Treatment | Vital Health Endometriosis Center

A Survival Guide to Bowel Preps

Vital Health Endometriosis Centers — Fri, 13 Feb 2015 18:00:03 +0000

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I just love bowel preps! ~ Said nobody ever

The purpose of the pre-operative bowel preparation is to cleanse your intestinal tract so that it can be safely operated on. While this process is unpleasant to endure it is absolutely necessary in minimizing the risk of complications during bowel surgery.

There are several bowel preparations on the market. Some involve drinking large volumes of laxative drink while others combine a single laxative drink with an enema solution or oral tablets. The prep may be combined with a low fiber diet during the days that precede it, and on the day of the prep (the day before surgery), you will be required to follow a strict diet of clear liquids only. Whichever method you are given, be sure to follow all instructions carefully.

Tips on getting through the bowel prep

Eat lightly the days prior to the prep. This should make cleansing your intestines a little easier.
Some patients find the prep drink difficult to palate because of the unpleasant taste. Allowing it to cool in the fridge or packing it in ice in the sink may make the drink that little bit more palatable.
To get the unpleasant taste out of your mouth, follow-up the prep drink with something pleasant tasting such as broth, a hard boiled sweet, or chewing gum (but be sure to keep to the dietary instructions provided by your physician).
Drinking the prep through a straw can help reduce contact with your taste buds as the liquid passes through your mouth.
If you feel nauseous try alternating between a pleasant tasting liquid, such as broth, clear fruit juice, and ginger ale, and the prep. Ginger is good against nausea. Either sipping ginger ale or sucking on boiled ginger candy may help. Another trick is to compensate and counteract the unpleasant taste with something pleasant smelling, such as scented candles or a handkerchief sprayed with your favorite perfume. Lavender scents are good against nausea and can help boost pain tolerance (such as intestinal cramps).
Be sure to remain hydrated during the prep. Drink plenty of clear fluids throughout.
Once the cleansing process begins, use wet wipes instead of regular toilet paper and apply topical non-prescription hemorrhoid cream, which contains a local anesthetic and will numb the area. This will help prevent soreness and discomfort.
Once the prep begins to take effect you may start to experience intestinal cramping. Applying a heat pad or ice pack may help sooth this pain.
Provide yourself with pleasant distractions – reading materials, puzzles etc. to tide you over during the prep.
Lastly, remind yourself that many have gone before you and that this is the last hurdle before a surgery that will hopefully provide you with ongoing relief from your pain. You can do it!

Remember, this is the last hurdle before a surgery that will hopefully provide you with ongoing relief from your pain. You can do it!

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What is Hormone Therapy and Should it be Used to Treat Endometriosis?

Libby Hopton — Wed, 28 Jan 2015 20:25:58 +0000

The typical medical treatment for endometriosis provided by most OBGYNs consists of manipulating a woman’s hormones, primarily her estrogen and/or progesterone levels. The rationale behind this treatment is that estrogen tends to stimulate the growth of endometriosis and progesterone is believed to balance or stabilize the effect of estrogen. In a very simple example, one can think of estrogen as fertilizer for the lawn and progesterone as the lawn mower. The goal of medical treatment of endometriosis is to increase the ratio of progesterone to estrogen (progesterone-only treatment), decrease the amount of both estrogen and progesterone (combinational birth control pills) or to eliminate estrogen from the body (GnRH agonist treatments such as Lupron and Zoladex).

Unfortunately, all hormone therapies commonly employed to treat endometriosis are fairly crude and are frequently associated with unacceptable side effects, making these medications difficult to tolerate. Some patients find the side effects even more debilitating than the symptoms of the disease itself. Hormone therapies do not provide a cure for the disease, are only effective in a portion of endometriosis patients, and even when this treatment option provides relief the results are typically short-lived and symptoms return. Furthermore, hormone therapies are not appropriate in patients presenting with infertility or who are trying to conceive. Even use of a GnRH agonist such as Lupron that causes a temporary medical menopause is frequently ineffective in managing endometriosis as endometriotic tissue itself can produce its own source of estrogen, allowing it to remain active and symptomatic despite the treatment.

When should hormone therapies be considered?

If hormone therapies are only temporarily effective in some patients and do not make the endometriosis go away nor necessarily stop the disease in its tracks (treating the symptoms but not the disease), why are they so commonly prescribed?

When a patient first presents with pelvic pain, and in particular period pain, the doctor and patient face a dilemma: How long should her symptoms be managed symptomatically (via medical therapy) and at what point should more invasive treatment options be considered (such as laparoscopic surgery) to actually diagnose and treat any underlying disease? On the one hand the patient wants to avoid unnecessarily invasive treatments and the risks associated with surgery (albeit minimal,) yet on the other hand she also wants to get to the root of her problem so that it can be effectively treated and she can get on with her life. This is obviously a very personal decision that needs to be made based on the severity of symptoms and the individual needs and priorities of the patient. Importantly, however, the patient needs to be informed of her options so that she can play an active role in the decision-making process.

Prescribing hormone therapies requires limited expertise and is a treatment option that is readily available to all. Surgery, in contrast, may require a level of expertise that most OBGYNs do not have. Moreover, if a patient is presenting with erratic and painful menstrual periods, a prescription of birth control pills may lighten, regulate and shorten her periods, easing her pain. It is when a patient keeps returning to her doctor complaining of the same symptoms despite trying different hormone therapies or cannot tolerate the side effects, that it is time to consider other treatment options.

Adenomyosis

A condition that is common among women with endometriosis is adenomyosis. Adenomyosis is when endometriotic tissue is found within the muscular walls of the uterus. Typically these areas of rogue tissue are scattered diffusely throughout the muscular uterine walls and so are not amenable to surgical removal. Endometriosis patients who also have suspected adenomyosis may find that some of their pelvic pain persists despite endometriosis excision surgery. While surgery to destroy or sever the nerves that innervate the uterus may help reduce this residual uterine pain, in most cases the only curative surgery for adenomyosis is hysterectomy (removal of the uterus). Obviously, many women will not be a position to undergo hysterectomy because they wish to retain their fertility. In these patients, conservative management of the chief symptoms of adenomyosis (pain and abnormal uterine bleeding) with hormone therapy provides an important alternative.

Pre-operative ovarian suppression

Another example where hormone therapy may be appropriate is in managing pain in patients who are waiting for surgery. For example, a teenage patient who plans her surgery during her school vacation so as not to disrupt her studies may benefit from hormone therapy to manage her symptoms and help her function in the mean time. Importantly, however, it is best that the patient is not on ovarian suppressive therapy shortly before or at the time of her surgery as this can hamper the surgeon’s ability to visualize all areas of disease. Ideally, all ovarian suppressive therapy should have be discontinued 6-8 weeks prior to surgery.

Should hormone therapies be prescribed following surgery to prevent recurrence?

If a patient has undergone the complete surgical removal of her endometriosis and her pain has been resolved there is no clinical indication for continued use of hormone therapies (other than for contraceptive purposes). Post-operative hormone therapy has not been found to reduce the rate of symptom nor disease recurrence. Recurrence of endometriosis rarely occurs following the complete excision of the disease regardless of whether the patient follows up surgery with hormone therapy.

Post-operative ovarian suppression following cystectomy

Some surgeons recommend post-operative hormone therapy following endometrioma (cystic ovarian endometriosis) removal (cystectomy) with the hope that ovarian suppression will reduce the risk of recurrence of the endometrioma(s). Research into this, however, has been inconclusive. Another reason for post-operative ovarian suppression following endometrioma removal is to give time for the ovary to heal before ovulation recommences, which might otherwise cause additional pain during post-operative healing.

Management of Pelvic Pain in Women with Endometriosis

Libby Hopton — Wed, 28 Jan 2015 19:22:30 +0000

Adequate management of pain is paramount in women with endometriosis, due to the chronic and debilitating nature of this painful condition. The type of treatments offered will depend on the type of pain, its severity and duration, and the specific needs and wishes of the patient.

What can be done about my pain?

Our aim is to offer permanent relief and resolution of pain through surgical and non-surgical interventions (excision surgery, nutritional counseling, pelvic physical therapy etc.). In some cases, however, short-term or ongoing pain management is required to allow our patients to function. Not all sources of pain can be resolved by therapeutic intervention and in some cases definitive treatments, such as hysterectomy for uterine disease, may not be desired due to a wish to preserve fertility. Instead, ongoing palliative management in the form of prescription and non-prescription drugs and interventional pain management (nerve blocks, pain pumps and catheters) may be required. Interventional treatments may warrant the specialist expertise of a pain-management physician who will work in close coordination with the rest of the patient’s healthcare team.

Non-prescription (over-the-counter) pain medications

Common non-prescription pain medications used by pelvic pain patients include Acetaminophen or Tylenol and non-steroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen and naproxen, which suppress inflammation. Care needs to be taken to not exceed safe daily dosages of pain medication and, in particular, when combining different non-prescription and prescription drugs. It is important for your safety that even over-the-counter medications are disclosed and carefully discussed with your doctor when considering pain management options.

Prescription pain medications

Prescribed pain medications include prescription NSAIDS and narcotics. Narcotics can be short acting (e.g., hydrocodone, oxycodone and hydromorphone) or long acting (e.g., morphine and long-acting oxycodone). Narcotic pain medications work by slowing down or stopping the signals from the nerves to the brain. The choice of narcotics prescribed will depend on whether your pain is acute (such as post-operative pain) or chronic (ongoing pain).

Pain-narcotic contract

If a patient receives prescription-narcotic pain management, she will be required to enter into a pain-narcotic contract which specifies what she can and cannot do while taking prescription-narcotic pain medications. All members of her healthcare team are aware of this contract and regular meetings are held among the staff to discuss and monitor the patients who are receiving prescription-narcotic pain management.

Interventional pain management treatments

Interventional pain management treatments for long-term pain include pain pumps (an implantable pain-management device), spinal cord stimulators (pain catheters), trigger-point injections or nerve blocks (temporary numbing injections to painful areas or overly sensitive nerves), and radiofrequency ablation (RFA), where targeted nerves are “stunned”, offering more prolonged relief than nerve blocks.

At Vital Health we offer an array of options to both resolve your pain and to manage acute and chronic pain. We firmly believe that no woman should suffer from pelvic pain and we strive to provide optimal relief to each and every patient who comes to us for help. Even when a patient suffers from intractable pain that does not respond to surgical and non-surgical intervention, ongoing pain can be managed with a variety of palliative approaches, offering hope, relief, and restoring your quality of life.

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What Happens During a Diagnostic Laparoscopy?

Libby Hopton — Mon, 26 Jan 2015 22:21:15 +0000

Diagnostic laparoscopy is a form of minimally invasive abdominal surgery that is performed to investigate potential sources of pelvic pain and infertility. During the procedure, the inside of the pelvic and abdominal cavities are carefully inspected for any abnormalities, such as endometriosis and adhesions. Diagnostic laparoscopy is typically performed under general anesthesia [1] and is commonly combined with therapeutic laparoscopy to treat any disease that is found.

What happens during the procedure?

First of all, the patient is put to sleep, her airways are intubated, her vital signs monitored and her bladder emptied with a catheter. The surgeon then performs a pelvic exam to check for any abnormalities. If a bladder condition is suspected (such as interstitial cystitis) a cystoscopy may be performed (the bladder is slowly filled with saline solution and a small camera is inserted to inspect the inside of the bladder for abnormalities). If abnormalities are suspected involving the inside of the uterus a hysteroscopy may be performed (a small camera is introduced through the cervix into the uterus to inspect the uterine cavity and obtain biopsies). An instrument called a uterine manipulator is then inserted through the cervix and into the uterine cavity. The uterine manipulator enables the surgeon to adjust the positioning of the uterus within the pelvis enabling complete visualization of the pelvic structures. Endometriosis often involves the tissue between the uterus and the large bowel (referred to as the Pouch of Douglas or the posterior cul-de-sac). In order to inspect this area during surgery, the uterus needs to be elevated forward.

After the placement of the uterine manipulator, a hollow needle is introduced to the pelvis through a tiny incision and the pelvic cavity is slowly insufflated (inflated) with CO2 gas. Normally the pelvic structures all rest together. The use of gas provides more space within the pelvis, separating the various structures and enabling visualization by the surgeon. Three small incisions are then made in the patient’s lower abdomen (these incisions are sufficient for both the diagnosis and treatment of endometriosis). One incision is made in the umbilicus (the belly button) and two are made beneath the bikini line, one on the right and one on the left. [2] After surgery the scars where these incisions were made will fade in time until they are barely noticeable and will be fully concealed by a bikini. A trocar (a cylindrical sheath through which the instruments are placed) is inserted through each incision. The laparoscope is introduced through the umbilical trocar (the trocar that is inserted through the patient’s belly button). A laparoscope is a thin fiber-optic tube with a camera integrated at the tip, which is connected to large video monitors so that the surgeon can inspect the inside of the pelvis. Surgical instruments are introduced through the other two trocars. These instruments may be used to grasp and move the pelvic structures, to irrigate (clean) surfaces, to suction (remove) free fluid from the bottom of the pelvis, and to dissect (separate) organs and structures that are fused together by adhesions (scar tissue) to allow the surgeon to inspect all surfaces.

The entire pelvic cavity is carefully examined with the tip of the laparoscope held close to the surface of the peritoneum (a thin layer of tissue that cloaks the pelvic structures). This enables the surgeon to detect any abnormalities, no matter how subtle. The pelvic structures, including the appendix, intestines, and diaphragm, are carefully examined for possible disease and adhesions. Any abnormalities in the appearances and consistency of the uterus are noted.

What are the challenges in identifying all areas of endometriosis?

The inside of the body is not like an empty room (where it’s easy to see if there is anything on the floor or walls). Instead, there are a lot of folds and nooks and crannies, and the search for endometriosis is more like trying to find a penny amongst a bunch of wadded up, unfolded cloths. With endometriosis, very small, difficult-to-see lesions can cause excruciating pain. When the end of the laparoscope is very close to the tissue, the laparoscope magnifies it. But this also decreases the area that is seen, similar to the effect of looking through a telescope or a set of binoculars.

A surgeon must be very thorough and meticulous, and use a systematic approach in looking for endometriosis. He or she also needs to understand the many different appearances of endometriosis, and work with an excellent pathologist who does not overlook mild endometriosis. The visual appearance of endometriosis is highly varied: The lesions can be dark, pigmented lesions, similar to a blood blister, or clear, vesicular lesions, appearing like miniature water balloons. It can also look like specks of salt or even leathery scar tissue. Some endometriosis is hard to see, but if the proper time and magnification are used, it can be found. In addition, scar tissue in an endometriosis patient should be considered and treated as endometriosis until proven otherwise.

The pathologist is an unseen and largely unappreciated member of the endometriosis team. If the pathologist is not meticulous in his or her examination of the tissue, then endometriosis will be missed, and the feedback to the surgeon will be false. Worst of all for the patient, the surgeon will leave endometrial lesions behind because the pathologist has incorrectly told the surgeon that this appearance is not endometriosis, when in fact it is. I work with a physician whom I believe to be one of the best endometriosis pathologists in the country. He has a lot of respect for endometriosis, and is very meticulous in looking for the disease. He takes extra steps in preparing the tissue, which helps to maximize the chance of finding all the endometriosis that is present.

Will diagnostic laparoscopy be proceeded by therapeutic laparoscopy?

After the pelvis has been carefully examined, the surgeon then proceeds to surgically treat any areas of suspected disease. The process of treating any abnormal findings is referred to as a therapeutic laparoscopy. Diagnostic and therapeutic laparoscopy are typically combined, although some surgeons first perform a diagnostic laparoscopy to assess the severity of the disease and then either plan in a further surgery to treat the disease or else refer the patient to a specialist. Dr. Cook always diagnoses and meticulously treats all areas of abnormal tissue during the same one procedure.

What happens once the surgery is complete?

Once the surgery is complete, the instruments and trocars are removed, the abdomen is carefully deflated and the incisions are glued or sutured closed and small dressings are applied. The patient is then taken to recovery and closely monitored. Anti-nausea and pain meds are provided via IV to keep the patient comfortable. Following surgery Dr. Cook admits his patients overnight so that they receive optimal management of their post-operative pain. During the first hours following surgery you may feel groggy and tired and your throat may feel sore from the intubation tube. The fatigue may last for some days to several weeks, depending on the length of surgery and your physical condition prior to surgery. In most cases any post-operative pain is well managed by the IV, PCA pump and orally administered pain medications while in hospital and the pain medications prescribed following discharge. Residual gas from the surgery may take some time to dissipate, causing temporary shoulder tip pain but usually resolves within a few days. Likewise, the incision sites may be tender and bruised for the first week or two after surgery but will recover in time. Slowly you will find yourself returning to your normal activities. The length of recovery will depend on the patient’s general health as well as on the extent of surgery that has been required.

Dr. Cook and his team carefully follow up all surgery patients to make sure they are comfortable and recovering well. If any concerns arise, the Vital Health team is on hand to help you.

How effective is a diagnostic laparoscopy at identifying endometriosis?

In the capable hands of an endometriosis specialist diagnostic laparoscopy is a highly accurate method of identifying any abnormal tissue and confirming the presence or absence endometriosis. Surgeons who are less familiar with endometriosis, however, may fail to recognize subtle areas of disease and may misinterpret the clinical significance of dense adhesions (which to a specialist is often a sign of significant underlying invasive disease). An unfortunate outcome is where a patient with endometriosis is incorrectly told by her surgeon that she does not have the disease, further delaying correct diagnosis and treatment. It takes a trained eye to recognize endometriosis in all its forms and make an accurate diagnosis. It is therefore important to request that your surgeon documents the surgery by taking photos and/or providing you with a complete digital copy of your procedure on DVD. This way, you can seek a second opinion if you suspect disease has been missed. Ideally, it is best to find an endometriosis surgical specialist to conduct your surgery. Dr. Cook records all of his surgeries and provides his patients with comprehensive surgical photos and a complete copy of the procedure on DVD on request.

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Dr. Cook and his team performing a diagnostic laparoscopy.

Notes

Occasionally patient-assisted laparoscopy (PAL) will be performed, in which the patient is awake during the procedure and can guide the surgeon to the source of her pain. PAL may be indicated if previous laparoscopic surgery has failed to identify and resolve the patient’s pain.
In patients with symptoms suggestive of diaphragmatic endometriosis an extra incision may be required in the upper right quadrant of the abdomen (just under the right rib margin) in order to fully visualize the right side of the diaphragm behind the liver.

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Treating Pelvic Floor Dysfunction in Women with Endometriosis & Other Pelvic Pain Conditions

Vital Health Endometriosis Centers — Tue, 13 Jan 2015 01:04:01 +0000

Pelvic floor dysfunction (PFD) is a common condition in women with endometriosis and other pelvic pain conditions and occurs when the muscles that form the pelvic floor have tightened in response to chronic pelvic pain. Even after the original source of pelvic pain has been resolved, PFD persists as an acquired or secondary source of pelvic pain. In severe cases, the patient suffers from pelvic floor spasms, which can be excruciating and make intercourse impossible. Other common symptoms are pain and/or difficulty emptying the bladder or bowel and painful intercourse. Pelvic floor dysfunction can affect all the organs in the pelvis, including the urinary, genital, and bowel systems, and can have further reaching effects on the body (coordination, alignment, breathing, and mobility).

Pelvic Floor Dysfunction is a common condition in women with endometriosis and other pelvic pain conditions and occurs when the muscles that form the pelvic floor have tightened in response to chronic pelvic pain.

Once a woman’s endometriosis has been successfully removed during surgery and healing is complete, if pain persists, she may be assessed for PFD and referred to our specialized pelvic floor physical therapist. Most physiotherapists lack the training and expertise to treat pelvic pain and pelvic floor spasm. If you are seeking relief of PFD it is important to find a practitioner who understands the specific needs of women with endometriosis and who has experience and training in treating PFD.

What happens during pelvic floor physical therapy and how does it help?

Chronic pelvic pain can affect body posture, muscle tone and alignment. Muscles may become shorter, tighter and misaligned due to the perpetual responses of the body to pelvic pain. The role of the pelvic floor physical therapist is therefore to train the patient to relax her body and restore balance and alignment. While the pain emanates from the pelvis, the effects of chronic pain are far-reaching due to the role of the pelvic floor in core activities such as movement and coordination. Effective physiotherapy may need to involve muscle groups throughout the body.

Patient history

Pelvic physical therapy begins with a thorough patient history. In her own words, the patient tells her story about living with endometriosis, her pain and the treatments she has endured. She is also asked to recant any other incidents in her life history that might have jolted her pelvis, such as a previous skiing accident.

Biomechanical and musculoskeletal assessment

The next step is a biomechanical and musculoskeletal assessment; the therapist observes how the patient moves and walks, her posture and breathing, where her core areas of pain are, and takes note of the overall condition of her muscles (strength, coordination, alignment, and contraction).

Relaxation skills

Following this general assessment, the therapist focuses on relaxation skills. Massage is directed at loosening and relaxing muscles and relieving abdominal and pelvic pain. The patient is then directed in self-massage and relaxation exercises, which she can continue at home.

Physical examination

Next the therapist performs a thorough physical exam to test overall body flexibility and mobility, paying particular attention to the hips and possible joint malformations, the sites of abdominal scars and the motility of the internal pelvic organs. The physical exam comprises both an external and internal exam. During the internal exam, the different layers of the pelvic floor are assessed to check muscle spasm, tone and mobility, tissue rigidity and pain trigger points. While some patients may feel uncomfortable, internal work is essential in order to access the core muscles and tissues involved by PFD.

Retraining of muscles

Pelvic muscles that have been identified as tense and in spasm are then “down trained” by teaching the patient the difference between tensing and relaxing these muscles. This can be achieved with the help of biofeedback sensors placed on the muscles so that the patient can see her pelvic muscle activity fluctuate on the biofeedback monitor.

Home exercises

To improve flexibility and stretch tightened muscles, the patient will be instructed in stretching exercises, focused on opening the hips. The patient may also be instructed in vaginal dilation exercises to be performed digitally or with a home-dilation kit to further mobilize tissue within the pelvis. Further exercises will focus on core strength, and trunk and spine flexibility. Once pain and mobility improve, the patient will be retrained in basic movements such as walking and standing without tensing the pelvic floor and to improve pelvic-girdle coordination. The patient will be instructed in gentle exercises to restore coordination and mobility, such as basic yoga and Pilates, gradually building up over the course of 6 to 12 weeks.

Pelvic floor physical therapy helps chronic pelvic pain sufferers to retrain and recalibrate their bodies, reversing the harmful effects of ongoing pain on the body. The goal is to improve (sexual, bladder and bowel) function, coordination, core strength and to relieve pain.

Ready to start your healing journey? Request a free virtual consultation today.

The post Treating Pelvic Floor Dysfunction in Women with Endometriosis & Other Pelvic Pain Conditions appeared first on Vital Health Endometriosis Center.

Dr. Cook’s Guide to Hormone Therapy Treatments for Patients with Pelvic Pain

Dr. Cook — Mon, 28 Jan 2013 20:39:52 +0000

The typical medical treatment for endometriosis provided by most OB/GYN’s basically is manipulating a woman’s hormones, primarily her estrogen and/or progesterone levels. The concept behind this approach to treatment of endometriosis is that estrogen tends to stimulate the growth of endometriosis and progesterone balances or stabilizes the effect of estrogen. In a very simple example, one can think of estrogen as fertilizer for the lawn and progesterone as the lawn mower. The goal of medical treatment of endometriosis is to increase the ratio of progesterone to estrogen (progesterone only treatment), decrease the amount of both estrogen and progesterone (combinational birth control pills) or to eliminate estrogen from the body (GnRH treatments such as Lupron).

Unfortunately, all of the medical treatment options for endometriosis treatment are fairly crude, commonly with unacceptable side effects. The medical treatments do not provide a cure for the disease, only work for a portion of endometriosis patients and even when the treatment option is effective the results are only temporary. Even use of a GnRH agonist such as Lupron that cause a temporary medical menopause may not be effective in treating endometriosis as the actual lesions of endometriosis can produce their own estrogen and remain active and potentially invasive despite ovarian suppression.

All treatment options using progesterone as the choice of endometriosis treatment are trying to suppress the effect of estrogen on the endometriosis. This endometriosis treatment option can be effective in some women, especially if the patient’s pain is primarily around her period and if she does not tolerate estrogens (nausea, etc.)

The different kinds of progestin (a progestin is a substance that has progesterone like effects on the body) used to treat endometriosis include, bio-identical compounded progesterone creams, a pharmaceutical bio-identical oral micronized progesterone, synthetic progestins, progesterone only birth control pills, Depo-Provera and the Mirena IUD.

Topical

Progesterone cream is the most common form of topical progesterone. Non-prescription progesterone creams usually do not have enough progesterone to alter the menstrual cycle. Some women find this low dose of hormone to be effective. Prescription progesterone cream is usually made in a compounding pharmacy at the requested strength of the ordering physician. It can be difficult to get consistent and adequate absorption of progesterone using this delivery method.

Oral

Oral Progesterone can include compounded bio-identical progesterone pills, oral micronized progesterone in oil pill (Prometrium), synthetic progestin Aygestin (Norethindrone acetate) or Provera (Medroxyprogesterone) or the progesterone only birth control pill.

The progesterone only birth control pills do not have any estrogen and the amount of progesterone is about 1/3 the dose of progesterone (thus the term mini-pill) found in the average combinational estrogen/progesterone pill.

Injectable

Depo Provera is a long acting form of progesterone that is given as a shot and lasts for months. The most common side effects include weight gain, break through bleeding and depression.

IUD

Use of the Mirena IUD as a treatment option for endometriosis delivers a daily dose of about 20mcg of the progesterone, levonorgestrel. Birth control pills with levonorgestrel contain a daily dose of 90mcg to 150mcg. This is four and a half to seven and a half times the dose of the Mirena IUD. On average women using the Mirena IUD have about a 50% to 90% reduction in their menstrual flow and 20% stop having a period within one year (this is only temporary and periods start again shortly after removal of the Mirena IUD). Every treatment option has drawbacks including the Mirena IUD as 23% of women will have some spotting or bleeding in between their periods, 13% will have abdominal or pelvic pain and 12% ovarian cysts. If you experience significant side effects you may need to have it removed and look at your other options for endometriosis treatment.

Progesterone treatment options for endometriosis treatment

Type of progesterone	Brand name	Generic name	Typical treatment schedule
Bio-identical compounded progesterone cream	No brand name (Only available through compounding pharmacy with prescription)	Bio-identical progesterone cream	Apply to skin once daily
Bio-identical oral micronized progesterone	Prometrium	Micronized progesterone	100mg tablet by mouth before bed
Synthetic progesterone	Aygestin	Norethindrone acetate	15mg by mouth once a day. Start at 5mg once a day for 2 weeks, then increase by 2.5mg every 2 weeks
Synthetic progesterone	Provera	Medroxyprogesterone	One tablet once a day
Progesterone only birth control pills	Camila	Norethindrone 0.35mg	One tablet once a day
Progesterone only birth control pills	Errin	Norethindrone 0.35mg	One tablet once a day
Progesterone only birth control pills	Heather	Norethindrone 0.35mg	One tablet once a day
Progesterone only birth control pills	Jolivette	Norethindrone 0.35mg	One tablet once a day
Progesterone only birth control pills	Nora-BE	Norethindrone 0.35mg	One tablet once a day
Progesterone only birth control pills	Nor-QD	Norethindrone 0.35mg	One tablet once a day
Progesterone only birth control pills	Ortho Micronor	Norethindrone 0.35mg	One tablet once a day
Long acting progesterone shot	Depo-Provera	Medroxyprogesterone acetate	One shot every three months
Progesterone IUD	Mirena IUD	Levonorgestrel intrauterine device	Change every 5 years Dose of progesterone is equivalent to levonorgestrel 20mcg each day

Different types of progestin and associated characteristics used for endometriosis treatment

NORETHINDRONE
Generation of Progestin	1st
Progesterone Activity	LOW
Estrogen Activity	Slight
Relative Androgen Activity	>Gen #3
Drawbacks	–
Advantages	May improve cholesterol (lower LDL, raise HDL)

NORETHINDRONE ACETATE
Generation of Progestin	1st
Progesterone Activity	LOW
Estrogen Activity	Slight
Relative Androgen Activity	>Gen #3
Drawbacks	–
Advantages	May cause less nausea, fluid retention or migraines

ETHYNODIOL DIACETATE
Generation of Progestin	1st
Progesterone Activity	MEDIUM
Estrogen Activity	Slight
Relative Androgen Activity	>Gen #3
Drawbacks	Higher risk of breakthrough bleeding
Advantages	–

LEVONORGESTREL
Generation of Progestin	2nd
Progesterone Activity	HIGH
Estrogen Activity	–
Relative Androgen Activity	>Gen #1
Drawbacks	May increase bad cholesterol (LDL) and decrease good cholesterol (HDL)
Advantages	1. Used in FDA approved extended birth control pills such as Seasonique and Seasonale 2. Most commonly used progesterone

NORGESTREL
Generation of Progestin	2nd
Progesterone Activity	HIGH
Estrogen Activity	ANTI-E
Relative Androgen Activity	>Gen #1
Drawbacks	May increase bad cholesterol (LDL) and decrease good cholesterol (HDL)
Advantages	–

DESOGESTREL
Generation of Progestin	3rd
Progesterone Activity	HIGH
Estrogen Activity	MINIMAL
Relative Androgen Activity	LOWEST
Drawbacks	May have higher risk of blood clots than other progestins
Advantages	1. Can increase good cholesterol (HDL) 2. May have less weight gain, effect on metabolism and risk of acne

NORGESTIMATE
Generation of Progestin	3rd
Progesterone Activity	HIGH
Estrogen Activity	SLIGHT
Relative Androgen Activity	LOWEST
Drawbacks	–
Advantages	1. Minimal effect on cholesterol and carbohydrate metabolism 2. FDA approved for treating acne 3. Lower risk of nausea and vomiting risk than other birth control pills

DROSPIRENONE
Generation of Progestin	4th
Progesterone Activity	HIGH
Estrogen Activity	SLIGHT
Relative Androgen Activity	LOWEST
Drawbacks	Can increase potassium levels – do not use if liver, kidney or adrenal disease
Advantages	1. Lessen PMS associated water retention and moodiness 2. FDA approved to treat Premenstrual Mood Disorder (PMDD) and acne

Combined Estrogen & Progesterone Treatment Options

Combinational birth control pills (contain both estrogen and progesterone) are commonly the first step in treating patients with endometriosis, pelvic pain and painful periods. If most of the pain a woman is experiencing is around her period then reducing the intensity of pain and/or the frequency of periods with the use of birth control pills may be an effective endometriosis treatment in some patients. With cyclic use of birth controls pills for treatment of endometriosis associated menstrual cramps, the period is often lighter with decreased pain. Some women can take the pill continuously (skipping the sugar pills each month and taking hormone pills every day without a break,) either completely avoiding periods or significantly reducing the number of periods over time (for example 4 periods a year instead of 12 periods a year).

Even though this endometriosis treatment involves actually taking estrogen and progesterone, women taking a combinational birth control every day actually experience a significant reduction in the amount of estrogen and progesterone in their body. At first this may not make sense but the ovaries make a lot more estrogen than that found in the pill. The small consistent does of estrogen and progesterone in the pill is enough to signal the ovaries not to make estrogen, temporarily turning the ovaries off and eliminating their relatively large release of estrogen. Less estrogen in the body as a result of the pill can result in less stimulation and activity of the endometriosis. Periods are usually shorter and lighter on the pill because there is less stimulation and growth of the endometrium (inside lining of the uterus that sloughs off during menstruation).

The most common treatment option in this category is the standard combinational estrogen/progesterone birth control pill. Other forms of combinational estrogen/progesterone treatment include the Nuvaring and the Ortho-Evra patch. The patch, however, delivers about 50% more estrogen than a standard 35mcg birth control pill and thus is not the best for endometriosis treatment.

If your doctor prescribes a particular birth control pill as treatment to help with your endometriosis symptoms hopefully it will work well without any side effects. In these cases you have found a good treatment option for your endometriosis (note, while the treatment may manage your symptoms it does not eradicate the disease).

Unfortunately, the pill does not always work well or patients may have significant side effects. In these cases a different birth control pill may work better, but there are so many birth control pills on the market it can be confusing trying to decide which option is right for you. Not all birth control pills are the same. Understanding these differences will help you and your doctor choose the best birth control pill option to treat your endometriosis symptoms while minimizing the side effects you may experience.

The difference in the various pills really comes down to a couple of things including the amount of estrogen, the type and amount of progestin and the balance or relative amount (ratio) of estrogen and progesterone. The type of estrogen is the same in virtually all of the combinational birth control pills (Ethinyl Estradiol). The amount of this estrogen in the pill can vary from 10 micrograms (micrograms=mcg) to 35mcg. The combinational pill has one of eight types of progestin (substance with progesterone like activity). The types of progestin in the pill include norgestimate, desogestrel, norethindrone, norethindrone acetate, ethynodiol diacetate, drospirenone, levonogestrel, and norgestrel. Nuvaring has a different progestin than found in any pill and is called etonogestrel.

Side effects

If you have any significant side effects (nausea, decreased sex drive, not feeling well, etc.) with this treatment option, using a pill with a different type of progestin or estrogen dose may work better for you. One of the more common side effects patients experience is break through bleeding, that is bleeding in between the normal period time. This is often associated with cramping and pain. Birth control pills in part provide an effective option for endometriosis treatment by eliminating or reducing the number of bleeding and pain days. Often bleeding in between the period is a result of either the wrong overall estrogen level or the ratio of estrogen and progestin. There are over 100 different brands of combinational birth control pills. If the pill your doctor has given you as the best treatment option for your endometriosis but you still have cramping and bleeding, find your pill on the tables below. Perhaps even make a copy and take it with you to your next doctors appointment and see if there might me a better birth control pill option for your endometriosis treatment. A pill with a different estrogen level, different type of progestin or different ratio of estrogen and progestin may be a better option for managing your pelvic pain.

Break Through Bleeding (BTB) and continued pain while taking BCP

There are many causes of BTB on the pill and your OB/GYN should be able to help resolve this for you. One of the many possible contributing factors to your BTB can be a dominance of either estrogen or progesterone. When your doctor preforms a transvaginal ultrasound he or she will be able to measure the thickness of the endometrium (the inner lining of the uterus). BTB can be the result from the lining of the uterus being either too thick or too thin. If you are on the pill, changing the balance of the estrogen and progestin in the pill may help.

If endometrium is thin on sonogram (<5) one treatment option is to switch to a higher estrogen pill (or less progestin) and or higher estrogen to progestin ratio pill. If endometrium is thick on sonogram (>5) one treatment option is to switch to a lower amount of estrogen in the pill and/or a pill with a lower estrogen to progestin ratio or a progestin only pill.

Estrogen/Progesterone combinational OCP treatment options for endometriosis treatment by type of progestin

Danazol (Danocrine) Treatment Option

Danazol was approved in 1976 by the Food and Drug Administration (FDA) as the first medication specifically for treatment of endometriosis. It is a synthetic hormone and there is nothing natural about this treatment option. It is a cross between progesterone and testosterone. If a woman with endometriosis has severe pain around the time of her period and only minimal pain during the rest of the month, then stopping her period can be a very effective treatment option. Unfortunately a significant percentage of women will continue to have a period even when taking the birth control pill continuously (skipping the “sugar pills” and taking the hormones pills without a break). Danocrine can be an effective treatment option, as it usually will stop a woman’s period while taking this medication. This treatment option also has several potential significant drawbacks including the possibility of acne, oily skin, extra hair growth and deepening voice. These are uncommon and the medication can be stopped immediately if any of these are noticed. This medication has to be taken two to three times a day, which can be both an advantage and disadvantage. In the case of significant side effects, danazol is rapidly excreted from the body, enabling rapid alleviation of side-effects following discontinuation. Consistently taking any medication three times a day is certainly a disadvantage and challenging.

GnRH (Lupron, Synarel) Treatment Option

Patients with severe endometriosis pain are often offered the treatment options by their OBGYNs: Lupron, coagulation of endometriosis at surgery or hysterectomy (with or without removal of the ovaries). Lupron is one medication in a class of drugs known as GnRH agonists. GnRH stands for Gonadotropin Releasing Hormone. Agonist means the medication activates the same cellular receptors as the natural hormone. Gonadotropin Releasing Hormone is normally released by a part of the brain called the hypothalamus. It is released in little boluses at a specific interval. This in turn stimulates the pituitary gland at the base of the brain to release FSH (follicle stimulating hormone) into the blood stream, which stimulates the ovaries to both mature an egg and produce estrogen. A GnRH agonist temporarily shuts down the ovaries’ production of estrogen. At first it might seem counter-intuitive that giving a medication that does the same thing as the natural hormone can have the very opposite effect. The GnRH agonist, however, is released continuously, not episodically like the natural hormone. Continuous stimulation of the hypothalamus by the GnRH agonist shuts down the release of FSH and thus the ovaries. As soon as the Lupron wears off the episodic release of Gonadotropin Releasing Hormone resumes, as do ovulation and the ovarian production of estrogen.

Estrogen stimulates the growth of endometriosis. Since Lupron stops the ovaries from producing estrogen, this medical therapy results in a temporary medical menopause creating a low estrogen environment in the body. Without estrogen from the ovaries it was thought endometriosis would be inactivated. Even under the best circumstances the pain relief provided by this treatment is temporary. There are, however, several significant problems with the use of GnRH agonists for endometriosis treatment. First, it may not work. Endometriosis can produce its own estrogen and in these cases Lupron will not suppress the endometriosis activity or pain. In more advanced cases of endometriosis, even if the Lupron suppresses the endometrial implant activity, it does nothing for the pain caused by scaring and fibrosis resulting from the invasive endometriosis.

The side effects with GnRH endometriosis treatment can be severe. Some of the more common side effects include, hot flashes, night sweats, moodiness and irritability, nausea, insomnia, and possibly mental fog to name a few. One also has to be concerned about risk of bone loss and this is the reason this drug is only approved for 6 months of use. There may be indications for prolonged use, but add back therapy and bone density surveillance are usually part of the treatment protocol.

The standard approach by the vast majority of doctors is to start a patient on this treatment with a long acting form of GnRH agonist such as Depo Lupron, which lasts one to three months depending on the dose given.

It just does not make sense to me to start a long acting form of a treatment that offers no chance of a cure, but rather just helps relieve symptoms temporarily and has a fairly high chance of severe unacceptable side effects. Why not start out with a short acting GnRH agonist such as Synarel? This is a nose spray that is given twice a day. If this is a good option for endometriosis treatment with minimal side effects for any given individual, then she can switch over to a long acting form such as the one or three month Depo Lupron shot. If the patient has significant side effects, the nose spray can be stopped and the effects of the drug will wear off fairly quickly.

I think part of the frustration with many patients who have had a bad experience with Lupron are related to the prolonged time for the side effects to wear off. The other complaint I hear a lot is that of patients feeling mislead by their doctors telling them it would help their pain without any significant side effects.

Aromatase Enzyme Inhibitors (Letrazol, Femara, Arimidex) Treatment Option

Aromatase enzyme converts a precursor hormone to estrogen. Blocking aromatase enzyme prevents estrogen production anywhere in the body, potentially including the endometriosis implant itself. Examples of Aromatase Enzyme Inhibitors include Letrazol, Femara and Arimidex. Unfortunately this group of medications as a treatment option for endometriosis does not provide a cure, if effective is temporary, can have the same severe side effects including significant bone loss experienced with GnRH agonists (Lupron) and does not successfully treat all endometriosis related pain.

The post Dr. Cook’s Guide to Hormone Therapy Treatments for Patients with Pelvic Pain appeared first on Vital Health Endometriosis Center.

What does Aromatase have to do with my Endometriosis?

Dr. Cook — Wed, 25 Jul 2012 14:14:35 +0000

Aromatase is an enzyme that is responsible for the production of estrogen. Although estrogen is important for our health, too much estrogen and poor elimination of old estrogen can lead to high levels of estrogen. There is strong evidence that estrogen stimulates the growth of endo, and studies have shown that aromatase inhibitors can help to reduce endo symptoms. Like all drugs and medications, there can be side effects. The good news is, you can eat foods that will help reduce aromatase activity as well as foods that will aid in metabolism of old estrogen. You can also make lifestyle changes to improve your aromatase production.

Lifestyle

Lose weight if you are overweight, especially in your mid-section. The fat around your waist, visceral adipose tissue (VAT), produces aromatase.
Address hyperinsulinemia. Insulin stimulates aromatase.
Decrease inflammation. Inflammation stimulates aromatase.
Reduce stress. Chronic stress elevates cortisol, which leads to inflammation, which stimulates aromatase.
Do daily exercise.

Diet

Natural aromatase inhibitors include chrysin, naringenin, apigenin, and genistein. Include foods such as dietary fiber, lignins from flax seed, genistein and daidzein from soy (non-GMO), resveratrol as a supplement or found in red wine (particularly French Cabernet and CA Pinot Noir), grape seed extract (proanthocyanidins), white button mushrooms, brassaiopsis glomerulata, and green tea.
Foods which increase the metabolism of old estrogen include cruciferous vegetables (kale, broccoli, cabbage, onions, garlic, radishes, cauliflower, and collard greens). Aim to eat 3 servings daily raw and cooked.
Strong anti-inflammatory foods include ginger, curcummin, and cinnamon.

For more information please call our office for an appointment.

To your health,
Vital Health Endometriosis Center

The post What does Aromatase have to do with my Endometriosis? appeared first on Vital Health Endometriosis Center.