Living in New York City, we don’t usually see those forest fires some of you ladies see out West. While we watch it on TV and read about it on the Internet, those days and days of blazes are something of a foreign concept to us. However, what we have taken away from those images are the hoses upon hoses and the buckets upon buckets that those firefighters must use to quell those flames.
Endometriosis (a.k.a. endo) is to your pelvis as a big forest fire is to California. If it is not put out quickly, it can be devastating. The good news is that, just as the firefighters have many tools in their truck, we too have several potential treatment options.
For women who do not have babies on the brain, there are many “hoses” that can help put out your fire. You have both medical and surgical options. When fertility is not in the near future, shutting your own system off medically with hormonal therapy is no big deal. Most GYNs will recommend that you start basic (non-steroidal anti-inflammatory agents/NSAIDs plus hormonal contraceptives).
Go big only when the fire continues to rage. NSAIDs combined with continuous hormonal contraceptives (continuous birth control pills) are usually pretty good at putting out “smaller fires” (mild/moderate endometriosis). It doesn’t matter if you prefer the oral, vaginal, or skin (a.k.a. patch) route for hormonal treatment. They all work the same, and here, it is more a matter of preference than potency. If estrogen is out because of a medical contraindication (clots, smoking etc.), then progesterone can be given in isolation with NSAIDs.
If this concoction is not keeping your symptoms quiet, we start climbing the treatment ladder. Our next step is usually a GnRH agonist (cue Lupron) combo’d with add-back hormonal therapy (estrogen and progesterone). If this doesn’t bring things to a halt, we usually give aromatase inhibitors (think Femara) a try. The aromatase inhibitors work by decreasing circulating estrogens in the body. Estrogen is like gasoline to the endo fire. It doesn’t take a firefighter to tell you that it’s probably not a good idea to throw gasoline on a fire!
One treatment is not necessarily better than another. Some just work better in certain people. What is different is how they are administered (oral, injection), how frequently they must be taken (daily, weekly, monthly), and how much they cost (a little vs. a lot!). You have to see what works best for you and your symptoms.
When medical treatment isn’t cutting it, surgery is an option—no pun intended. We try to reserve the bigger guns for the bigger flames; starting with surgery is usually not a good idea. In general, the basic tenant of endo is to max out on medical treatment and avoid repeat surgeries—repeat trips to the operating room do not earn you frequent flier miles. It just earns you a lot of scar tissue, a lot of risk, and a lot of anesthesia. It’s not something you want to do.
If you do find yourself needing to make that trip down the runway, make sure your pilot has been around the block several times—no first-timers here. Endo surgery is no walk in the park; you want your surgeon to be experienced.
Gynecology has gained a couple of new subdivisions in the past few years. There are now GYNs who spend years after their residency learning how to do endo surgery. Their second home is in the operating room. Let’s just say that, when you need a tour, they should be the ones to do it! There are a variety of surgical procedures that can relieve your symptoms. The specifics are above the scope of our conversation, but what you do need to know is the following. Know your surgeon, know why they are doing what they are doing, and know how many times they have done what they are suggesting you do. Trust us; it’s super important.
No two fires are exactly alike. Similarly, no two cases of endo are exactly alike. While for some, pain is the biggest problem, for others, it is GI symptoms. Because of the variability in symptoms, in severity, and in life plans (fertility vs. no fertility), the treatment plan that “puts out your fire” will likely vary. What gets you going or stops your endo from growing may be different than what helped your sister or what helps your BFF.
Although we probably won’t ever treat you, we can recommend that you treat yourself with the utmost respect. Be aware of your symptoms and what makes them better or worse. Have your GYN on speed dial—don’t tell them we told you that!—and tell them when things are not going so well. And while we don’t recommend you ringing them on weekends and in the nighttime unless urgent, you should feel comfortable calling them. If their answers are not cutting it, don’t be afraid to remove them from your contacts and find a different doctor.
Unfortunately, endo is a chronic condition. Once the treatment hoses are turned off, the fire will likely return. After your baby days are done, you may elect to undergo definitive surgical treatment (a.k.a. a hysterectomy and bilateral salpingo-oophrectomy: simply stated, ovaries, tubes, and uterus out) to ensure that you never face another forest fire. Until then, let us help you temporize the flames so that you can fight whatever fires, be it professionally or personally, that you choose to extinguish. There is nothing you can’t put out if you put your mind to it!