Treatment of endometriosis
In choosing the right therapy, it is important to adapt it individually to the patient. The main complaints should be identified and the therapy selected based on the patient’s needs and preferences. Thus, the patient is an essential member of the treatment team. In the selection of the treatment it plays a big role, in which age one is, whether immediately a pregnancy is aimed as well as which pretreatments already took place and which were their side effects. Endometriosis is also classified into different severity levels, which has a significance for therapy.
In order for the doctor to get an idea of the situation and complaints before the first consultation appointment, we ask all patients to fill out a short questionnaire and send it to us.
Endometriosis is a disease that affects women over all the years up to menopause – in extremely rare cases even beyond. Endometriosis can thus be described as a chronic disease. If it is detected early and treated specifically, it can cause little damage. Over time, endometriosis symptoms may change, just as the preferences and needs of affected women change depending on the situation. Thus, it is important to dynamically address the changing ailments and changing needs and provide appropriate care for those affected.
During the consultation, we will work together to develop a treatment plan for you and your individual situation. We discuss complex cases with experts from other disciplines, at the so-called “pelvic pain board” or directly with colleagues in reproductive medicine.
Endometriosis is a hormone-dependent disease. Many of today’s therapy recommendations are also based on the connection with hormones. Regulation with hormones can prevent endometriosis from growing, which has a positive effect on pain. Inhibition of estrogens stops the proliferation and breaks the vicious cycle between inflammation and proliferation/scarring.
Taking a combined contraceptive pill (pill with estrogen and progestin) reduces the influence of the body’s own estrogens and thus puts endometriosis on a “diet”, so to speak. Continuous use of the contraceptive pill can improve its effect (so-called long cycle). The absence of menstruation further prevents the spread (or recurrence after surgery) of endometriosis. This is because bleeding into the abdomen or endometriosis cysts occurs with each menstrual period, which can cause pain and scarring. However, the greatest effect is achieved with so-called progestogen pills (“mini-pills”), which are completely free of estrogens. This not only takes the drive, but actively brakes it. Depending on the progestin form, additional effects may be unleashed, such as additional direct inhibition of inflammation and pain.
The progestogens can be given not only in pill form, but also by means of a so-called hormone coil. Unlike the pill, there is no risk of forgetting to take an IUD. The IUD can be left in place for up to 5 years and provides an excellent treatment option.
In the second line, so-called GnRH analogues (gonadotropin-releasing hormones) are used, which centrally stimulate the body’s own estrogen production. at the level of the pituitary gland. The main side effect of this therapy is menopausal symptoms. These can vary from woman to woman and disappear completely after the end of the active period. Nine out of ten women suffer from hot flashes/sweats during this therapy. About half of the women treated complain of headaches, mood changes/depression, sleep disturbances, vaginal dryness – less frequently also hair loss, acne, and joint and limb pain. Since a weakening of the bones can occur, especially with a longer therapy duration of more than 6 months, this therapy is often combined with a small addition of estrogens – a so-called “add-back” therapy. Thus, the therapy can be carried out for a longer period of time without the manifestation of side effects. After discontinuation of GnRH analogs, resumption of the natural cycle occurs.
Anti-inflammatory painkillers (NSAIDs)
Another essential treatment approach is to combat the vicious cycle of endometriosis using anti-inflammatory drugs – so-called non-steroidal anti-inflammatory drugs (NSAIDs). These agents not only combat pain, but also inhibit the inflammatory response associated with endometriosis. There are various NSAIDs that contain, for example, mefenamic acid, ibuprofen, or nimesulide as the active ingredient. Many endometriosis patients report that they avoid taking pain medications whenever possible and only take them when the pain is unbearable. Since the painkillers mentioned can also have side effects, it is certainly correct that they are not taken without reason. However, pain that is left untreated for a long time can become entrenched – that is, chronic. Chronic pain can adversely alter nerve sensitivity in the long term, which can be partially prevented with pain medications. Therefore, it should be noted that the painkillers are taken only already at the onset of period pain and in enough high dosage. If, on the other hand, the medication is taken rather late, it usually takes much more of it to break through the pain peak.
Other treatment methods
It is known that endometriosis can directly lead to pain due to the chronic inflammatory state in the abdomen and the resulting adhesions. Complex physical processes in the brain and nerve cells can cause pain that persists over time to “burn” into the brain and become chronic. Pain can be felt in such a situation even without a recognizable stimulus. Specialized pain management can address chronic pain.
The feeling of being helpless in the face of pain can lead to anxiety and despair. Teaching them skills to do something about the pain themselves is central to chronic pain therapy in particular. It is equally important to normalize the altered body perception caused by the constant pain and to modulate the increased pain sensation.
Complementary medicine therapies
In addition to conventional medical treatment, we also offer supportive complementary medical treatment options. These are not only used when hormonal therapy is not an option for the patient, but should also be seen as a supplement to conventional therapies. For this purpose we cooperate with the Institute for Complementary and Integrative Medicine. The anti-inflammatory and hormone-regulating effects of some herbal preparations can be used, but also methods of traditional Chinese medicine (TCM).
Nutritional counseling/gastroenterological therapies/bladder problems
Involvement of nutrition counseling and gastroenterology for bowel problems and urogynecology for bladder problems may be helpful. Avoidance of pro-inflammatory dietary components and exclusion of coexisting irritable bowel syndrome or irritable bladder symptomatology are important for proper management of the disease. Beverages or foods can trigger irritation or bloating, which can be improved with appropriate counseling and changes in dietary habits.
If indications for a muscular component of the pain pattern in the muscular pelvic floor (so-called “myofascial pelvic floor pain syndrome” (=pain caused by problems in the musculature / muscular membranes of the pelvic floor) are found during the examination, specialized pelvic floor physiotherapy can lead to an improvement of the pain.
Active cooperation in the therapy is central. The support of a physiotherapist experienced in the field of pelvic pain is a great help for many patients.
Pain is not always and in all endometriosis patients in the foreground, but often infertility. Whether the occurrence of pregnancy can be achieved by surgery (endometriosis removal) or by artificial insemination depends on several factors. The inclusion of reproductive medicine is of great importance for these questions. With the correct treatment selected individually to your situation but also needs, very good results can be achieved, sometimes by surgery or artificial insemination alone, sometimes by the combination of both.
Chronic diseases in the genital area not infrequently affect sexual life. Pain during sexual intercourse, lack of desire for sexuality, psychological stress and worries about absences from work can put a strain on the relationship. At the Women’s Clinic of the University Hospital, the psychosomatic and sexual medicine consultation hours are open to all patients who wish to receive sexual medicine support. The partners are also welcome to the consultations.
Surgery is usually minimally invasive by means of laparoscopy (= laparoscopy) under general anesthesia. A larger abdominal incision is only necessary in very rare cases.
It is important to us that the operations – also so-called simple, diagnostic laparoscopies (= abdominal endoscopy for clarification) – are performed by surgeons experienced in the field of endometriosis, since endometriosis is like a chameleon and can take on different forms. In this way, we ensure that the diagnosis can be made even in the case of very small endometriosis lesions. The removed tissue is then examined under the microscope.
In this diagnostic laparoscopy, however, not only the diagnosis is confirmed, but also the severity of the endometriosis is determined (classification according to the “American Society of Reproductive Medicine – ASRM” grade 1 to 4). In case of mild affection (grade 1-2), direct complete removal of endometriosis can be performed. In severe cases (grade III-IV), however, we recommend performing this in a 2nd operation: In these cases, organs (intestine, urinary bladder) and important structures (ureter, diaphragmatic dome, vagina, etc) are affected, which usually requires a procedure with other specialties (visceral surgery and urology). From the patient’s point of view, it has the advantage of being fully informed and knowing exactly what to expect during and after the operation.
During surgery, the tissue altered by endometriosis is removed and adhesions are loosened. Complete removal of endometriosis foci is important because there is evidence that incomplete removal may even lead to increased pain perception by increasing activity of nerve fibers remaining in the foci. This operation can help in situations when the pain cannot be controlled by all the above means, but cannot replace the means in the long run
The correct management of endometriosis is considered complex and differs from patient to patient, which is why the right therapy is not always found right away. However, we accompany and support you on your way out of pain towards regaining a high quality of life or fulfilling your desire to have a child.