Endometriosis

Recently in my practice, I’ve had several patients recently diagnosed with endometriosis.  The gold standard for diagnosis is a surgery - exploratory laparoscopy.  However, occasionally one can see signs on pelvic imaging, particularly pelvic MRI. 

Symptoms

Symptoms of endometriosis include pelvic pain, painful periods (“dysmenorrhea”), pain with penetrative activities like tampon insertion and penetrative sex, bowel issues (pain, constipation, rectal bleeding), bladder issues (urinary urgency, frequency, sensation of a UTI), pain around ovulation, prolonged heavy menstrual bleeding (“menorrhagia”), and that about sums up the major symptoms! You can see that these symptoms are not specific to anything! This is what makes this diagnosis challenging.

In my clinic, I say that painful periods are endometriosis until proven otherwise.

Treatment

Treatment for endometriosis is a spectrum. The mainstay of treatment is symptom reduction.  This is mostly through lifestyle changes! Using aids to help with period pain - heating pads, K-taping, supportive clothing, NSAIDs, magnesium + B6, gentle body movement such as stretching and yoga, and pelvic floor therapy are all great modalities. 

Some women will require prescription medications in the form of ovulatory suppression with birth control pills/patches, progestins such as norethindrone or medroxyprogesterone acetate, GnRH antagonists such as elagolix (Orlissa) or relugolix (Myfembree) and GnRH agonists such as leuprolide acetate (Lupron). In Canada, dienogest (which is a progestin) has approval to treat endometriosis. We don’t have a product like this in the US but we do have a birth control pill with dienogest in it called Natazia, and I use this a lot in my practice.

The IUD doesn’t suppress ovulation, but it may treat heavy or painful periods.  The Mirena has an indication for treatment of heavy menstrual bleeding.

Interestingly, there is some preliminary studies that show Duavee, which is a menopausal hormone therapy, may have some therapeutic benefit for endometriosis. 

Severe or refractory cases may require surgery which includes excision of the endometriosis as well as hysterectomy (uterus removed), bilateral salpingectomy (tubes removed), and perhaps even oophorectomy (ovaries removed) depending on your age.

Important considerations for peri/menopause

Sometimes endometriosis gets a label of “estrogen dominance”, but the thing is this is not really accurate. For one, this is not a medical diagnosis.  For two, what does this even mean? Our (cisgendered females) hormones fluctuate on a day to day basis.  One of the reasons that progestins are used to treat endometriosis, is because there tends to be not enough progesterone, not just too much estrogen.

Also, during perimenopause and then postmenopause, estrogen is not in abundance. It is actually quite the opposite! You spend longer and longer periods of time with estrogen deficiency until after the menopause transition occurs, then you are in a state of estrogen depletion for life.  That is why thinking of endo as an estrogen dominance issue is very problematic.

Some women experience early menopause or premature menopause (POI - premature ovarian insufficiency). Early menopause is defined as last menstrual period before age 45, and premature ovarian insufficiency/premature menopause is defined as last menstrual period before age 40.  

Can you take menopausal hormone therapy if you have endo?

YES! Yes, yes, yes, yes. Endometriosis is NOT a contraindication to menopausal hormone therapy.  Period. (or no period if you are menopausal - LOL).

There is no one best menopausal hormone therapy regimen for women with endo - it is a nuanced conversation, and you deserve to have this with a menopause specialist who understands the options.  Here are my general recommendations:

• Don’t be scared of estrogen! You can use this in any form: pill, patch, ring, cream, gel, spray.  You can use local therapies for vulvovaginal symptoms and systemic or total body therapies for systemic or total body symptoms.

• Consider progestin over progesterone. Work with your provider to understand if you would benefit from this even if you’ve had your uterus removed.

• Consider bazedoxifene (Duavee). This is a tissue selective estrogen complex (TSEC), and it may be beneficial in women with endo!

• Consider testosterone, especially if you’ve experienced surgical menopause.

Check out my podcast to hear more about menopausal hormone therapy options in general, and also specifically for endometriosis gals!

*information here is for informational purposes only and is not medical advise. Contact your healthcare provider for individual treatment plan.