By Iris Kerin Orbuch, MD

 

Did you know that Gastrointestinal (GI) symptoms are as common as gynecological symptoms in women with endometriosis? Do you suffer from bloating and/or constipation? Endometriosis may be the cause of your bloating and/or constipation. Over 90% of women diagnosed with endometriosis actually present with GI symptoms as their initial symptoms. Before we delve into why women with endometriosis present with GI symptoms years before they are diagnosed with Endometriosis, let’s review some basic facts about Endometriosis. There is so much misinformation about endometriosis in media, so let’s set the record straight with facts about endometriosis.

 

What is Endometriosis?

 

Endometriosis is an inflammatory condition which occurs when cells similar to those found in the lining of the uterus (endometrium) are found external to the uterus. More specifically, it occurs when cells similar to endometrial glands and stroma are found in locations other than the lining of the uterus.  

 

How many women are affected by Endometriosis?

 

Endometriosis is common affecting 176 million women worldwide. It occurs in 7-15% of women.   

 

What are symptoms of Endometriosis?
The symptoms of endometriosis vary and can include all of the listed symptoms below, some of the symptoms, only one symptom in some cases, or no symptoms other than infertility.

 

• Pelvic pain during menses, before menses, after menses and/or anytime during the month
• Constipation
• Bloating
• Painful intercourse with deep insertion or certain positions
• Right and/or Left sided pelvic and abdominal pain
• Diarrhea
• Painful bowel movements
• Lower back pain
• Heavy or irregular periods
• Urinary frequency, and/or urgency, and/or painful urination
• Fatigue
• Malaise
• Infertility

 

Symptoms of Endometriosis

 

The symptoms of endometriosis can be related to the areas where endometriosis invades. Endometriosis of the uterosacral ligaments/cul-de-sac often leads to painful intercourse, constipation, diarrhea and painful defecation. Endometriosis on the ovary can lead to left sided or right sided pain. Bladder endometriosis may lead to urinary frequency or urgency. You may have only one of the above symptoms or many. Even one symptom can be suggestive of Endometriosis. Many of women do not have any symptoms listed above, and only discover they have endometriosis when they are having trouble conceiving.  If your doctor told you that you have ‘unexplained infertility’, endometriosis is the culprit in 40-50% of cases of unexplained infertility. Dr. Orbuchs’ surgical Excision of endometriosis decreases inflammation and can improve fertility.

 

Where is Endometriosis found?
Endometriosis has been reported in every organ except the Spleen! More commonly, endometriosis is found on the ovaries, bowels, bladder, uterus, cul de sac (the area in front of the rectum and behind the cervix/vagina and uterus), appendix, and abdominal wall. It also can occur on the diaphragm, lungs, surgical scars and less commonly throughout the rest of the body.

 

Treatment of Endometriosis

 

Laparoscopic surgery is the definitive method to diagnose and treat endometriosis. Excision of Endometriosis is the gold standard treatment for endometriosis. Ideally all endometrial lesions should be excised. Unfortunately most gynecologists are not trained in these advanced surgical techniques for treatment of endometriosis. Others approach endometriosis with laser, electrocautery, coagulation or burning. All of these modalities have been shown to be far inferior to excision using scissors, the method performed by Dr. Orbuch. With scissors, the endometrial implants are removed, but with cautery or a laser (the unskilled surgeons only superficially treat lesions), the lesion remains and continue to cause pain necessitating more surgery. A surgeon utilizing laser may vaporize the surface of the lesion, but still leaves active endometrial tissue below. Deep fibrotic endometriosis usually does not respond well to hormonal suppressive therapy.  Drug therapy may suppress symptoms of endometriosis, but not eradicate the endometriosis.  Adequate surgical excision of endometriosis implants provides the best symptomatic relief and long term results. In addition, surgical excision has been shown to improve fertility rates in women. The definitive treatment of endometriosis is NOT hysterectomy or removal of both ovaries; rather it is the complete excision of endometriosis lesions.

 

da Vinci Excision of Endometriosis

 

Advantages of Robotic Surgery

 

Robotic Surgery is an advanced form of Minimally Invasive Surgery. Minimally Invasive Surgery, which includes laparoscopic surgery, uses small incisions instead of large incisions to perform surgery thus reducing the damage to human tissue. The da Vinci System is a sophisticated robotic platform designed to expand a surgeons capabilities. With da Vinci, small incisions are used to introduce miniaturized wristed instruments and a high-definition 3D camera. This allows Dr. Orbuch to view a magnified, high-resolution 3D image of the surgical site allowing for superior visual clarity of anatomy with up to 10x magnification. At the same time, state of the art robotic and computer technology converts Dr. Orbuchs’ hand movements into precise small movements resulting in extreme dexterity. The robotic ‘wrists’ rotate a full 360 degrees that enable Dr. Orbuch to control the miniature surgical instruments with unprecedented accuracy with a wide range of motion. These technological advancements allow Dr. Orbuch to perform complex surgery with precision, dexterity and control. The da Vinci System enables Dr. Orbuch to perform more precise, advanced techniques and enhances her capability to perform complex minimally invasive surgery.

 

Risk Factors for Endometriosis
It is important to note that while the following risk factors increase one’s likelihood for endometriosis, there are many women who develop endometriosis without any of the following risk factors:

 

• Family history, especially mother or sister. If your mom has endometriosis, you have a 7 times higher risk of developing endometriosis
• Early menses
• Early onset painful periods
• Short frequent menstrual cycles
• Mullerian abnormalities
• No children
• Autoimmune disorders (thyroid, rheumatoid, eczema, food allergies/sensitivities)

 

Endometriosis and GI Symptoms

Bloating is the most common presenting symptom, and is typically reported by 83% of women with endometriosis¹. In addition to bloating, other gastrointestinal symptoms including diarrhea, constipation, painful bowel movements, nausea and/or vomiting are also common symptoms in women with endometriosis. It is also interesting to note that GI symptoms are independent of location of endometriosis lesions in relation to the bowel.  This means that you can have GI symptoms without endometriosis actually infiltrating into the bowel. Your endometriosis lesion may be nearby to your bowel without actually being on it². It is nonetheless important to remember that for some women, endometriosis can often infiltrate the bowel, distort intestinal anatomy, alter normal bowel physiology, which then can also lead to constipation, bloating, painful bowel movements, diarrhea, nausea and vomiting.

 

Complicating matters, endometriosis can also present primarily with cyclical bloating and altered bowel habits indistinguishable from Irritable Bowel Syndrome (IBS)³. Many women seek help from a gastroenterologist and are subsequently diagnosed with Irritable Bowel Syndrome long before they seek help from a gynecologist. Here’s a typical and unfortunate scenario…a young woman suffers from constipation and bloating. What does she do? She schedules an appointment with a gastroenterologist. What happens? She undergoes an upper endoscopy and colonoscopy, both of which find no identifiable gastrointestinal abnormalities and is subsequently labeled as suffering from Irritable Bowel Syndrome (IBS).  Has this happened to you? Despite treatments from their GI for IBS, women rarely get better—that’s because endometriosis is the cause of their IBS symptoms. It is therefore critical to establish the diagnosis of endometriosis in order to effectively relieve the gastrointestinal symptoms.
Endometriosis must always be considered in the differential diagnosis of women with GI symptoms. Make sure that your endometriosis is treated properly–see my websites for more information: www.LAGynDr.com or www.nygyn.com or www.nycrobotic.com.

 

About The Author

 

Dr. Iris Orbuch is the Director of the Advanced Gynecologic Laparoscopy Center in Los Angeles and New York City. Dr. Iris Orbuchs’ practice is limited to Laparoscopic and Robotic Gynecologic Surgery, and is primarily a referral practice.

 

Her training, under the guidance of Dr. C.Y. Liu and Dr. Harry Reich — both pioneers in the field of advanced laparoscopic surgery — allows Dr. Orbuch to be one of a handful of physicians across the country trained to perform advanced minimally invasive procedures.

 

Dr. Orbuch provides both compassionate and individualized care while performing advanced laparoscopic techniques at St. Johns Hospital in Santa Monica, California. Dr Orbuch also operates at Lenox Hill Hospital, Mount Sinai and Beth Israel Hospital in New York City. Dr. Orbuch is board certified in OB/GYN.

 

Dr. Orbuch offers Gentle, Compassionate Care and a Personal Touch.

 

When you visit her office, you won’t find a rushed, impersonal environment. Instead, Dr. Orbuch and her staff are committed to providing personal, compassionate services to each and every client. Dr. Orbuch is devoted to helping women live a productive and pain-free life.

 

Dr. Orbuch specializes in pelvic pain and endometriosis. She understands that endometriosis is a major reason women experience pain, though she strives to assess for all additional co-existing generators of pain in order to help women live pain free productive lives.

 

Dr. Orbuch is a fellowship trained Endometriosis Excision Surgeon. She sees the value in addressing Endometriosis, an inflammatory and autoimmune disease, via eastern and western approaches. The cornerstone of endometriosis treatment is surgical excision of endometriosis, though she understands the importance of incorporating integrative medicine and combining eastern & western medicine approaches in helping her patients heal and getting them on the road to recovery.

 

 

References:

 

1. Maroun P, Cooper MJW, Reid GD, Keirse MJNC. Relevance of Gastrointestinal Symptoms in Endometriosis.  Australian and New Zealand Journal of Obstetrics and Gynecology 2009; 49: 411-414
2. Malin E, Roth B, Ekstrom P. Gastrointestinal symptoms among endometriosis – A case cohort study.  BMC
3. Women’s Health (2015)

By Melinda Fontaine

 

Mary is an amazing story because in a matter of months, she went from not having any penetrative sex for many years to having unrestricted intercourse with her partner. When Mary was a young woman, she saw a gynecologist for a routine exam. Now, lying on the exam table with your butt almost falling off the edge, your feet in stirrups, and a physician coming at you with a cold hard speculum is enough to make anyone anxious and uncomfortable. On top of that, when the physician had difficulty inserting the speculum causing lots of pain, he rudely blamed Mary for being a prude. He exclaimed “You are the kind of girl who will make a cold wife”. Can you believe that?! This extremely rude and sexist doctor missed the perfect opportunity to educate her on the pelvic floor muscles and how increased tension can lead to difficulty with speculum exams and penetration. I wish this weren’t a common complaint that I hear. Not many doctors are as rude, but with our fast-paced health care system, the education is often missed. He screwed up, so Mary walked out of the office feeling very bad and not understanding what was going on with her body. Her future pelvic exams were all variations on this theme.

 

Mary became very successful in life and met and married a lovely man named Alan. She had a rousing sex life consisting of outercourse and clitoral stimulation which she really enjoyed. She developed a great relationship with her clitoris, could have orgasms, and was fully satisfied through their many years of marriage. She never attempted vaginal intercourse, in fact she never realized that intercourse was a possibility. Her husband had “found the door locked” and did not talk to her about it or try again.  It also never occurred to her to examine her own vagina and figure out what it what…until she met Patrick. Patrick was her new lover and a very passionate and patient man. They shared a love of poetry and music, and their relationship grew more intimate. Good fortune shone upon them because Patrick happened to be an obstetrics and gynecology nurse in his prior career.  He taught Mary that sex could involve vaginal penetration. Even before they attempted intercourse, he knew that Mary should seek help.

Mary went to see a gynecologist with a lot of experience and a friendly demeanor. This practitioner was the exact opposite of the first gynecologist Mary met many years ago. She taught Mary how to find her vaginal opening behind the set of double doors (labia majora and labia minora). The doctor taught her how the muscles around the opening of her vagina were so tight for so long, that they effectively pinched the opening closed. The good news is these changes were reversible.  She recommended that Mary buy a book about vaginismus and a set of dilators, and go see a pelvic physical and occupational therapists. Check out Malinda’s blog for more on vaginismus.

 

When Mary first came to see me, she was 64 years old with 2 goals:

 

• pain free vaginal intercourse
• pain free pelvic exams

 

She had read the book on vaginismus and began the self-help program. She began with inserting a Q-tip in the vagina and was surprised when she saw the tip disappear inside her, and with no discomfort. She then repeated the process with the smallest dilator and the next two sizes after that. The book also told her to do Kegel exercises.  When she began PT, I told her to stop the exercises because they were actually making her muscles tighter.  For more information, see Why Kegels are bad for your tight pelvic floor.

 

I like to do a guided anatomy tour of the vulva using a handheld mirror for all my female patients, but I felt it was an extremely appropriate review in this case because part of achieving her goal was going to be becoming comfortable and familiar with her body. During the visual inspection, I mentioned that the color of the tissue in the vestibule (the area between the labia minora) was pale, almost white. It is typically a nice pink like the inside of your cheek. This pale color commonly happens when the estrogen level in the vulva is low, as happens after menopause or in young women who use birth control pills; see Dr. Gonzalez’s blog. This can also cause the tissue to become fragile, tender, dry, and stiff. Luckily, Mary’s gynecologist had noticed this as well and had prescribed her a topical estrogen cream which she had used a few times. I encouraged her to use it consistently as prescribed because it would help make for a resilient, comfortable, and flexible vagina, very useful for intercourse.

 

I also examined the muscles of her pelvic floor internally. I found that they were very tight, even when she was not actively squeezing them. The muscles were probably squeezing all the time without her realizing it, making it very hard to insert anything in the vagina: a penis, a finger, a speculum. Over a series of visits, I could make the muscles release with massage, verbal cues to let go of the tension, and guided meditation.

 

But what caused the tension in the first place, and how can we keep it from happening again?  Many different things can cause muscles to tense up and try to protect themselves.  It is usually something that the muscles perceive as dangerous, such as an infection or trauma, but sometimes it is not so clear.  Some people carry their stress, fear, and anxiety in their muscles. You may  be familiar with the phenomenon of people having tight shoulders when they are stressed out; the same thing can happen in the pelvis. Her muscles were short and tight and full of knots (trigger points). They may have been clenching for a large part of her life without her knowing. We found that any stress causes her pelvic floor to tighten up more. For example, we landed on the subject of politics during one treatment and her pelvic floor tension was through the roof! Luckily, she now knows how to reverse that, and bring her muscles back to baseline. Her history of painful pelvic exams and inability to tolerate penetration was a result of those tight pelvic floor muscles, and now she finally had an explanation for what she experienced.  Mary is not alone; check out this short film about tight pelvic floor muscles, Tightly Wound.

 

To coax these muscles out of their holding pattern, we did internal myofascial release in the office,  a dilator home program, partner education, and a lot of encouragement. After 4 months, she was able to comfortably use the largest dilator and tolerated vaginal penetration by her partner’s two fingers. After 9 months, she could tolerate vaginal penetration by her partner’s penis. With physical and occupational therapy to stretch the tissues, estrogen cream to improve the quality of the tissue, and lots of practice, Mary is now able to have comfortable penetrative sex with her partner, a HUGE difference from where she started months ago.
I asked Mary for a comment for this blog post and she said “It was hard for me to believe that, after all this time, I would actually be able to have penetrative sex, but you always encouraged me to believe that this was the case.  When one is starting with a Q-tip (and at a late age), it is really important to have a conviction that one’s goal is truly achievable.” Mary is a great example for all the other women out there in similar situations.

 

By Stephanie Prendergast, Cofounder, PHRC Los Angeles

 

Severe menstrual pain is not normal. If you experience severe pain during your period it is possible you are suffering from an underdiagnosed disease called Endometriosis.

 

Endometrial tissue lines the uterus. In response to hormonal influences, the endometrium of a healthy uterus thickens and then sheds through the cervix, through the vagina and out of your body. This is your normal period and it should not hurt!

 

When endometrial tissue implants outside of the uterus, it also thickens and needs to shed, but there is no outlet. These implants can adhere to other organs such as the bowel and bladder; they can cause cyclical urinary and bowel dysfunction, severe pain, pain with intercourse, bloating, and nausea.  One in ten women have endometriosis; it is the leading cause of pain in women, and it is responsible for more than half of all female infertility.

 

What makes matters worse is that it takes women an average of 11.4 years in the United States to get diagnosed. This is not acceptable. March is Endometriosis Awareness Month and we here at PHRC want to help raise awareness about this disease and the role physical and occupational therapy can play in treatment.  Many people do not realize that pelvic floor dysfunction and other musculoskeletal impairments are common in women with endometriosis and can be causing some of their symptoms. Pelvic floor physical and occupational therapy can help.

 

While diagnosing and treating endometriosis has been a challenge, the treatment landscape is improving for women. In this post we will examine some of the current management controversies and discuss the range of available treatment options.

 

PROBLEM: Endometriosis is hard to diagnose.

 

1. Currently endometriosis cannot be detected through diagnostic tests such as ultrasound, MRIs, blood work, or physical examination. However, MRI technology is improving and with further studies specific MRI scans may be useful diagnostic tools.
2. The symptoms of endometriosis mimic other syndromes and women with endometriosis often also have comorbid conditions, such as Irritable Bowel Syndrome, Interstitial Cystitis, Vulvodynia, and pelvic floor disorders, leading to further diagnostic confusion.
3. The diagnosis is only truly confirmed from surgical extraction and (+) histological findings.
4. Not enough physicians are adequately trained to surgically diagnosis and treat endometriosis.

 

Generally speaking, people prefer conservative therapies over surgical options. People rarely rush to the operating room to get relief from back pain, knee issues, etc., and they do not want to rush to the operating room for endometriosis treatment either. As a result, women are often treated with medications empirically without diagnostic confirmation. These treatments can be effective for some people but they can also have significant physiological consequences.
THE PROBLEMS: Oral Contraceptive Pills and Progesterone Treatments

 

1. These medications do not cure the disease; they work by suppressing menstruation and therefore also the painful endometrial implants.
2. This may act as a temporary ‘band-aid’ in some cases but can also be less effective in others based on the severity of the disease.
3. The majority of women have their symptoms return when they stop taking the medication.
4. Oral contraceptives may lead to the development of vulvar pain in certain women, adding a second pain condition into the picture.
5. Oral contraceptives have a negative effect on libido and can be associated with mood disorders, both of which have a significant impact on a woman’s quality of life.

 

THE PROBLEMS: Intrauterine Devices (IUDs)

 

1. The insertion of a small device into the uterus can also help the symptoms by suppressing menstruation. However, the insertion process and adjustment to the IUD can be more painful in women who have not yet had children.
2. Certain women experience significant ongoing side effects such as headaches and nausea from the hormones.
3. The IUDs are possibly uncomfortable for several months as the body gets use to it.

 

THE PROBLEMS: Gonadotropin-Releasing Analogs Treatments

 

1. These medications stop the production of estrogen which in turn ‘starves’ the endometrial implants.
2. This also ‘starves’ other tissues of the estrogen they need, such as the vulva and peri-urethral tissues, which can lead to vulvar pain and urinary urgency and frequency.
3. Estrogen is necessary for health bone density and these medications therefore have side effects of bone density loss.
4. Endometriosis symptoms can begin when a woman first gets her period. The average age of menarche in the United States is 13. These medications create ‘chemical menopause’ in the bodies of teenagers and the end result can be teenage women with osteoporosis.
5. The symptoms return when the medication is stopped in most woman and may not be completely controlled while on this medication.

 

THE PROBLEM: Hysterectomy or Pregnancy

 

1. The glaring problem with the hysterectomy suggestion is many of the women who need help are in their childbearing years and have not yet had children.
2. Due to a lack of comprehensive interdisciplinary care, young women are often told a having a baby may be their solution if they do not want a hysterectomy. This information is understandably shocking to teenage women with endometriosis and their families.

 

THE SOLUTIONS: Differential Diagnosis and Interdisciplinary Treatment Options

 

In the last decade there has been an exponential increase in the amount of evidence-based information on pelvic pain, including endometriosis. We know that endometriosis itself can be a source of pain. We also know endometriosis is associated with other treatable pelvic pain syndromes and impairments, such as Interstitial Cystitis, Vulvodynia, and Pelvic Floor Dysfunction. The key to successful treatment is to identify which impairments are causing the most bothersome symptoms and start to treat them with the appropriate therapies. This needs to be individualized per patient, each woman with endometriosis will present with different sources of pain despite having the same disease.

 

Last year I was able to participate in an educational program for women called Tendo, aka known as Ten Days Of Endometriosis, organized by Heba Shaheed of The Pelvic Expert. Heba organized 20 experts from around the world to participate in a series of video lectures on Endometriosis management. There is no charge for this program, you can access all of the lectures here.
During my lecture, I discuss the following therapeutic options. We recognize that many of these treatment may be new options for suffering women, giving them the opportunity to explore conservative therapies that may dramatically improve their quality of life.

 

1. Physical and Occupational Therapy
   1. pain physiology education
   2. manual therapy
   3. case management
   4. restore function
   5. temporary lifestyle modifications
   6. Home Exercise Programs: therapeutic and general fitness
   7. dry needling
2. Behavior Health Strategies
   1. Cognitive Behavioral Therapy
   2. mindfulness training
   3. sex therapy
   4. hypnosis
   5. pain psychology education
3. Integrative Medicine Strategies
   1. yoga
   2. acupuncture
   3. nutrition/diet modifications
   4. rolfing/massage/bodywork
4. Pharmacologic Options
   1. Simple analgesics
   2. Neuropathic analgesics
   3. NMDA antagonists
   4. Cannabis
   5. Antidepressants/antianxiety
   6. Benzodiazepines
5. Female Pelvic Pain: Hormonal
   1. topical estradiol/testosterone
   2. systemic hormonal therapy
6. Interventional Pain Management
   1. Trigger Point Injections
   2. Peripheral Nerve Blocks
   3. Ganglion Impar Blocks
   4. Caudal Epidural
   5. Pulsed RF/ Ablation/ Cryoablation
   6. Botulinum Toxin injections
   7. Neuromodulation
   8. Transcranial Magnetic Stimulation
   9. Ketamine Infusions
7. Surgical Intervention
   1. Skilled extraction of endometrial implants
8. Home program/self care

 

It is important to understand that most women with pelvic pain may not tolerate or may not respond to certain therapies or treatments and often more than once. Hopefully knowing this will make women feel less ‘broken’ as they work through the process of finding the treatment that is right for them. Women can and do get better with persistence and a solid medical team!

 

And last but certainly not least, a documentary titled Endo What? was released around the world. If you are suffering from Endometriosis or know someone who is this movie is a must-see. You can view the movie trailer here.
We hope you find this blog and these resources helpful!