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.  
• Less commonly, endometrial implants  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- 70% of women presenting with chronic pelvic pain will have endometriosis. 
• Infertility - 50% of women presenting with infertility will have endometriosis.
• Heavy menstrual bleeding 
• Dysmenorrhea: painful periods 
• Abdominal or pelvic pain outside of your period. 
• Dyspareunia: pain with sexual intercourse 
• Post-coital bleeding: spotting after sexual intercourse  
• 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 Natural Women's Health 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 Charting 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 order a pelvic ultrasound which should be done on day 5-7 of your next menstrual cycle. I will also order FSH/LH and estrogen labs which should be done on day 3 of your next menstrual cycle. You will be asked to begin charting your menstrual cycles using the Creighton Model System (CrMS). Please choose a Fertility Care Practitioner by clicking the button below and reach out to schedule your first Introductory Session. 

Second Appt: You will be asked to return to the office in one month for a follow-up appointment to review the results of your imaging and lab tests. Together we will review your Creighton Model Chart and look for specific biomarkers in your menstrual cycle.  Please upload an image of your CrMS chart two days prior to all follow up visits and send to me via the portal. 

A full GYN physical examination will be preformed (unless you have had a recent well-woman exam), and additional laboratory and/or imaging tests may be considered to continue to guide your medical management. 

Third Appt:  You will return to the office in one month to review the results of your laboratory and imaging studies. At this time, we will consider ordering progesterone and estrogen panels, which will be specifically timed to your CrMS chart. Click the "Laboratory Tests" button below for more detail. You may be asked to start medications and/or perhaps make an appointment with another specialist such as an endocrinologist, dietician and/or a counselor. 

Follow Up Appts:  You will return to the office every two months to monitor and/or make adjustments to your medications and treatment plan. 

After 6 months, if medical management has been unsuccessful you will be referred to Dr. Naomi Whittaker, MD who is a NaPro surgeon. You will undergo an evaluation. Dr. Whittaker will review your Creighton Model Charting as well as the medical management you have received. Together you will formulate a surgical treatment plan.