By Jill Case
What do pain, infertility, scar tissue formation, adhesions, and bowel problems have in common? They are all things that can be caused by endometriosis, a condition that affects at least 6.3 million women and girls in the U.S., 1 million in Canada, and millions more worldwide. It occurs when tissue like that which lines the uterus (tissue called the endometrium) is found outside the uterus — usually in the abdomen on the ovaries, fallopian tubes, and ligaments that support the uterus; the area between the vagina and rectum; the outer surface of the uterus; and the lining of the pelvic cavity. Other sites for these endometrial growths may include the bladder, bowel, vagina, cervix, vulva, and in abdominal surgical scars. Less commonly they are found in the lung, arm, thigh, and other locations.¹
To learn more about this condition, “Austin Woman” spoke to Dr. Lisa Jukes, an Austin gynecologist.
Austin Woman: What causes endometriosis?
Dr. Jukes: Knowing what can occur at the different sites [in the body] helps to understand what causes it. One theory is that it’s menstrual. This theory says that the endometrial tissue debris flows backward from the uterus toward the fallopian tube and spreads into the pelvis and abdomen during a menstrual period; the tissue will then implant and grow where it lands in the pelvis, which is called a retrograde menstruation theory. One of the other theories is that you are born with this type of tissue in places where it should not be.
AW: Are there risk factors that people should know about that make them more prone to endometriosis?
Dr. Jukes: It is seen more commonly if somebody has a developmental disorder of the uterus, so if we have somebody with a uterus that did not develop normally (unicornuate or bicornuate uterus), we do see a high incidence of endometriosis. As far as its prevalence, it’s seen in at least 25% of the female population.
AW: What are the symptoms?
Dr. Jukes: Some women with endometriosis have no symptoms. The most common symptom is pain, especially in the pelvic area. It is most likely to occur with your period so the pain typically will occur just before starting the menstrual period, and painful periods can get worse over time. You can also have:
- Pain between the periods, especially starting with ovulation, until the period begins.
- Pain during or after intercourse.
- Pain with bowel movements or while urinating, especially during your period.
There are also some patients that were thought to have irritable bowel syndrome (IBS) or painful bladder syndrome, and it’s actually endometriosis.
AW: Is there a typical age when endometriosis starts?
Dr. Jukes: Twenties to early thirties would be the most common time for diagnosis.
AW: Why does endometriosis cause pain?
Dr. Jukes: If you think about why endometriosis hurts, it’s because your abdomen was not made to have blood in it, so when you have a period and these endometrial implants bleed in response to the fluctuations in your hormones or for any other reason, your body reacts to that blood as a foreign object, creating inflammation. The body wants to wall off that area so it creates inflammation and that creates scar tissue, too. That’s where we have a lot of the pain.
There are other theories. Endometriosis can embed into the nerves which can cause the pain; it can make it difficult to have a bowel movement, or the ovary can attach itself to other organs, which can cause pain, especially when you ovulate. What we don’t know is why somebody with severe endometriosis can have no pain and somebody with very mild, pinpoint endometriosis can have severe pain.
AW: Does endometriosis cause infertility?
Dr. Jukes: It can be a cause of infertility; however, there are many patients who have endometriosis and have no problem conceiving. Some of these patients are women who have had three and four children and no pain. We can’t always know if their infertility is caused by endometriosis. When we suspect that it could be an endometrioma, which can definitely cause infertility, the endometrioma needs to be removed prior to pursuing fertility treatments.
AW: How do you treat endometriosis?
Dr. Jukes: Most practitioners approach is medical management, which is typically composed of anti-inflammatory medications, such as ibuprophen and/or contraceptives . We do that type of management for pelvic pain for three to six months, and, if the pain doesn’t improve, we would do a laparoscopy. We put a camera in a tiny opening in the abdomen to look directly for endometriosis, and then we treat it. You can treat it by excising (removing) it, cauterizing it or using a laser to excise it. The studies have shown that if you can excise it, it gives you the best chance of having sustainable pain relief.
AW: Does removing the endometriosis require abdominal surgery or it usually done laparoscopically?
Dr. Jukes: We prefer a minimally invasive approach. My preference is da Vinci assisted laparoscopy because I have 3D visualization with it. I’ve noticed that under the da Vinci robot console I can see implants that I miss by looking at the regular 2D video monitor. I prefer DaVinici because I have better control over my instrumentation, more finite movements and that helps me excise the implants better. I prefer this over open surgery. There are occasionally times when I find myself still returning to open surgery, but I would say 99% of the surgeries I do now are minimally invasive and that is largely in part to the better ability to excise the implants with da Vinci assisted laparoscopy. When you do open surgery, it’s because you may have to involve a general surgeon to excise a bowel adhesion, for example.
AW: Is there anything people could do to prevent endometriosis?
Dr. Jukes: There is no way to prevent endometriosis. One of the best things you can do is stay healthy—keep your body weight down, and choose an anti-inflammatory diet, rich in antioxidants and green leafy vegetables. There are some studies out there showing that the anti-inflammatory diet may reduce some of the symptoms of endometriosis.
Lower body weight is important because when you are overweight, the fatty tissue produces extra estrogen, which further stimulates the endometrial implants, causing problems.
AW: What is your advice for someone who has endometriosis?
- Make sure you are comfortable with your physician—have an open dialogue—it should be a partnership.
- Make sure that your physician is someone that has experience treating endometriosis.
- Come into your appointment with a list of questions.
- Make sure that you have adequate follow-up with your physicians, especially when you are initially diagnosed with endometriosis. You should be seen every three to six months so that your symptoms can be properly evaluated.
- Keep a symptom log to make sure that you’re keeping track of the intensity of your pain. The best way for you to know if you are improving is to write down how you feel.
- Look into some support groups. One to try is: https://www.dailystrength.org/group/endometriosis
- Be open to different treatment options, and to seeing other specialists. Sometimes I have to involve a gastroenterologist—just because you have endometriosis doesn’t mean you don’t have other causes of pain which can be gastrointestinal, urologic or bladder-related . It can also be musculoskeletal, and it can also be psychological. Sometimes with pain (even if it ‘s not psychological), over time, that can contribute to some depressive symptoms. We want to make sure that the patient is open to seeing other specialists if needed. We sometimes will involve a pain management specialist just to give them a variety of ways to cope with the pain.
- Do not be afraid to get a second opinion if you feel like you are not getting the results you need.
- If your doctor counsels you that you need open surgery, you should ask if there is anybody they would recommend that would offer a minimally invasive approach.
¹Endometriosis Association: https://endometriosisassn.org/
Terms to Know
da Vinci Assisted Laparoscopy: The physician makes small incisions to insert miniaturized wristed instruments and a high-definition 3D camera, allowing them to see endometrial implants so they can be removed (or excised).
Endometrioma: A pelvic mass that develops from a growth of ectopic endometrial tissue within the ovary.
Implant: Normal endometrial cells locate themselves, or “implant” themselves outside of the uterus, causing endometriosis.
Open Surgery: What we think of as traditional surgery (with a bigger incision).
For more information about endometriosis, go to:
The Endometriosis Association: https://endometriosisassn.org/
WebMD Endometriosis Center: https://www.webmd.com/women/endometriosis/default.htm
Dr. Jukes is on staff at most Austin area hospitals and surgery centers as well as the surgery center in Marble Falls. She is well-trained, experienced, and highly skilled in the Laparoscopic surgery, enabling her surgical patients to recuperate faster and with less discomfort. Dr. Jukes has been focused on gynecology and minimally invasive procedures and surgeries since 2003. She serves as a proctor or teacher to other physicians wanting to incorporate use of the da Vinci system into their practice.