Treatments...

Symptom Management

Treatment of endometriosis is planned with the needs of each woman considered - her age, symptoms, medical history, fertility and her own preferences.

Pain is often a major and troublesome part of the range of symptoms of endometriosis. Prior to treatment, the pain suffered can be quite severe, causing major disruption in the lives of those affected.

If pain with periods is the only problem, it is reasonable to take the “Pill” in a continuous regimen to avoid having periods. This does not remove the endometriosis, but it can make minor endometriosis inactive. This may be all that is required in the overall treatment of women with painful periods who are suspected of having endometriosis. There are many pill preparations available. Your doctor along with the nurse coordinator can help you with a suitable regime and monitor your progress.

Specific pain relieving drugs are often required to control other types of pain related to endometriosis, for example pain during or after intercourse, or bowel pain.

Non Steroidal Anti inflammatory Drugs (NSAIDs)

This group of medications are the best way of controlling the pain of endometriosis. Endometriosis causes pain by inflaming or distorting the delicate pelvic lining, so it is logical that drugs which reduce inflammation should be effective.

There are a number of these drugs available. A discussion with your General Practitioner or a member of the Ballarat Endometriosis Clinic team will help to determine which of these agents is best for you. Some women, for example those who have severe asthma, bleeding problems or those who have a tendency to have indigestion and stomach ulcers should not use these drugs.

Non steroidal anti inflammatory drugs are highly affective pain relievers, and have the advantage of not causing sedation. They may be taken for short durations of time with confidence.

Paracetamol

This commonly used pain reliever should not be overlooked when trying to control the pain of endometriosis. It can be very effective in controlling pain and increases the effectiveness of NSAIDs when used in combination with them.

Codeine containing drugs

Codeine is a more potent pain relieving drug and is available in combination with paracetamol.Whilst it is effective in controlling pain, it causes sedation, so patients should not drive or operate machinery when using codeine containing drugs. Codeine containing drugs can be used in combination with NSAIDs, but can be addictive and should only be used for short periods of time.

Narcotics

These agents are not as effective as NSAIDS in controlling the pain from endometriosis. Narcotics are addictive and should only be used with the most severe pain. Most doctors believe that if narcotics are required to manage endometriosis pain, women should be referred to a Gynaecologist or admitted to hospital for treatment of the underlying cause of their pain.

Other Pain Relieving Methods:

It has been shown in properly designed studies that women who have been diagnosed with endometriosis who undertake one hour of exercise, either swimming, walking or running three time per week have less pain and enjoy life more than those with a sedentary lifestyle

In addition to the obvious health benefits, women who lose weight after a diagnosis of endometriosis have been shown to have less pain.

Acupuncture & Hypnotherapy

Diet/Herbal preparations - in consultation with Naturopath/Herbalist

The Ballarat Endo Clinic is easily contactable by phone. email or consultation in the rooms to optimise your health on an individual basis. It is important that you take an active part in your endo experience. Our staff can keep you informed with up to date advice.

Hormonal Treatment

Many women who have had endometriosis choose to use hormone replacement therapy. This may be required when a woman becomes menopausal naturally or as a result of surgery when the ovaries are removed.

There is often concern that oestrogen which is used as HRT may stimulate any residual disease. Following the observation that constant oestrogen levels do not usually increase endometriosis activity, this is not necessarily the case.

There can be some situations where pain and endometriosis symptoms do increase when HRT is used. To deal with this problem there are a number of options:

• The dose of oestrogen can be reduced to the absolute minimum required
• Progestagens can be added to the existing treatment to reduce the activity of any residual endomentriosis
• A new drug, tibolone, can be used instead of oestrogen as HRT

Tibolone has no activity in endometrial tissue and hence does not stimulate endometriosis tissue. This agent is probably the drug of choice for women who have had a diagnosis of endometriosis and are considering HRT. Tibolone has the additional advantage of not causing breast symptoms as it does not stimulate breast tissue in the same way that oestrogen does.

GnRH analogues (Zoladex) goserelin

Zoladex is an effective treatment for endometriosis. It is often used before and/or after surgery (and ART - Assisted Reproduction Therapy) to suppress endometriosis activity.

It results in temporary reduction in the release of oestrogen by the Ovaries, reducing pain and size of endometriosis deposits. Due to the low Oestrogen levels while using Zoladex, there are some side effects that are similar to menopausal symptoms which can include headaches, hot flushes, muscle pain and insomnia. 'Add back' oestogen tablets can improve these side effects if they occur.

Treatment with Zoladex implants is limited to six months. During this time thinning of the bones may occur whilst on these drugs and is reversible once the drug is ceased. Most women will not have periods while receiving Zoladex treatment.

Depo Provera

This is three monthly intramuscular injection. Progestagin therapy is not suitable for women wishing to become pregnant. They can be effective in controlling symptoms long term, but side effects can be troublesome. These include bloating, tiredness, depression and irregular bleeding.

Mirena IUD

This Intra Uterine Contraceptive Device releases small amounts of progestagens into the uterine lining and surrounding tissue. It has been shown to be effective in reducing endometriosis pain in some women. It can be removed easily if the woman decides she wants to become pregnant.

Surgical Options

Laparoscopy

Laparoscopy is a minor, relatively safe procedure performed under anaesthesia in a hospital. It has been shown clearly in numerous studies that laparoscopic surgery is the best way to treat endometriosis.

Laparoscopic Surgery benefits are:

• Higher cure rates
• Small incisions with less pain and scarring
• Less time off work
• Most can be performed as “day case surgery”

Laparoscopic surgery allows a skilled surgeon to carefully check all of the pelvic organs for any sign of disease and to gently remove it. All Gynaecologists perform laparoscopy, but not all are trained to diagnose and treat all types of endometriosis by laparoscopy.

During laparoscopic surgery, tissues are handled gently and drying of the delicate lining of the pelvis is prevented. Advanced video systems allow a magnified, close up view of pelvic organs. In this way, the amount of scarring caused is kept to a minimum and surgery is performed more precisely than with open techniques.

Many Gynaecologists believe it is impossible to remove endometriosis containing cysts from the ovary, and that where these cysts occur, it is best to remove the ovary involved. Clinicians at the Ballarat Endometriosis Clinic strongly disagree with this. We believe that it is almost always possible to remove cysts and preserve the ovary.

Laparoscopic surgery for severe endometriosis may take several hours. In some cases it may be necessary to undertake a second operation after drug treatment (ie. Zoladex) to reduce the size and activity of the endometriosis.

Open surgery

Hysterectomy

For some women, undergoing hysterectomy may be the best option to treat endometriosis. This option is often chosen when women have undergone a number of previous procedures and have additional abnormalities present such as fibroids, troublesome heavy bleeding or adenomyosis (Endometriosis in the lining of the uterus).

Every effort is made to preserve the ovaries when hysterectomy is performed for women before the menopause.

It is important to bear in mind that 10% of women will require further surgery to remove one or both ovaries at a later time.

Most women who request hysterectomy are able to have the procedure performed by laparoscopy which minimizes time in hospital and off work.

BEFORE YOUR OPERATION

• Please do a urine pregnancy test the day before your operation to exclude pregnancy
• Do not eat or drink anything after midnight the night prior to your surgery, unless advised
• Do not smoke before your operation, ideally stop 6 wks prior, but minimum 12 hours prior
• Reduce alcohol intake prior to surgery
• You will be admitted to the hospital on the day of your operation. You may need to ring the facility or sometimes they call you with an arrival time. There will be a waiting time prior to surgery to prepare you for theatre. The anaesthetist will usually come and explain your anaesthetic.
• Eat light meals the day prior to your operation
• You will need to remove umbilical piercings
• Wear comfortable loose fitting clothing and supportive footwear to hospital as you will be drowsy and may have some discomfort on discharge
  

AFTER YOUR OPERATION

• You will be provided with a written summary of your procedure and post operative instructions specific to your operation. A post op appointment in the rooms will be arranged for you to check your recovery
• Some discomfort can be expected after surgery-regular analgesic medicines can be taken regularly as instructed for example paracetamol/ibobrufen
• Shoulder tip pain is common after laparoscopy and can last 24-72 hours. It is caused by gas trapped under the diaphragm during surgery. Moving around gently, changing position, regular pain medication (see above) and heat packs can help to relieve this pain.
• You can expect light vaginal bleeding after a laparoscopy for up to a week. If dye has been used to flush your fallopian tubes there may be blue staining present.-this is expected
• Bruising is expected around the surgical incision sites
• Dissolving stitches are usually used for laparoscopic surgery, so you will not need stitches removed Local anaesthetic is often injected around the surgical incisions, so there may be a numb feeling around the dressings.
• You can expect to feel tired and rest is important. Bend your legs/wriggle toes while laying down to help prevent clots, and walking around within your limits is helpful in the recovery process.
• You may experience a sore throat due to the anaesthetic which is expected to feel better after a few days
• You will not be able to drive or operate machinery for 24 hours postoperatively, and a responsible person will need to drive you home and stay with you the night of your surgery
• You may remove the dressings 2 days after your operation. If there is a little drainage you may wish to replace the dressing to protect clothing, but it is acceptable to leave them off at this stage. Be sure to dry the area thoroughly after showering.
• You will be notified of any pathology tests which have results that are unexpected, otherwise these will be discussed with you at the post operative appointment
• Generally it is best to avoid public swimming pools the first week after surgery to minimize infection risk. Return to exercise regimes is generally acceptable when you feel up to it after the first two weeks.
• Eat a light diet the day following your operation to help minimize digestive problems and nausea. Ensure you drink plenty of water to maintain hydration
• In general sexual intercourse may be resumed when you feel ready postoperatively, keeping contraception in mind if pregnancy if not desired.
  

QUESTIONS TO ASK YOUR DOCTOR

• If you are unwell before your operation ring the rooms
• If taking regular medication, ask if any need to be discontinued prior to surgery, and which ones can be taken or missed on the day of the operation
• Ask if you will need a “bowel prep”, that is medicine to clear the bowel the day prior to surgery. This can be explained in more detail during consultation with your gynaecologist or nurse
• Please report heavy bleeding, temperature/fever (above 37.5 degrees), chills, offensive discharge, swollen or smelly discharge from wounds, swelling and tenderness in the calf muscles, shortness of breath,nausea/vomiting persisting more than 24hours, or constipation that does not resolve within a few days
• Ask you doctor how long he/she expects you to have leave from work
• Please notify your doctor if you intend to travel within the first week after your planned surgery
• Occasionally an infection can occur in the Urinary Tract after an operation, particularly when a catheter has been placed either during or after your operation. Symptoms including burning pain with passing urine, low abdominal pain and fever may suggest this and need to be reported to your doctor
• Persistant pain that is not relieved by the recommended pain killers should be reported to your surgeon
• Ask about any follow up treatment that may be required following surgery-ie artificial reproductive treatment, medication to suppress endometriosis, contraceptive pill
• Check if you are expected to be discharged from hospital on the day of your operation, or stay overnight
• Do I Need a Bowel prep?
• How likely is it that I will need further surgery?
• Is it likely that I will have to have my ovary/ovaries removed?
• Do you work in collaboration with a bowel surgeon?
• How often do complications occur?
• Is it likely that I will need 'open surgery?'