Endometrosis

IMORTANT DEFINITIONS: 

Endometrium: the inner lining of the uterus. The lining is made up of specialized endometrial glands and stromal cells. The endometrial glands  make and secrete nutrients essential for survival and development of the baby. Whereas, the stromal cells make up the largest portion of the endometrium. Under the direction of estrogen and progesterone, the stromal cells direct the growth, remodeling, and the breakdown of of the endometrium throughout the woman's normal healthy reproductive cycle. 

Menses: the "breakdown" or shedding of the endometrium (ie: your period).  

Ectopic: in an abnormal place or position. Eg: an "ectopic pregnancy" is when the baby is growing somewhere else outside of the uterus, such as in the fallopian tubes. Whereas, ectopic endometrial tissue is when endometrial glands and stromal cells are growing somewhere outside of the uterus. 

• A condition where a woman has ectopic endometrial tissue, often referred to as "ectopic implants".
• Common sites are: ovaries, uterine ligaments, bladder, the Pouch of Douglas (a space between the uterus and the rectum), on the outside on the uterine wall and hidden within folds of the membrane that lines the abdominal and pelvic cavities called the peritoneum.  
• Endometrial implants can occur in the vagina, on the cervix, on the intestines, liver or pancreas. 
• Endometrial implants have even been found in the breasts, kidneys, lungs and bones of some women. 

• The ectopic endometrial implants grow in response to estrogen, and they elicit an inflammatory response. 
• Implants can invade and cause damage to the tissues, furthering inflammation and predisposing the woman to chronic pain and reproductive complications. 

• pelvic pain- premenstrual and at other times in the cycle; 70% of women presenting with chronic pelvic pain will have endometriosis. 
• infertility - 50% of women presenting with infertility will have endometriosis.
• menorrhagia: heavy menstrual bleeding
• dysmenorrhea: painful periods
• dyspareunia: pain with sexual intercourse 
• nausea and/or vomiting premenstrually or during your period
• dyschezia: pain with bowel movements, especially premenstrually
• post-coital bleeding: spotting after sexual intercourse
• mid-cycle spotting: spotting around ovulation time  
• urinary frequency: especially premenstrually

Note: 

- hormonal birth control (pill or IUD) will suppress your natural cycle and often mitigate or abate your symptoms. 

- during pregnancy, the ectopic tissue undergoes regression and symptoms often lessen or disappear. 

• A definitive diagnosis of endometriosis can only be made by visualization of the ectopic tissue via laparoscopy (see below for more detail on laparoscopy). Sadly, the diagnosis of endometriosis is made on average of 9 years after the woman first reports her symptoms. 
• A woman with a mother or sister with endometriosis has a 7-fold higher risk of having endometriosis. 
• Evidence to predict endometriosis based solely on the patient's report of symptoms alone is weak. 
• A report of multiple symptoms listed above should increase the clinician's suspicion that endometriosis is present. 
• A history of pelvic inflammatory disease (PID) and/or irritable bowel syndrome (IBS) should further increases suspicion of endometriosis. 

• Although the endometrial implants typically regress in women during pregnancy, studies show the risk of pregnancy complications in women with endometriosis is significantly increased. Such complications include: miscarriage, ectopic pregnancy, preterm birth, low birth weight, preeclampsia, placenta previa and hemorrhage. 
• Women with endometriosis in their ovaries are at increased risk of developing ovarian cancer later in life. 
• Some studies even show that women with endometriosis have a higher risk of developing cardiovascular disease.  

Your appointments at MyCatholicDoctor with me will be one FULL HOUR in length. Generally speaking, NaPro appts will follow a typical protocol as outlined below. However, every individual is different and your situation may warrant a more expeditious process. Please know, the Creighton Model System (CrMS) is very important. Your CrMS chart will help direct me to what diagnostic tests and imaging tests should be done and what treatment plan would be most appropriate. 

First Appt: I will take a comprehensive medical history and provide you with education about normal healthy reproduction and oftentimes about a condition I suspect you may have after we have talked a while. 

I will order a pelvic ultrasound which I will ask you to schedule on day 5 of your next menstrual cycle. I will order a series of laboratory tests. Click the "laboratory tests" button below to learn more. 

You will be asked to begin charting your menstrual cycles using the Creighton Model System (CrMS). Please choose a Fertility Care Practitioner (FCP)  by clicking the "Fertility Care Practitioners webpage" button below to learn more about scheduling an Introductory Session to get started. 

Please consider joining me as I pray for you here.

Second Appt:  You will be asked to return to the office in 2 mos for a follow-up appointment to review the results of your imaging and laboratory tests. Together we will also review your Creighton Model System (CrMS ) chart to look for specific biomarkers which will help me make a diagnosis. 

Please upload an image of your CrMS chart two days prior to all follow up visits and send to me via the portal. 

Please add the length of your post-peak phase and your mucus cycle score (MCS) to the R-hand margin of the chart. Your Fertility Care Practitioner (FCP) will calculate your MCS for you. 

During this appointment, you may be asked to begin some supplements and/or medications. We will also discuss drawing a full set of hormone panels. We will make a decision if you should have a peri-ovulatory estradiol panel, a post-Peak estradiol & progesterone panel, or both panels. 

 Hormone Panels: 

• Peri ovulatory estradiol panel: start on CD8, go to the lab EOD for an estradiol draw, until you have one draw post-peak. 
• post-Peak estradiol and progesterone panel: P+3, 5, 7, 9, and 11. See Handout #3 on the the Patient Handout webpage.
• Hormone panels require 2 mos of CrMS charting AND the patient must be able to confidently identify her Peak day.

Many patients will be asked to consider working with a dietitian or a nutritionist to help optimize your reproductive health. Oftentimes I may also recommend a Psychotherapist or Health Coach to help with anxiety, depression and or disordered eating habits. Oftentimes I may also recommend a mental health appointment to help with anxiety, depression and/or disordered eating. 

Third Appt:  You will return to the office in 2 mos to review the results of your hormone panels as well as the biomarkers on your CrMS chart. Most often at this time I will have made one or more more diagnoses to identify the root cause of your symptoms. Together we will discuss a treatment plan, which will be implemented. 

Follow Up Appts: You will return to the office every 2 mos. During this time, I will conduct a comprehensive medical interview to ensure your symptoms have resolved, and to ensure you are responding well and not having any negative responses to the management plan. Depending on the individual patient and your individual diagnosis, I may need to monitor your progress with serial laboratory tests and/or serial imaging. 

After 6 -9 months: If medical management has not been successful, it is likely you may wish to move forward with a diagnostic laparoscopy. However, this would be your personal decision after we discussed benefits vs risks for your individual case. All surgeries present risks, which can sometimes be serious.  Oftentimes, we will have identified additional medical conditions which are treatable with supplements and/or medications. Therefore, discuss if you would like to be referred to NaPro surgeon.  On occasion, I may come to know a surgical evaluation will be of benefit to you earlier on in this process, and an expedited surgical referral will have been recommended. NaPro surgeons typically book out 5 mos to 18 mos. At any time, if you feel you would like an expedited surgical referral, please feel free to discuss this with me. 

Please review my laparoscopy page. You will notice NaPro surgeries are done very differently as compared to laparoscopies done by mainstream medicine surgeons. We use a near contact approach and a near adhesion-free technique", which has been described as pelvic surgery of the pelvis.  

At any point in time, if a diagnosis has been made, treatment initiated, and/or you are satisfied with the medical management we have implemented, you can schedule annual or biannual visits, per your choice.