Gynecology - Endometriosis & Pelvic Pain
Endometriosis is a common cause of pelvic pain, and in more severe cases, a cause of infertility. The endometrium is the lining of the cavity of the uterus. The shedding of the endometrium at the end of each menstrual cycle results in the menstrual blood flow. Endometriosis is a condition where islands of endometrium implant outside of the uterus, such as on the fallopian tubes, ovaries, pelvic floor, surface of the uterus, or even the bladder or bowel. These endometriosis deposits, often functioning the same as the endometrium in the uterine cavity, will bleed during the menstrual cycle, causing much localized inflammation and pain, and in some cases, infertility. We do not know the exact cause of endometriosis yet.
Symptoms of Endometriosis
The most common symptoms of endometriosis are:
- Painful periods. The bleeding into the endometriosis deposits causes local irritation, inflammation and pain, especially during menstrual periods. The painful periods can become more severe, causing nausea and vomiting at times.
- Painful intercourse. The endometriosis deposits on the pelvic floor, fallopian tubes, and ovaries are very sensitive to touch and thus can cause much pain during sexual intercourse.
- Pelvic pain. As the endometriosis deposits can cause local inflammation, irritation and eventually adhesions (scar tissue), women with endometriosis may have pain all the time, even when they are not having their menstrual period or sexual intercourse. Just like a small piece of sand can cause much pain in the eye, even a small deposit of endometriosis close to a nerve in the pelvic area can cause much chronic pelvic pain. Also, there may be pain with bowel or urinary functions with endometriosis.
- Infertility. Endometriosis can cause local inflammatory changes in the pelvis that can interfere with becoming pregnant. In the case of more severe endometriosis, there can be extensive adhesions (scar tissue) on the pelvis or on the fallopian tubes and ovaries, directly affecting the fertility process and making it difficult to conceive.
Diagnosis of Endometriosis
The symptoms of endometriosis described previously can suggest the possibility of pelvic endometriosis. On physical examination, the physician can often elicit “point tenderness” during the pelvic examination. There are specific points behind the uterus, on the pelvic floor, and on the fallopian tubes and ovaries that are very tender to touch, and the locations of these points are consistent. In severe cases of endometriosis, the physician might even feel the scar tissue and thickening of the pelvic tissue from the endometriosis. Pelvic ultrasound cannot see the small endometriosis deposits, except in the case of endometriosis cyst (endometrioma) of the ovaries. In some cases, a MRI scan can see suggestions of endometriosis, but it is a rather expensive test. Currently, there is no blood test for endometriosis.
The only definitive diagnosis of pelvic endometriosis is by laparoscopy, an outpatient surgery under anesthesia where the surgeon inserts a thin telescope into the abdominal cavity through a very small incision inside the belly button to look around the pelvis to discover the endometriosis deposits. With laser laparoscopy, these endometriosis deposits can be treated at the same time as diagnosis.
Treatment of Endometriosis
Medical Therapy - Medication can be used to control the pain of pelvic endometriosis in some cases. The basis for medical treatment is to render the patient without menstrual periods, causing local endometriosis tissue change by using continuous oral birth control pills (BCP), Depo-Provera injections, Depo-Lupron injections, or vaginal Danocrine capsules.
While medication can be effective in some cases, the limitations are:
- Side effects, such as emotional changes with BCP and Depo-Provera injections, hot flashes with Depo-Lupron, and vaginal discharge with vaginal Danocrine.
- In the case of scar tissue secondary to endometriosis, medication is not going to relieve the pain from the adhesions.
- If one is trying to conceive, all the medical treatments prevent pregnancy.
- The endometriosis and associated symptoms tend to recur soon after stopping the medical treatment.
Surgical Therapy - The most efficient way to treat pelvic endometriosis and pelvic adhesions is to perform operative laparoscopy during the laparoscopy to diagnose endometriosis. The key elements of a successful surgical therapy for endometriosis are:
- Correctly identify all the areas involved with pelvic endometriosis. Often endometriosis deposits have the classic brown or red color from the bleeding into the endometriosis deposits, making them obvious to identify. However, at times, the endometriosis deposits without blood pigment will appear to be white or just thickened with abnormal blood vessel patterns. Experience with endometriosis surgery helps to properly identify all the endometriosis during laparoscopy so all the deposits can be treated.
- Removal of all endometriosis deposits. The key for a successful surgery to treat endometriosis is to remove all the endometriosis deposits at the time of laparoscopy. The excision of the endometriosis deposits includes not only the areas of endometriosis, but also the depth of endometrium penetration. Laser laparoscopy is such a useful procedure to treat endometriosis.
Using advanced electronics and optics, the surgeon can insert a very thin telescope through the patient's naval into the abdominal cavity and see in detail the various organs in the abdomen. Specially designed instruments, including electrical probes, then can be introduced into the abdominal cavity to dissect, cauterize, or remove abnormal tissues, such as ovarian cysts, uterine fibroids, endometriosis, or adhesions. Laser beams can be passed through the instruments under optical guidance to vaporize and dissect diseased tissue with pinpoint accuracy, minimizing damage to the surrounding normal tissue.
Laser laparoscopy is performed under general anesthesia as an outpatient procedure. Post-operative recovery is brief, and down time from work is minimal. Dr. Lau is one of the pioneers in laser laparoscopy. Utilizing his background in physics, he has taught other surgeons in the use of surgical lasers. Dr. Lau has used laser laparoscopy exclusively in the treatment of endometriosis, adhesions, and in tubal surgery for fertility with measurable success.