Officially, endometriosis affects up to 10% of all women, but this figure may be too conservative. Despite its wide prevalence, it is also widely undiagnosed, with many unaware of what the condition involves, and hence not seeking help.

Aware of the debilitating effects that this condition has on so many women, Dreaming of Baby enlisted the professional help of Dr Abhishek Mangeshikar, Gynecological Endoscopist and Robotic Surgeon. Dr Mangeshikar’s hospital specializes in laparoscopic procedures for gynecological conditions, with a special focus on endometriosis. Charles and Daniela from Dreaming of Baby speak to Dr Mangeshikar on the symptoms, causes, and treatment of this condition, as well as how it affects fertility.

Charles: Hello and welcome Dr Abishek Mangeshikar. I would like to start by getting an understanding as to what endometriosis is exactly? Can you explain the condition to us?

Dr Abhishek Mangeshikar: The endometrium is the lining of the uterus which is shed off every month when a woman gets her period. The condition arises when these endometriotic cells are found elsewhere within the body, typically surrounding the uterus, and the tubes and ovaries, but it may also spread to distant sites like the appendix, rectum, bladder, etc. When this occurs, due to the influence of monthly hormones, they produce blood and inflammation and cause pain and adhesion formation around themselves. Endometriosis is a pet passion of mine because it goes largely undiagnosed due to lack of awareness and patient education.

Symptoms of Endometriosis

Charles: What are the main symptoms to look out for?

Dr. Abhishek Mangeshikar: Endometriosis affects women from ages 14 to 50, which goes to show it affects women in the menstruating age group. The symptoms vary widely. Most women experience this condition as dysmenorrhoea, or pain during their periods, which their mothers tell them to grin and bear and that once they have babies everything will be fine. The symptoms depend on the site of the disease. If the ovaries or tubes are affected it will cause infertility; if the rectum is affected there may be constipation, or if the bladder is affected there may be pain during urination. Another common complaint is painful intercourse which may inadvertently be another reason for decreased fertility.

Charles: You did mention above that it frequently goes undiagnosed, is this a hard condition to diagnose? What would the process to a diagnosis look like? To better clarify my question; from an individual entering a clinic with a particular complaint to end diagnosis what normally happens and how can potential patients help increase the likelihood of a correct diagnosis?

Dr. Abhishek Mangeshikar: The absolute diagnosis is given through a laparoscopy, but that is the treatment stage. There are no specific tests to ascertain whether a woman has endometriosis. Listening to the patient’s complaints and history gives me a good idea that it might be endometriosis. This may be corroborated by a pelvic exam. I prefer to do my own pelvic ultrasounds because I believe that only gynaecologists can see the subtle signs of endometriosis. Sometimes a CA125 may be ordered and the levels may be indicative of endometriosis. If we suspect Deep Infiltrating Endometriosis we may order an MRI but that is not a routine part of the workup. The gold standard where I can evaluate the extent of the disease and what needs to be done is by laparoscopy. There is no role for open surgery or ultrasound guided drainage in the treatment of endometriosis.

The symptoms of endometriosis vary widely. Most women experience this condition as pain during periods, constipation, pain during urination, painful intercourse, or even infertility.

Charles: Are there any other conditions with similar symptoms that are ruled out prior to proceeding with a laparoscopy? Generally speaking, once a medical professional such as yourself arrives at the stage of recommending a laparoscopy how likely is it that it is Endometriosis?

Dr. Abhishek Mangeshikar: The tests we do are basically to rule out other conditions, the ultrasound will rule out most other conditions, like fibroids and pelvic inflammatory disease. Depending on the symptoms we rule out every other differential but the general rule of thumb after evaluating the patient is “endometriosis until proven otherwise”. Once we decide upon a laparoscopy it is more or less always endometriosis. The findings vary from big endometriomas to frozen pelvises to very subtle cystic endometriosis but it’s always there.

How Does Endometriosis Affect Fertility?

Charles: How common is endometriosis and how does it impact fertility?

Dr. Abhishek Mangeshikar: It’s probably a lot more common than the numbers say (although those are quite high) but a large number of cases go unreported. With regards to how it affects fertility, endometriosis as a disease loves the ovaries and the tubes so it goes and sits on one ovary and grows inwards producing a chocolate cyst or endometrioma which impairs the ability of the ovary to produce eggs. It affects the tubes by distorting the anatomy by producing strictures and inflammatory changes which do not allow fertilization between the egg and the sperm to occur. And finally, as I have already mentioned, it may cause severe pain during intercourse and subsequently the woman may not be inclined to even try.

‘Endometriosis as a disease loves the ovaries and the tubes so it goes and sits on one ovary and grows inwards producing a chocolate cyst or endometrioma which impairs the ability of the ovary to produce eggs.’

Charles: How is endometriosis generally treated?

Dr. Abhishek Mangeshikar: There’s pain medication, surgery and hormone therapy. Pain medication is not going to treat the disease but it may treat the symptoms temporarily. These vary from over the counter painkillers to opioid derivatives. Laparoscopy, in my opinion is the gold standard of treatment. It is a one stop diagnose and treat. Of course, you have to tailor the radicality of the surgery to what the patient’s symptoms are. One cannot do ultra-radical surgery on a woman whose complaint is only infertility. Success of the surgery depends on the skill of the surgeon. Infertility specialists will just drain the chocolate cyst and not remove it so that they can reach the eggs and go for IVF. But those cysts will recur in a few months. And finally, hormonal therapy may be given after surgery if a woman is not planning to get pregnant soon as it takes care of the microscopic residual disease. But it should be used with caution as it creates a state of pseudo menopause and may lead to osteoporosis.

Charles: Our writer and interviewer Daniela has been following the interview and has some questions she would like to ask, can we trouble you for a few more minutes of your time? This discussion has been enlightening and I believe our readers will value this important information.

Laparoscopy for the Treatment of Endometriosis

Dr Abhishek Mangeshikar: Good afternoon Dr Mangeshikar, a pleasure to be discussing this very important subject with you. You mentioned that a laparoscopy is the gold standard of treatment. Once this is done, is the issue solved permanently?

Dr. Abhishek Mangeshikar: Hi Daniela, it’s my pleasure to add what I can. That’s an interesting question. In many cases the issue may be resolved completely but in a few there may be microscopic lesions which even the laparoscope will not be able to see and those may grow at a later date. Also, surgeon experience and skill has a lot to do with the results. It’s very similar to cancer surgery, actually more difficult. So the better clearance of disease the surgeon can get the lesser chances of recurrence. Unlike cancer it’s not life or death so you have to stemper your surgical aggression and treat the patient not just the disease.

Daniela: Interesting to know. And what is the usual recovery period like following a laparoscopy? Does it involve considerable down time?

Dr. Abhishek Mangeshikar: My patients go home in the evening of their surgical day or the next morning depending on how quickly their anaesthesia wears off. They are advised to rest at home for a couple of days and can go back to work within 5 days.

Hormonal Therapy for Managing Endometriosis

Daniela: You also mentioned hormonal therapy as an option for treating endometriosis. In simpler terms, does this mean that the pill is prescribed?

Dr. Abhishek Mangeshikar: The pill is one of the options but may not be the most effective. The others are what we call GnRH agonists which create a state of pseudomenopause and inhibit FSH and LH secretion which prevents the woman from getting her period. Also, since endometriosis is estrogen dependent for its growth, the lack of FSH and LH prevents the growth of the disease. GnRH agonists can be given for 1 or 3 months but if they are used for a longer time they may cause osteoporosis. Also, other drugs like Letrozole or Anastrazole are available which can be used but they cause increased testosterone which is understandably not acceptable to many women. We have been having success with progestogins especially in younger adolescents where extensive surgery may harm future reproductive potential.

Daniela: So it’s quite far from the general assertion that the pill is provided. Once the treatment you described is prescribed, are women and teenagers faced with a life of taking this medication? And what would be the general side effects, especially amongst younger women and adolescents? Does it decrease libido?

‘Medication does not cure endometriosis, it suppresses it.’

Dr. Abhishek Mangeshikar: Are you talking about just progestogins or all hormonal treatments?

Daniela: Progestogins, especially.

Dr. Abhishek Mangeshikar: So, like I said I am not a big fan of medication because they have to take it for a long time and it doesn’t cure the disease, it suppresses it which means once they stop the medication it starts growing again. For young women, they can take the medication for some time or can be put on the pill until they are ready to conceive. Progestogins may decrease libido but I haven’t had any of my patients tell me that although it does say that in the literature.

A good laparoscopic clearance of endometriosis allows women to get pregnant naturally.

Daniela: That’s very informative. I assume then, that whilst on hormonal therapy, women cannot get pregnant. What is the process for achieving pregnancy in such a case?

Dr. Abhishek Mangeshikar: Women cannot get pregnant on hormonal therapy. They have to stop the medication till their cycle becomes regular again and then they can try to conceive. Usually, a good laparoscopic clearance of the disease allows women to get pregnant naturally. Of course, there are a few cases where endometriosis and PCOD often coexist or if she has poor ovarian reserve where assisted reproductive techniques may be especially beneficial.

Daniela: And what kind of assisted reproductive techniques would be used in such cases?

Dr. Abhishek Mangeshikar: Anything from IVF to Donor Oocytes to surrogacy. It depends on the condition.

Does Pregnancy Affect Endometriosis?

Daniela: You mentioned earlier that many women are told to simply grin and bear the pain of endometriosis, and that once pregnancy occurs, everything would be fine. Is this simply an old wives’ tale, or it holds true, scientifically? How does pregnancy affect endometriosis?

Dr. Abhishek Mangeshikar: Well, women don’t get their period for the 9 months of pregnancy and while they are breast feeding so they have no pain then. Once their cycles start again the disease comes back. Yes, it’s an old wives tale mired with a small amount of truth. That’s why I believe patient education, especially for young girls, is the most important. No woman should ever have a painful period.

Daniela: I agree with that perfectly. Going through all that pain is no easy feat. Once pregnancy occurs in a patient with endometriosis and who was also experiencing fertility issues, would a second pregnancy be more straightforward? That is, can a pregnancy be planned back to back, before endometriosis rears its head again, or assisted reproductive techniques must be used again?

Dr. Abhishek Mangeshikar: The old wives’ tale in perpetuation would be to go forth and reproduce, till the family is complete. If the first pregnancy happened through natural conception, then there’s no reason that the second one should not. But if the first one was through an IVF cycle then the couple may want to consult their doctor and make a decision on whether to go through another IVF cycle or any other technique. It actually boils down to what the other factors are for the infertility.

Daniela: I would really like to thank you for sharing this information with us. In consideration of all that we have discussed today, is there any message or information you would like to ensure potential sufferers of endometriosis are aware of? Also, is there anything one can do to reduce the likelihood of endometriosis?

Dr. Abhishek Mangeshikar: Thank you for having me. It was my pleasure to give some advice about this subject. No woman should ever have a painful period. Endometriosis surgery affects a wide range of women in varying degrees of severity. There are many support groups and online forums for women who are suffering. Choosing the right gynecologist is key, as endometriosis surgery is the most difficult and complex gynecological surgery to perform. You should choose a doctor who is an experienced trained laparoscopic surgeon and preferably a centre that specializes in endometriosis, with a multi-specialty team on standby in case there may be bowel bladder or ureteric involvement. Unfortunately, there is nothing anyone can do to reduce the likelihood of whether they get endometriosis or not. Basically, all the 10 foods or 10 tips that prevent endometriosis, which you can find on many “wellness sites” are a sham. Steer Clear!

Daniela: The insight you have shared with us today will be most valuable to our readers. Endometriosis affects many; and as you rightly state, no woman should experience painful periods. Being informed remains key. Thanks again for joining us today!

Get in touch with Dr Abhishek Mangeshikar at https://www.facebook.com/mmagichosp/

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