. It is worth mentioning that women with heart or liver diseases, high blood pressure, and kidney disorders should avoid danazol. Also, patients who want to get pregnant shortly should reconsider taking danazol because it will stop their ovulation and menstruation for months.
This hormonal medication controls the menstrual cycle and reduces the symptoms and pains of endometriosis by preventing the production of estrogen; however, it is not considered a treatment for endometriosis-based infertility. GnRH agonists are in two forms; injections (daily, monthly, and three-monthly) and nasal spray.
In most cases, the patient should take this medication for three to six months; but some patients should take it up to 12 months. Like other hormonal treatments for endometriosis, GnRH agonists have possible complications such as insomnia, headache, dizziness, vaginal dryness, breast tenderness, depression, bone thinning, etc.
Aromatase inhibitors (Endocrine therapy)
Aromatase is an enzyme responsible for producing estrogen and transforming testosterone into estradiol. This enzyme is mainly found in testes, ovaries, fat, skin, brain, and endometrial tissues. Since Aromatase helps the endometrial tissue to grow, Aromatase Inhibitors are prescribed for patients with endometriosis to minimize their symptoms, inflammation, and pelvic pain.
Usually, aromatase inhibitors are taken along with other medications such as birth control pills or GnRH agonists in order not to form ovarian cysts. Moreover, since this medication can reduce the patient’s bone mass, it is recommended to take calcium supplements, vitamin D, and bisphosphonate.
Surgical Treatment for Endometriosis
If the patient does not respond to hormonal medications, she should undergo a surgical procedure. The type of surgical treatment for endometriosis depends on several factors, such as:
- The desire of the patient to get pregnant in the future;
- The patient’s history of pregnancy and miscarriage;
- The severity (stage) of the endometriosis; and
- The symptoms of the patient.
There are three types of surgical treatments for endometriosis; laparoscopy, hysterectomy, and laparotomy. In the following, these surgical methods are introduced in detail.
Laparoscopy for Endometriosis
Laparoscopy is a noninvasive surgery suitable for women who do not respond to hormonal treatments and have severe pain in the pelvic area due to endometriosis. Also, this method is suitable for women who want to become pregnant in the future because, in this surgery, the reproductive organs are preserved, and only the endometrial tissue is removed.
Before undergoing laparoscopy:
- Ask someone to be your caregiver for 48 hours;
- Do not eat or drink for 10 hours;
- Do not smoke or drink alcohol for three days;
- Take a shower on the day of the surgery because you cannot bathe for 48 hours after the operation;
- Take the prescribed medications on time; and
- Inform your doctor about your allergies.
During laparoscopy for endometriosis, done under general anesthesia, the surgeon first makes a small incision in the patient's abdomen, usually near or in the navel, to minimize the scarring. Then, they fill the abdomen with carbon dioxide gas to have a more vivid image of the pelvic area. Suppose the laparoscopy is done to diagnose endometriosis. In that case, the surgeon removes a part of the lesion for biopsy. Still, if the surgery is done as a treatment, the surgeon removes or burns the whole endometrial tissue (cystectomy) using laparoscopic surgical tools.
Except for the side effects of anesthesia, laparoscopy for endometriosis has some other complications such as vaginal bleeding, mild pain in the incision site, infection, scarring, damage to bowel or bladder, hernia, pain in the pelvic and lower back, etc.
The good news is that the full recovery from laparoscopy will take up to six weeks, although most patients can return to everyday life after four weeks. During this period, take a lot of rest and avoid strenuous activities..
Laparotomy for Endometriosis
Laparotomy or open surgery is major surgery and is done under general anesthesia. In laparotomy, the surgeon makes a large incision on the abdomen to have more access to the endometrial tissue. Since this surgery is excruciating and has a long recovery period, many patients and surgeons prefer not to use it nowadays.
Hysterectomy for Endometriosis
Hysterectomy is the last option for treating endometriosis. In this operation, the endometrial tissue is removed, the uterus and ovaries are taken out, and the woman would be infertile for the rest of her life. Hysterectomy is mainly done for women with heavy menstrual bleeding, fallopian tube cancer, severe inflammation and pain in the pelvic area, cervix or ovarian cancer, prolapsed uterus, and endometrial cancer.
Hysterectomy may be performed abdominally, laparoscopically, or vaginally. In general, there are three types of hysterectomy:
- Partial hysterectomy: in this procedure, also known as supracervical hysterectomy (SH), the uterus and endometrial tissue are removed, but the cervix is preserved.
- Total hysterectomy: in this type of surgery, the endometrial tissue, uterus, ovaries, and cervix are all removed.
- Salpingo-oophorectomy: in this operation, either a) the uterus and one ovary and one fallopian tube are removed, or b) the uterus and both ovaries and fallopian tubes are taken out along with the endometrial tissue.
You will recover in three to four weeks if you have had a vaginal or laparoscopic hysterectomy. People with an abdominal hysterectomy usually need more time to recover fully. During recovery, do not lift, push, or pull heavy objects, avoid sexual intercourse, avoid bending and sudden movements, and have a healthy diet rich in fiber.
In %85 of women who undergo hysterectomy, the endometrial lesion will not grow back, and their pain will be relieved forever. However, this operation has some side effects, including damage to the bladder, intestine, and blood vessels, vaginal dryness, reduction in sex drive, pain during sexual intercourse, insomnia, chronic constipation, night sweats, and most importantly, infertility.
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