Dr. McNamara on endometriosis: “An often missed and delayed diagnosis.”

Endometriosis is one of the leading causes of pelvic pain and infertility, affecting 1 in 10 women. Unfortunately, endometriosis often goes undetected for years because the pain associated with the condition is mistaken for severe menstrual cramps or there may be no symptoms other than an inability to conceive.

“There’s often a tremendous delay in diagnosing endometriosis from when women start to experience symptoms until they get to physicians who are listening to them,” said board-certified OB/GYN Jeremiah McNamara, MD, of Boulder Women’s Care. “People suffer for a long time—an average of 10 years—before getting a diagnosis. It's a problem that needs to be brought to light.”

Watch Pelvic pain? Painful periods? Maybe it’s endometriosis.

About endometriosis

Endometriosis is a condition in which tissue similar to the lining of the uterus—called endometrial cells—grows outside the uterus.

Most often, endometriosis is found on the:

• Ovaries
• Fallopian tubes
• Tissues that hold the uterus in place
• Outer surface of the uterus

Other sites for growths can include the vagina, cervix, vulva, bowel, bladder or rectum.

Risk factors

You might be more likely to get endometriosis if you have:

• A family member (mother, aunt, sister) with endometriosis
• Never had children
• Menstrual periods that last more than seven days
• Early first occurrence of menstruation (before age 11 to 13 years]
• Short menstrual cycles (27 days or fewer)
• A health problem that blocks the normal flow of menstrual blood from your body during your period

Symptoms

Symptoms of endometriosis can include:

• Severe pain. This includes:
  • Very painful menstrual cramps. The pain may get worse over time.
  • Chronic (long-term) pain in the lower back and pelvis.
  • Pain during or after sex. This is usually described as a "deep" pain and is different from pain felt at the entrance to the vagina when penetration begins.
  • Intestinal pain.
  • Painful bowel movements or pain when urinating during menstrual periods.

“Endometrial cells respond to monthly hormones. They cause the uterus lining to grow as part of a woman's monthly cycle, and that lining sheds in the form of a period. With endometriosis, those endometrial cells escape the uterus and land somewhere else inside a woman's belly, growing slowly over time, responding to monthly hormones and triggering pain and inflammation when these cells are activated by estrogen,” Dr. McNamara explained.

He added, “The pain and inflammation from endometriosis causes an activation of the immune system, which tries to repair the damage. The activation occurs over and over again, forming scar tissue and adhesions that can distort normal anatomy and cause chronic neuropathic or nerve pain.”

Other symptoms of endometriosis include:

• Bleeding or spotting between menstrual periods. This can be caused by something other than endometriosis. If it happens often, you should see your doctor.
• Digestive problems. These include diarrhea, constipation, bloating or nausea, especially during menstrual periods.
• Infertility, or not being able to get pregnant.
  
  “As many as 50% of infertility cases may ultimately have endometriosis discovered. The mechanism for this we don't fully understand,” Dr. McNamara stated, “but it's reasonable to assume that adhesions are physically altering the ovaries and the tubes, which need to be anatomically normal to catch the egg for pregnancy to happen.”

Treatments

According to the American Society of Reproductive Medicine’s Practice Committee, endometriosis should be viewed as a chronic disease that requires a lifelong management plan.

“Unfortunately, there's not a pill for this, nor is there a surgery that just takes it away. It is a process that starts and propagates, and we do our best to get control of it. But it is truly chronic,” Dr. McNamara stated. “However, there are conservative, safe, lifestyle interventions that can help.”

Lifestyle intervention

Lifestyle changes that may help with endometriosis include:

• Supportive practices - “Better sleep should be number one for every single thing that has to do with human health. Also, parasympathetic practices such as mindfulness and relaxation practices are very important. Excellent gut health, and there are some supplements that can be helpful for this,” Dr. McNamara shared.
• Avoidance - Stress, inflammatory foods such as gluten, dairy, sugars and corn, and blood sugar spikes are all things that have the ability to increase your immune and inflammatory response and should be avoided.
• Low-Inflammation diet – Eat a lot of fresh vegetables, especially leafy greens (kale, collards, broccoli, Brussels sprouts) and fresh fruits (especially berries) each day. “Organic vegetables can help avoid toxins,” Dr. McNamara recommended.
• Supplements: Those that support our body's ability to deal with inflammation include:
  • Melatonin, 10mg nightly
  • N-acetyl-cysteine (NAC), 600 mg three times daily
  • Pycnogenol, 30mg, twice daily for 1 year
  • B-vitamins, but B6 specifically, 50 to 100 mg/day
  • Omega-3’s, 2 to 3g of a combined EPA/DHA product daily
  • Curcumin, 500mg twice daily

Medical Management

Dr. McNamara said, “There are medical options to help control and improve the situation – but not eliminate it.”

Your doctor may recommend that you take an over-the-counter pain reliever, such as the non-steroidal anti-inflammatory drugs (NSAIDs)—ibuprofen (Advil, Motrin IB, others) or naproxen sodium (Aleve)—to help ease painful menstrual cramps.

Supplemental hormones are sometimes effective in reducing or eliminating the pain of endometriosis. The rise and fall of hormones during the menstrual cycle causes endometrial implants to thicken, break down and bleed. Hormone medication may slow endometrial tissue growth and prevent new implants of endometrial tissue. You might also be prescribed medication for treating the neuropathic pain.

Surgery

Even in severe cases of endometriosis, most can be treated with minimally invasive laparoscopic surgery.

“The purpose of these surgeries is two-fold,” said Dr. McNamara. “First, the laparoscopic surgery is diagnostic and helps us get to know what we're up against in treating the endometriosis. Second, we look for all the places endometriosis might be and treat it by removing it.”

He added, “The plan is to have a safe surgery, where you safely treat all the endometriosis. When we treat and remove endometriosis, it’s an outpatient surgery that lasts about 30 minutes, depending on how much endometriosis is there.”

Dr. McNamara stated that one study showed pain relief was achieved in approximately 75 percent of patients who undergo laparoscopic ablation or excision (removal) of endometriosis. However, the risk of recurrence is estimated to be as high, with 40% recurrence at 10 years follow-up, and approximately 20% of patients will undergo additional surgery within two years.

“On the other hand, a study of 154 patients who underwent surgery for endometriosis or chronic pelvic pain reported that 90% agreed or strongly agreed that choosing excisional surgery was the right decision, and 87% stated they would choose surgery again,” said Dr. McNamara.

Removal of the uterus (hysterectomy) can sometimes be used to treat symptoms associated with endometriosis, such as heavy menstrual bleeding and painful periods from uterine cramping, in those who don't want to become pregnant.

Advanced technologies for a shorter recovery

Finding a doctor with whom you feel comfortable is crucial in managing and treating endometriosis. If you need surgery for endometriosis, Boulder Women’s Care’s experienced team of surgeons offer compassionate care and the latest in minimally invasive approaches to surgery for a shorter recovery, including da Vinci Robotic-Assisted Surgery.

Click here to view/download slides from this lecture on endometriosis.

To make an appointment with Dr. Jeremiah McNamara, call Boulder Women’s Care at 303-441-0587.