Authors: Dr. Allyson Shrikhande and Dr. Natalia Obzejta
How does the management of endometriosis change over a person’s lifetime, and why is ongoing care essential?
Endometriosis is a common and challenging condition of cells similar to the lining of the uterus growing outside the uterus. Given its similarity to intra-uterine tissue, development of new drug therapies and/or treatments has proved to be challenging. Although surgery is the gold standard for definitive diagnosis and treatment it comes with its own set of risks including surgical morbidity, decrease in ovarian, or even recurrence of endometrial lesions.
Medical therapies such as hormonal birth control are suppressive, rather than curative, however, play an important role in endometrial treatment.
Choosing how to treat symptoms associated with endometriosis depends on the patient’s age, as well as the degree of symptoms. Symptoms may wax and wane, even disappear in the occurrence of pregnancy. Continuous care is important to determine the best course of treatment. If symptoms progress, a step up in medical management is warranted. With the growth of new lesions, new symptoms arise – this is why continuous care is important.
What are some common misconceptions about endometriosis management, and how can lifelong care help dispel them?
A common misconception about endometriosis management is that surgery will cure all symptoms of endo. Endometriosis causes the muscles, nerves and joints to undergo an enormous amount of stress due to the chronic inflammation it causes. When this happens our pelvic floor muscles go into a spastic state, our nerve that course through the pelvic floor become hypersensitized which in turn causes hyperalgesia ( pain threshold decreases and you experience pain that’s far more severe than expected).
At PRM, we help restore the pelvic floor muscles and nerves to their optimal state and environment so patients can live a pain free life.
How do lifestyle factors play a role in the lifelong management of endometriosis, and what strategies can individuals adopt to optimize their well-being?
Every individual is different however diet plays a large role in lifelong management of endometriosis. We recommend an anti-inflammatory diet for most patients however every individual is different and will notice certain food/beverage triggers. Thus, it is important to keep a food log to help differentiate possible triggers. With chronic pain comes nerve hypersensitization, PRMs protocol can help desensitize the nerves however we always recommend continuing modalities that would support this once treatment is complete. Things such as acupuncture, meditation, yoga are all great modalities to desensitize the nerves in our central nervous system.
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What challenges might individuals face when seeking lifelong care for endometriosis, and how can they overcome these obstacles?
As Endometriosis is a complex systemic inflammatory disease, the challenges often are centered around handling all the different aspects of Endometriosis. These aspects include nutrition, infertility, central sensitization, pelvic floor nerves and muscles, and addressing co-morbidities of the bladder, bowel, and sexual dysfunction. Finding a pelvic pain and Endometriosis specialist to “quarterback” your care such as our providers at PRM is a great place to start. Joining online support groups such as Worthy Warrior to learn from the experiences of other Endo Warriors can also be very helpful. Being your own advocate, asking how to stay ahead of the inflammatory process that is Endometriosis is key. Also, as Endometriosis has been traditionally ignored and undertreated, and the health insurances also are “behind the times”. Educating both your Employer and your health insurance carrier on the importance of providing optimal women’s health care in the Endometriosis and fertility space is essential for us to bring them to where they need to be to bridge the gap as they are supposed to between patients and care.
In what ways can healthcare providers and support networks adapt to better meet the needs of individuals navigating endometriosis throughout their lives?
Listening more to patient needs and then executing on a plan to fulfill their needs. A patient focused approach with putting the needs of the patients first and foremost. Providing educational resources based on data in peer reviewed journals. Connecting Endometriosis patients with each other through platforms such as Worthy Warrior, where they can hear other people’s stories, and create an authentic community to help each other along their journey. Also, connecting Endometriosis patients with expert’s expert in the medical field in a multi-disciplinary fashion. Hosting webinars led by national experts with a question-and-answer opportunity.
How has the understanding of endometriosis evolved over time, and how does this impact the approach to lifelong care?
The Pathogenesis of Endometriosis remains under debate and may be complex and multifactorial. We do know from data that there is a hereditary component to Endometriosis and the genetic/epigenetic theory is compatible with all observations in Endometriosis. The genetic/epigenetic theory stresses that genetic incidences are required for the development of typical, cystic or deep endometriosis but it also takes into account the surrounding pelvic environments’ influence on the development of endometriosis. An abnormal pelvic environment that is inflamed, under oxidative stress with pro-inflammatory cytokines can be causative factors to induce the genetic or epigenetic changes in endometriosis. The PRM Protocol™️ aims to reverse the abnormal inflamed pelvic environment, therefore, decreasing the changes of endometriosis proliferation and growth.
Diagnosis of Endometriosis
In America a 6–8-year delay in Endometriosis diagnosis remains. However, in June of 2022 the Society of Radiologists in Ultrasound convened a panel of 16 experts in imaging and managing Endometriosis aimed at making recommendations on using ultrasonography to improve the screening process for Endometriosis. The Society recommended performing augmented pelvic ultrasound in premenopausal or early postmenopausal individuals who are symptomatic for endometriosis or have a history of endometriosis or infertility.
In summary, the panel recommends transvaginal ultrasound of:
- The posterior compartment (93% of Deep Endometriosis is located in the posterior compartment)
- The uterine sliding maneuver (as Endometriosis is an inflammatory disease with repetitive inflammatory plaques that then scar
- Inflammation and scarring repeated with every menstrual cycle (the scar tissue in the pelvic cavity will “pull” or deviate the uterus restricting the gliding ability of the uterus)
- Observation of the relative positioning of the uterus and ovaries
These additional ultrasound techniques take 5 minutes and may help patients receive a diagnosis sooner and help patients with a known pathological diagnosis of endometriosis be watched for disease recurrence post-operatively.
If you think you may have endometriosis, click here to take the PRM Endo Quiz Now.
Comorbidities Involved with Endometriosis
We now have a clearer understanding of the common comorbidities that present with Endometriosis:
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- bladder pain syndrome/IC
- pelvic floor guarding
- central and peripheral sensitization
- hernias
- auto-immune disease prevalence and the need to treat the whole person to address these
Infertility is common with endometriosis and educating endometriosis patients on their fertility preserving options early on is important.
Treatment for Endometriosis
As Endometriosis is a surgical diagnosis, starting with Excision Surgery is a great first step. However, as it is a systemic inflammatory disease process, the “treatment” options have expanded to address the co-morbidities discussed above. These include:
- Nutrition to focus on decreasing the inflammation in your body
- Foods that help bladder function and can help control hormonal imbalances
- Treating not only the guarded pelvic floor and the sensitized pelvic nerves in Endometriosis with the PRM Protocol™, but also using the PRM Protocol ™to aid in reversing the “abnormally inflamed pelvic environment” described in the Genetic/Epigenetic theory of Endometriosis as a strong driver of promoting Endometriosis lesions. Essentially, if the pelvic cavity is inflamed, with an abundance of pro-inflammatory cytokines and oxidative stress Endometriosis lesions will proliferate in this environment.
The goal of the PRM Protocol™ is to:
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- Improve blood flow to the pelvic nerves and muscles
- Reduce the pro-inflammatory cytokines with targeted medicine placed around the nerves and muscle
Working with pelvic floor physical therapy either in a virtual program or in person is also helpful, addressing Central Sensitization with Behavioral therapy techniques such as Cognitive Behavioral Therapy, mindfulness, mediation, and EMDR is important as well. Recognizing and working with hernia surgeons and auto-immune specialists if needed. Working closely with fertility specialists to optimize the patient’s wishes is another aspect of quarterbacking a patient’s care.
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