Treatments

While there is no cure for endometriosis, there are two types of interventions; treatment of pain and treatment of endometriosis-associated infertility, knowing your patient's End Goal will help determine this path.

In women and those assigned to female at birth, in the reproductive years, endometriosis is managed: the goal is to provide pain relief, to restrict progression of the condition, and to restore or preserve fertility where needed. This may involve both specialist infertility and endometriosis working together before and after surgery, depending on how long the condition went undiagnosed.

In younger women, surgical treatment attempts to remove endometriotic tissue and preserve the ovaries and other reproductive organs without damaging normal tissue to help reduce pain and allow for a normal quality of life for their age.

  • Laparoscopy - The gold standard in the diagnosis of endometriosis. It will also be used to perform ablation or excision surgery as part of the treatment of endometriosis.

  • Endometriosis recurrence following conservative surgery is estimated as 21.5% at 2 years and 40-50% at 5 years.

  • Meaning the need for surgery will not be a one off event, it maybe required numerous times to achieve its aim and the patients End Goal.

  • Pain Ladder

  • First step. Mild pain: non-opioid analgesics such as nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen with or without adjuvants 

  • Second step. Moderate pain: weak opioids (hydrocodone, codeine, tramadol) with or without non-opioid analgesics, and with or without adjuvants 

  • Third step. Severe and persistent pain: potent opioids (morphine, methadone, fentanyl, oxycodone, buprenorphine, tapentadol, hydromorphone, oxymorphone) with or without non-opioid analgesics, and with or without adjuvants 

  • NSAIDs: Anti-inflammatory. They are commonly used in conjunction with other therapy such as pain management and talking therapy as well as stronger based pain relief.

  • Hormonal birth control therapy: Birth control pills reduce the menstrual pain associated with endometriosis. They may function by reducing or eliminating menstrual flow and providing estrogen support.

  •  Combined estrogen–progestogen birth control is the first-line treatment for most women with endometriosis due to its ability to be used over long periods of time, relative inexpensiveness and ease of use, and additional benefit of reducing ovarian/endometrial cancer risk.

  • HOWEVER long term use can reduce the impact of the pain it will not guarantee a reduction in the spread of endometriosis. Endometriosis can still spread causing more damage to be done to internal organs, reduction in fertility and damage to the bowels. Long term use needs to be monitored to ensure it is still the best path for the patient. Time changes peoples End Goal, ensure your patients is up-to-date and in line and not counteractive with the their current wishes.

Creating another human life is a huge decision and SHOULD NEVER be considered a form of treatment. 
Do Not Advise people to get pregnant as a cure.
It is not a part of any guidelines for treating endometriosis and would not be offered as "treatment" for any other condition.
MEDICATION
Pain

Extract from Clair Dempsey's Photovoice story

Paracetamol 8 a day

Gabapentin 300mg 11 tablets a day

Anxiety tablets 3 a day

Morphine/tramadol for my pain spikes

HRT

Migraine tablets.

This isn't the life I want.

2021-03-28.png
Only 19% of APPG respondents knew if they had been seen in an endometriosis specialist centre.
Over 60% of respondents may be being seen in hospital settings where there is not necessarily the expertise to operate on or treat them effectively. 
Ablation Surgery

Ablation Surgery is the removal of endometriosis lesions by the use of diathermy (heat) to destroy the endometriotic lesions. This surgery could be compared to surface removal of endometriosis lesions.  Surgeons may prefer to use this method if the lesions don't appear to be deeply inflating, this can hep preserve healthy tissue around the lesions i.e. ovaries.

Research shows the even the smallest amount of endo being removed in this way can sometimes improve fertility. This can be beneficial if your patients Endo Goal is to get pregnant this maybe the best option for them.

Excision Surgery

Excision is a surgical method used to treat endometriosis, this can be likened to small scissors. Unlike ablation, this type of surgery will cut the lesions from the area affected. It is sometimes preferred when removing deeper lesions or nodules found during a laparoscopy. It can ensure they are removed in their entirety. 

At times both surgical techniques can simultaneously be used to treat endometriosis.

MRI ( magnetic resonance imaging )

MRI can be used to detect hidden endometriosis lesions and nodules, often found on the bowel or other areas of the body not commonly associated with endometriosis. It can be used to make a clearer assessment of the areas affected before more complex surgery is undertaken.

MRI on its own is not a diagnostic tool for endometriosis but can used as an assessment aid to further treatments.

Menopause

In some women, menopause (natural or surgical) may abate the process.

Artificial menopause can be used to allow a patient a break from their symptoms. It can have serious side effects and should not be used for long periods of time. It may be used in preparation for some surgeries and will be directed by the specialist treating the patient at the time of surgery.

Any treatments or services offered to people going through menopause naturally should be offered in conjunction with conventional menopause supportive treatments as well as talking therapy.

Hysterectomy

People with adenomyosis will often find a huge benefit to their pain when they have a hysterectomy, due to the nature of the condition.

 

This will not always be the case when a person has endometriosis, both conditions function and react in different ways.

If a patient is offered a hysterectomy, talking therapy would be highly beneficial before the surgery. Allowing them time to mental and physically prepare for such a life-changing operation.

Most patients being offered a hysterectomy will generally be younger than average for this operation. Many fill find themselves with no additional support as they are considered for older patients. Ensure your patient is informed of all support offered to people experiencing menopause, no matter their age.

A hysterotomy removes physical parts of  internal organs, it can stop hormone production in a person. It should always be supported with hormone supplements AND FOLLOW UP CARE, both by general practioners and by surgical teams.

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