Pelvic pain, dysmenorrhea (painful menstruation) and infertility are the hallmarks of endometriosis. Other symptoms may include:

• Pain with deep intercourse (dyspareunia)
• Pain with voiding (dysuria) or blood in urine (hematuria), occurring cyclically
• Pain with bowel movements (dyschezia)
• Cyclical rectal bleeding
• Rarely patients may experience leg pain, sciatica or shortness of breath that occurs cyclically with menses

In some cases endometriosis is found by chance at surgery for something else. These women are completely symptom free and do not require any treatment for their endometriosis.

Not all pelvic pain is endometriosis. Many of the symptoms of endometriosis overlap with other conditions. It is important for the healthcare provider to perform a thorough history and physical examination to rule out gynecological and non-gynecologic conditions. Gynecological conditions that may mimic endometriosis include:

• Pelvic inflammatory disease
• Adhesions
• Ovarian cysts/masses
• Degenerating fibroids
• Adenomyosis
• Non-gynecologic conditions such as irritable bowel syndrome, inflammatory bowel disease, interstitial cystitis, myofascial pain syndrome, neuropathic pain syndrome, depression, and history of sexual abuse can also mimic endometriosis.

There is no accurate blood test for endometriosis. There are biochemical changes that have been seen in the blood and peritoneal fluid (fluid from inside the pelvis, surrounding the organs) of women with endometriosis that are not present in women without endometriosis. However, none of these are currently able to diagnose endometriosis.

No imaging test is sensitive in diagnosing endometriosis. The implants of endometriosis in the pelvis are usually not seen by ultrasound or magnetic resonance imaging (MRI). However, both transvaginal ultrasound and MRI are able to detect endometriomas (cysts of endometriosis on the ovary).

Definitive diagnosis is made through visualization of endometriosis implants at surgery and histopathological confirmation. If the diagnosis is uncertain, the surgeon may biopsy suspicious lesions and await histopathological confirmation.

The necessity of surgery for diagnosis before initiating therapy is now questioned. The response of symptoms to therapy-positive or negative may indicate that the disease is or is not the primary cause of the symptoms.

The extent of endometriosis at surgery can be classified as minimal, mild, moderate or severe based on specific criteria. However, this staging criteria does not correlate well with patient symptoms. In many situations when endometriosis is suspected by symptoms alone, treatment may be appropriately started before obtaining a tissue diagnosis from surgery.

Conventional Treatment

Different treatment options are available for women with endometriosis depending on their individual circumstances and needs. Choosing the best treatment option is influenced by several factors including age, severity of disease, family planning considerations, and previous treatments. Medical and surgical options are available.

Medical management of disease is often preferred as initial treatment of endometriosis while surgical interventions are reserved for specific situations.

Oral contraceptive pills

Widely used first line medical management for endometriosis. They work by regulating the menstrual cycle and reducing the amount of estrogens in the circulation while providing progesterone that inhibits the growth of endometriosis. The oral contraceptive pill can be taken cyclically (having a period every month) or continuously (without having a period).

Progestins

The progestins are a group of drugs that behave like the female hormone progesterone. They can be given as a pill or an injection and are effective treatments for the symptoms of endometriosis. However, like other hormonal drugs, they have side effects which some women cannot tolerate. They are cheaper than the GnRH-agonists and have been shown to be equally efficacious in treating endometriosis-related pain.

Levonorgestrel-releasing Intra Uterine Device (LNG IUD)

This is a small plastic T-shaped intrauterine device (IUD) that continuously releases a progesterone-like substance into the uterus. This results in thinning of the uterine lining and in many women experience either lighter or complete cessation of their period. The device has been shown to provide relief of endometriosis pain and is especially effective for deeply infiltrating or severe pelvic endometriosis. It can be inserted in the office with minimal discomfort and works for 5 years.

Gonadotropin Releasing Hormone (GnRH) Agonists

GnRH agonists work by producing a menopause-like state. This reduces the amount of estrogen in the body which causes the endometrial implants to become inactive and degenerate, resulting in significant improvements in symptoms. Side-effects may include symptoms of hot flashes, vaginal dryness and decrease in bone density. These side effects can be decreased by taking a very low dose of estrogen and progestin which will reduce the side effects but are not strong enough to reactivate the endometriosis (add-back therapy).

Androgen agonists

Medications such as Danazol act like the male hormone testosterone and lead to decreased levels of ovarian estrogen production. Although effective for the treatment of endometriosis, the side-effects make it poorly tolerated by many women.

Aromatase inhibitors

The aromatase inhibitors are a family of medications that act to stop the production of estrogens throughout the body. These medications are reserved as second-line treatment for severe endometriosis.

Surgical

Laparoscopic surgery is the mainstay in the treatment for many manifestations of endometriosis. This is best accomplished by minimally invasive surgery where surgeons operate in the pelvis using a camera, video monitors and small key-hole size skin incisions. The decision to proceed with surgery is an individual one based on the patient’s disease manifestation, their desire for fertility and the proximity in time to menopause.. Some indications for surgery (in symptomatic patients): the failure of medical therapy, deeply infiltrating disease, endometriosis involving other pelvic organs (appendix, bowel, bladder, ureters, pelvic nerves), large endometriomas (endometriotic ovarian cysts) and infertility (in select cases). Depending on the severity and location of the disease, various surgical procedures may be performed. Some common procedures are described below.

Resection of endometriosis implants

Areas of peritoneum affected by endometriosis are removed. This includes very careful dissection to avoid injury to surrounding structures. At our center we use a laser during surgery to remove the endometriosis. Sometime endometriosis will invade organs such as the bladder and bowel and will require more extensive surgery such as a bowel or bladder resection. Endometriosis may also involve the appendix, which can be removed at the time of surgery.

Adhesiolysis

Removing adhesions and scar tissue from endometriosis can help restore normal anatomy. This may help with pain symptoms and infertility.

Ovarian cystectomy

Endometriotic cysts on the ovary can be removed while leaving the ovary inside.

Presacral neurectomy

This procedure interrupts the nerve supply to the pelvis and has been shown to be effective in decreasing central pelvic pain, painful periods and other pain symptoms. Side-effects of this procedure may include constipation, some urinary problems and painless labour. These effects are not common and do respond to therapeutic interventions if necessary.

Hysterectomy and removal of ovaries

This is definitive surgery for the treatment of endometriosis. However, it is reserved for severe disease that has not responded to other treatments. It is also only considered for women who have completed their childbearing.

All surgery has risks that should be discussed with your healthcare professional. It is also important to understand that surgery may not provide relief of symptoms in some cases. While some patients may find a benefit from surgical management, endometriosis may recur and further treatment may be required.

Complimentary Treatments and Lifestyle Modifications

Mindfulness and Meditation Yoga/ Exercise

Routine exercise is recommended. Exercise helps your body to retrain the way pain is perceived and encourages your own body to release endorphins to help manage pain. Restorative and mindfulness based stress management can be helpful.

People in Pain Network:
http://www.pipain.com

Mindfulness Hamilton:
Free Bi-Weekly Meditations – An Official Mindfulness Hamilton event: http://mindfulnesshamilton.ca

Book suggestion:
Break Through Pain, by Shinzen Young, which also has a CD that leads the listener on a step by step way of managing/reducing pain through mindfulness.

Pelvic Floor Physiotherapy

Pelvic floor physiotherapy is the assessment and treatment of dysfunctions of the pelvic floor muscles which include pelvic pain, incontinence and organ prolapse. Assessment will involve vaginal and rectal exam of the pelvic floor muscles by a specially trained physiotherapist. Hyperirritable muscular nodules called “trigger points” are bands of muscle fibers and are palpable. These nodules can contribute to pelvic pain, painful intercourse, constipation, urinary hesitation, urgency or frequency. Pelvic floor physiotherapy can assist patients by working with trigger points internally and externally. It can also assist with connective tissue restrictions and central sensitization.

Additional links and a current lists for pelvic physiotherapists:

• http://www.pelvichealthsolutions.ca
• http://publicregister.collegept.org/PublicServices/Start.aspx

Naturopathic Approaches in the Treatment of Endometriosis

Endometriosis is a complicated, multifactorial disease that can pose significant challenges in management and therapeutic approach. Individuals with endometriosis can benefit from integrated, lifestyle-based therapy to help manage both primary disease and co-morbidities including irritable bowel syndrome, infertility, and chronic pelvic pain.

Naturopathic medicine focuses on non-pharmaceutical interventions, including dietary modification, lifestyle counseling, acupuncture, botanical medicine, and clinical nutrition (i.e. vitamins, minerals, and food supplements). These therapies are employed with the intention to modify risk factors for disease, and to treat the underlying cause of health conditions. Adhering to a fundamental strategy to treat holistically, naturopathic intervention in endometriosis includes assessing and appropriately addressing all factors making up an individual’s complete health picture.

Common Alternative and Complimentary Therapies in Endometriosis

Dietary Counseling: Based on epidemiological evidence comparing individuals with confirmed endometriosis and those without, several dietary strategies are commonly employed in the treatment of endometriosis. Restriction or elimination of alcohol and caffeine, increased fiber intake, and reduction in animal proteins may all be utilized after a review of a patient’s current dietary pattern.

Lifestyle Modification

As with any Naturopathic therapeutic strategy, stress reduction, adequate exercise, and sleep maintenance are all fundamental in treating a patient with endometriosis. Healthy weight management through both lifestyle modification and dietary counseling is a common strategy in many chronic diseases, including endometriosis.

Clinical Nutrition and Botanical Medicine

A number of supplemental and botanical interventions are commonly utilized to decrease menstrual pain, reduce menstrual irregularity, and alleviate chronic inflammation. Any recommended supplement or botanical medicine is chosen with respect to individual patient needs, with careful consideration of avoiding negative drug interactions. Below are a selected list of commonly prescribed botanical and nutraceutical agents studied for use in the treatment of endometriosis.

• Curcumin Studies have demonstrated that curcumin, a spice commonly used in ethnic Indian cuisine, can decrease proliferation of endometrial cells, and thus may be an effective therapeutic in the treatment of endometriosis.
• Resveratrol Recent animal model studies have demonstrated that resveratrol can reduce inflammation and angiogenesis in endometriosis. Further human data is needed, but based on its safety profile, resveratrol has potential as a therapeutic agent in humans.
• Vitamin D There is some evidence that vitamin D may be protective against endometriosis, as well as having a role in the treatment of PCOS and infertility. Assessing and correcting vitamin D deficiency may confer benefit to some patients with endometriosis.
• EGCG A component of green tea, EGCG has been shown to decrease lesion size in endometriosis, and reduce the adhesion and invasion of problematic tissue.
• Omega 3 Fatty Acids Used in many conditions as an anti-inflammatory, EPA, an omega 3 fatty acid, has demonstrated efficacy in prevention and treatment of endometriosis.

Therapeutic Strategy

As discussed, there are a number of therapeutic strategies commonly employed in the Naturoapthic treatment of endometriosis. A thorough, individualized treatment plan is developed based on individual presentation, co-morbidities, current conventional treatment plan, and patient goals. Although there are a number of therapies studied individually in the treatment of endometriosis, the primary goal of Naturopathic medicine is to treat the individual, not the disease process. Treatment should be customized to account for an individual’s complete health picture.

References

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• Fjerback, A., Kundsen, U. Endometriosis, dysmenorrheal and diet – what is the evidence? European Journal of Obstetrics and Gynecology and Reproductive Biology. 2007;132:140-7
• Gazavani MR, Smith L, Haggarty P, Fowler PA, Templeton A. High omega-3:omega-6 fatty acid ratios in culture medium reduce endometrial-cell survival in combined endometrial gland and stromal cell cultures from women with and without endometriosis. Fertil Steril 2001;76(4):717-22
• Kensuke T,. et al. Omega-3 Polyunsaturated Fatty Acids Suppress the Cystic Lesion Formation of Peritoneal Endometriosis in Transgenic Mouse Models. PLOS one 2013;8(9):1-8
• Lerchbaum E, Rabe T. Vitamin D and female fertility. Curr Opin Obstet Gynecol. 2014 Jun;26(3):145-50
• Leong FC. Complementary and alternative medications for chronic pelvic pain. Obstet Gynecol Clin North Am. 2014 Sep;41(3):503-10
• Ozcan Cenksoy P, Oktem M, Erdem O, Karakaya C, Cenksoy C, Erdem A, Guner H, Karabacak O. A potential novel treatment strategy: inhibition of angiogenesis and inflammation by resveratrol for regression of endometriosis in an experimental rat model.Gynecol Endocrinol. 2014 Nov 6:1-6
• Robertson, J. Endometriosis: Where dose naturopathic medicine fit? IHP 2010; Sept;74-8
  Sayegh L, Fuleihan GEH, Nassar AH. Vitamin D in endometriosis: A causative or confounding factor? Metabolism 63(1) 32-41
• Zhang Y, Cao H, Yu Z, Peng HY, Zhang CJ. Curcumin inhibits endometriosis endometrial cells by reducing estradiol production.Iran J Reprod Med. 2013 May;11(5):415-2