Endometriosis

Painful periods, also called dysmenorrhea, is very common, affecting up to 50% of reproductive age women. Between 30-50% of women with dysmenorrhea describe severe symptoms that significantly limit their activities or physical function.

Dysmenorrhea is typically divided into two groups: primary and secondary. Primary dysmenorrhea is menstrual pain without other obvious causes or contributing factors. Primary dysmenorrhea is more commonly diagnosed in adolescents or younger women. Secondary dysmenorrhea involves the same menstrual pain symptoms but with another condition that may be contributing to their pain, such as endometriosis, uterine fibroids, or adenomyosis. Secondary dysmenorrhea tends to develop later in life.

Fortunately, primary dysmenorrhea often improves as patients become older and particularly after childbirth. The natural course of secondary dysmenorrhea is much more variable and may either worsen over time or improve with treatment or time.

Dysmenorrhea symptoms typically include cramping and pain that is aching, dull, intense, or sharp in the lower abdomen and pelvis. Some women also have pain in the back and upper legs. Some women also report nausea, diarrhea, headaches, and fatigue during this time. Symptoms usually begin a day or two before bleeding begins. Symptoms typically begin to improve within a couple of days. Pain that occurs outside of menses is unlikely to be due to dysmenorrhea and other causes should be considered.

Production of inflammatory compounds, such as prostaglandins and cyclooxygenase, increase significantly at the start of menses. It seems that some women make even higher levels of some of the inflammatory compounds, such as PGE2 and PGF2a. These inflammatory compounds can cause many bothersome symptoms, but notably they cause the uterine muscle to contract, which causes menstrual cramping. In some women, the uterine muscle contraction is so strong that it limits the blood supply to the uterus. The resulting lack of blood and oxygen, called ischemia and hypoxemia, seems to be more pronounced in women who experience very severe dysmenorrhea symptoms.

Dysmenorrhea is primarily a clinical diagnosis that is based on symptoms. However, additional evaluation is needed in order to differentiate primary from secondary dysmenorrhea. Other contributing conditions that may be seen in secondary dysmenorrhea can include endometriosis, fibroids, pelvic inflammatory disease, adenomyosis, and structural abnormalities of the uterus or vagina. Your physician may recommend a pelvic exam, pelvic ultrasound, laboratory testing, or even surgery to evaluate for these conditions.

Nonsteroidal anti-inflammatory drugs (NSAIDs) improve dysmenorrhea symptoms in 80% of patients. NSAIDs improve dysmenorrhea pain by decreasing production of prostaglandins and by decreasing the intensity of uterine contractions. NSAIDs do appear to be helpful even in women with endometriosis and fibroids.

NSAIDs seem most effective when taken on a scheduled basis during menses. We usually recommend that patients begin taking ibuprofen 600mg as soon as dysmenorrhea symptoms begin and continue every 6 hours until bleeding has stopped. Some patients prefer naproxen to ibuprofen. If you’re using naproxen, we usually recommend 500mg every 12 hours. You should not use ibuprofen and naproxen at the same time and should not use more than the recommended doses. You should also consult your physician if to make sure that this regimen is safe for you.

When NSAIDs do not result in adequate improvement, hormonal suppression may be a very effective next step. There are many hormonal suppression options, including combined hormonal contraceptives (contain both estrogen and progesterone) and progesterone-only methods. You should talk to your physician to discuss the hormonal suppression options that might be best for you.

Combined hormonal contraceptives are available as pills, weekly patches, or monthly vaginal rings and can be taken cyclically (to have a lighter, less painful period each month) or continuously to completely eliminate menstrual periods. Continuous regimens that completely eliminate menstrual periods have been shown to improve dysmenorrhea symptoms more effectively than cyclic regimens.

Progestin-only methods include progesterone-only pills, levonorgestrel-releasing IUD, injection, or implant. These medications are taken continuously and often completely eliminate menstrual periods.

Many patients with dysmenorrhea also often suffer from associated pelvic floor muscle dysfunction (e.g. pelvic floor myofascial pain, levator ani syndrome). This refers to abnormal contraction and shortening of the pelvic floor muscles. Symptoms of pelvic floor dysfunction include many symptoms that overlap with dysmenorrhea or endometriosis, including chronic pelvic pain, painful intercourse, urinary urgency or frequency, and constipation.  Pain is often worsened by physical activity and worse at the end of the day. First line treatment is working with a physical therapist who is certified in the treatment of pelvic floor dysfunction.  This link provides more information on Myofascial pain and Pelvic Floor Physical Therapy.

Dysmenorrhea is usually treated by primary care physicians or gynecologists. Optimal care of dysmenorrhea often requires a team approach. This team might include the following specialists:

• Primary care physicians (PCP) – PCPs may include Family Medicine physicians, Internal Medicine physicians, or Pediatrician physicians. A PCP is a physician who specializes in general medical care and typically develops long-term medical relationships with patients over the course of many years. PCPs can initiate evaluation and treatment for dysmenorrhea and help to coordinate referrals to other specialist providers, such as OBGYNs or physical therapists, when needed.
• Gynecologists – Obstetrician-gynecologists (OBGYN) are physicians who specialize in women’s health, with a focus on conditions that affect the female reproductive system (uterus, ovaries, fallopian tubes).  OBGYN’s are usually the primary physician who coordinates the care of women with severe dysmenorrhea or endometriosis.  Subspecialists within OBGYN can often provide specialized care for the complex needs of women with endometriosis.  For example, some gynecologists have specialty medical and surgical training in endometriosis and can provide advanced pain management and minimally invasive surgery for complex and advanced endometriosis.
• Advanced practice providers (nurse practitioners, physician assistants) who specialize in reproductive health conditions and often work with PCPs or OBGYNs can help coordinate the long-term care of women with dysmenorrhea.
• Nurse educators – specialists who can educate about these conditions and help develop or refine a personalized treatment plans.
• Pelvic Health Physical Therapists- physical therapists who specialize in the evaluation and treatment of abdominal and pelvic musculoskeletal disorders, including chronic abdominal and pelvic pain.
• Integrative health practitioners - specialists who use mindfulness and other positive behavioral approaches to improve endometriosis symptoms, promote healing, and improve functional status and overall well-being.

Approximately 30% of women with dysmenorrhea have endometriosis. Endometriosis is estimated to affect about 10% of reproductive-age women world-wide. It is a condition where tissue similar to the inner lining of the uterus (endometrium) is found outside of the uterus. The most common location of endometriosis is in the pelvis around the uterus, ovaries and fallopian tubes. Rarely, endometriosis can occur in the intestine, appendix, bladder, diaphragm or other locations within the body.

Endometriosis typically affects women during their reproductive years, meaning any time after the first menstrual period. While symptoms usually subside after menopause, endometriosis can rarely affect women during their menopausal years. Some women with endometriosis have little or no symptoms, while others experience pelvic pain and/or difficulty becoming pregnant. Symptoms can fluctuate over time; there can be periods when symptoms flare up as well as periods of remission when they diminish or disappear. In women who experience pelvic pain, symptoms usually increase in the few days prior to and during menses. Endometriosis can affect many areas of a person’s life including work, school, daily activities and relationships. While there is currently no known cure for endometriosis, the symptoms of endometriosis can usually be managed effectively.

Endometriosis is one of many different conditions that cause pelvic pain.  Pelvic pain can be caused by a variety of conditions, including gynecologic and non-gynecologic causes.  The most common gynecologic causes of painful periods and/or chronic pelvic pain include primary dysmenorrhea, endometriosis, adenomyosis, uterine fibroids, and pelvic inflammatory disease.  Non-gynecologic causes of pelvic pain include irritable bowel syndrome, urologic pelvic pain syndrome (interstitial cystitis), pelvic floor muscle dysfunction, and pelvic neuropathies (e.g. pudendal neuralgia).  While some people with pelvic pain have only one cause of pain, many have more than one contributing cause.  A health care provider with expertise in pelvic pain can help accurately determine the most likely causes of pelvic pain in an individual patient.

Some women with endometriosis have little or no symptoms at all.  The most common symptom is pelvic pain, and this can be any combination of dysmenorrhea, chronic pelvic pain, painful intercourse (dyspareunia), pain with bowel movements (dyschezia), or pain with urination (dysuria). Women with endometriosis are more likely to suffer from infertility and may also develop ovarian endometriosis cysts (often referred to as chocolate cysts).

• Pelvic pain:  The hallmark symptom of endometriosis is pelvic pain. Pelvic pain associated with endometriosis most often occurs around the time of the menstrual period (dysmenorrhea), but can also occur between menstrual periods (chronic pelvic pain), during or after sex (dyspareunia), with bowel movements (dyschezia), and/or during urination (dysuria).  Patients with endometriosis may experience only one type of pelvic pain, or any combination of pelvic pain symptoms.  The frequency or severity of pain often does not correlate with the amount of endometriosis identified in the body. For example, some women with only a few, small endometriosis lesions experience severe daily pelvic pain and some women with extensive endometriosis throughout the pelvis organs experience little to no pain at all.  The symptoms of pelvic pain can vary, with some days being better than others. The location of pain is typically in the lower abdomen and pelvis but can radiate to the lower back and upper thighs.

• Infertility: Endometriosis can make it more difficult to become pregnant.  This might occur because endometriosis can cause scar tissue to develop, which can damage the ovaries or fallopian tubes.  But it may also decrease the healthy function of the ovaries or lining of the uterus, even if scar tissue is not present.

• Ovarian endometriomas (chocolate cysts): Some women with endometriosis can develop ovarian cysts containing endometriosis, which are called ovarian endometriomas.  Endometriomas are filled with old blood which resemble chocolate syrup, which is why they are called chocolate cysts.  Endometriomas can sometimes be felt on pelvic exam, but not always. They are usually seen on pelvic ultrasound.

• Bloating (a sensation of fullness in the belly) is a symptom experienced by some people with endometriosis. It is more commonly experienced in individuals with co-occurring irritable bowel syndrome (IBS), but is also reported by patients with endometriosis who do not have IBS.

• Fatigue: Fatigue or tiredness is often described by people with endometriosis. This may be associated with sleep difficulties or experienced during times of more severe pelvic pain.

• Sleep Problems: Some individuals with endometriosis may have difficulty falling asleep or staying asleep. Poor sleep has been associated with more bothersome pain symptoms. This link provides more information on improving Sleep.

• Anxiety and Depression: Endometriosis can co-exist with anxiety and/or depression but more often in individuals with more severe symptoms.  The depressive symptoms and anxiety do not need to be at the level of a diagnosable disorder to influence pain perception. Simply experiencing the symptoms of pelvic pain or infertility will likely have a negative impact on mood which in turn can make other pain symptoms worse. This link provides more information on Managing Emotions.

• Chronic Overlapping Pain Conditions (COPCs): If you have endometriosis, you may be at higher risk for developing another COPC. It is thought that these conditions may share common underlying causes. COPCs include Fibromyalgia, Chronic Low Back Pain, Migraine Headaches, Tension Type Headaches, Temporomandibular Joint Disorder, Painful Bladder Syndrome/Interstitial Cystitis, Chronic Fatigue Syndrome, Irritable Bowel Syndrome, and Vulvodynia. We have highlighted a few of the COPCs and other commonly contributing conditions that frequently occur in patients who have chronic pelvic pain.

  • Vulvodynia
  • Irritable Bowel Syndrome
  • Bladder Pain Syndrome/Interstitial Cystitis
  • Myofascial pain
  • Sexual Pain

It is extremely important to identify and manage ALL of the conditions and other factors that may be contributing to your pelvic pain in order to manage your symptoms as effectively as possible.

Although the exact cause of endometriosis is unknown, several theories have been proposed. The most likely theory is called “retrograde menstruation.” This theory states that endometriosis develops when a small amount of endometrium (uterine lining tissue) mixed with menstrual blood flows through the fallopian tubes into the pelvic cavity during a menstrual period, and begins to grow outside of the uterus. We know that over 90 percent of women have retrograde bleeding through the fallopian tubes during the menstrual period. But we don’t understand why only 5-10% of women develop endometriosis as a result. We suspect that the women who develop endometriosis likely have additional genetic, immune, inflammatory and biochemical differences that put them at greater risk for implantation and growth of the retrograde endometrium tissue.  Other theories include transformation of peritoneal cells into endometrium-like cells, spread of endometrium cells through blood vessels or lymphatic systems, and surgical scar implantation.  It is likely that different factors play a role in different patients with endometriosis.

Risk factors for endometriosis include having a family history of endometriosis, starting your period at an early age, short menstrual cycles (from start of one period to the next period), heavy periods that last longer than 7 days, and low body weight. Older studies showed that endometriosis seemed to be more common in women who were white or Caucasian. However, we are now finding that endometriosis seems just as common in women of other races or ethnicities, but just wasn’t being diagnosed as frequently.

Endometriosis is a hormonally sensitive condition. It is helpful to understand how hormones influence endometriosis, as this impacts much of how the disease is managed.  The ovaries make two hormones as part of the normal menstrual cycle: estrogen and progesterone. Estrogen production increases during the early to middle part of the menstrual cycle. Estrogen makes the endometrium (uterine lining) grow and thicken in preparation for a fertilized egg to implant (i.e., become pregnant). Progesterone production only occurs after the ovary makes an egg (ovulates) and is only produced for about 14 days per month. Progesterone stabilizes the endometrium by slowing its growth and allowing the tissue to mature. Assuming that pregnancy does not occur during the cycle, the progesterone levels drop significantly about 14 days after ovulation. It is actually the decreasing level of progesterone that causes the endometrial lining to shed (ie, have a period). A very simple analogy is that estrogen acts like the fertilizer and progesterone acts like the lawn mower for endometrium.

Because endometriosis is so similar to endometrium tissue, estrogen and progesterone have a very similar fertilizer/lawn mower effect on endometriosis. We can use this hormonal sensitivity to suppress growth and activity of endometriosis, which we discuss in detail in the Treatment section.

Laparoscopic surgery is the gold standard way to diagnose endometriosis and involves making small incisions in the abdomen, using a camera and surgical instruments to examine the pelvic organs, and then taking a surgical biopsy to confirm the diagnosis of endometriosis. If surgery is performed, the recommendation is to surgically remove (excise) all visible endometriosis lesions and not just biopsy one or a few areas of suspected disease.

However, all surgical procedures carry risk and waiting for a surgical confirmation can delay diagnosis and initiation of medical treatment, which is often just as effective as surgical treatment of endometriosis. Today, multiple medical societies and guidelines encourage beginning medical treatment for presumed endometriosis if symptoms, physical exam, or imaging tests are suggestive of endometriosis, allowing more women to begin medical treatment as soon as possible.  However, there are situations in which surgical diagnosis and treatment is considered first line therapy.  These include when a patient has an enlarging or complex (irregular) ovarian mass, obstruction of the intestines or urinary tract, or when a patient has severe pain but does not wish to take hormonal medication because they are trying to become pregnant.

Currently, there are no available blood tests to reliably diagnose endometriosis.  Pelvic imaging, such as ultrasound and MRI, can be helpful to diagnose ovarian endometriosis cysts and deeply infiltrative endometriosis but is not currently sensitive enough to detect superficial endometriosis in most cases.

Endometriosis is considered a chronic condition that requires long-term treatment during the reproductive years (from the time of symptom onset to menopause).  While there is no currently available “cure” for endometriosis, the symptoms of endometriosis can be managed effectively.

Treatment of endometriosis can take many forms. Many people find that their symptoms are better controlled when they use multimodal treatment – in other words, using several treatment strategies at the same time. Multimodal treatment is particularly important for people who have several separate pain conditions or have had pain for many years.

We have organized treatment strategies into options you do on your own (self-care) and options you can consider in collaboration with your health care provider (professional care).

Self-Care

There are many lifestyle and behavioral changes that can help to improve the symptoms of endometriosis. What you choose to focus on needs to be personalized to your specific situation.

So many people with endometriosis say that it’s not JUST the pain that bothers them – it’s the fact that having pain affects sleep, drains energy, and impacts their ability to fully participate in their lives.

In addition to using effective treatments aimed at endometriosis tissue, we want to also help you manage ALL of the ways that this condition impacts your life. Depending on the symptoms you are experiencing, this may mean trying some new strategies to improve sleep, manage your activity level so that you don’t feel exhausted, better communicate with your family or health care provider, or use relaxation or mindfulness techniques to address the anxiety that so often occurs during a pain flare.

The links below provide more information on strategies that tend to be very helpful for many people with endometriosis. You may want to talk with your health care provider to identify the self-care approaches that would be best for you.

• Cognitive and Behavioral Strategies
• Relaxation and Mindfulness
• Sleep
• Physical activity and exercise
• Acupressure

Professional Care

Hormonal therapy - Endometriosis is a hormonally sensitive condition. We can use this hormone sensitivity to treat endometriosis, quite successfully in many cases.

In the What causes endometriosis section above, we used the analogy of estrogen acting like fertilizer for endometriosis tissue and progesterone acting like a lawnmower. The level of estrogen is naturally quite a bit higher than the level of progesterone during most of the menstrual cycle. When endometriosis is present, the natural estrogen to progesterone ratio promotes growth and activity of endometriosis lesions.

Most currently available medical treatments for endometriosis work primarily by altering the estrogen to progesterone ratio or by reducing overall estrogen levels, with the goal of minimizing growth and activity of endometriosis lesions. Some of these work by simply adding progesterone (more “lawn mower” effect to make the lesions less active). Others, like birth control pills, actually suppress the natural estrogen surge that occurs during as part of the menstrual cycle (less “fertilizer” effect).

All of these hormonal medications can significantly reduce the various pelvic pain symptoms associated with endometriosis, but also reduce or eliminate the menstrual bleeding that so often exacerbates pelvic pain.  Many of them can be used “continuously” to eliminate menstrual periods. Remember that most endometriosis lesions are thought to form as a result of “retrograde menstruation”, so minimizing or eliminating menstrual periods is thought to actually decrease formation of new endometriosis lesions.

Like all treatments for endometriosis, medical treatments for endometriosis do not cure endometriosis, but they will help decrease pain, minimize menstrual bleeding, and may prevent progression of endometriosis. Because these medications suppress but do not cure endometriosis, recurrence of endometriosis symptoms is very common after stopping these medications.  Thus, these are considered important parts of a long-term treatment plan.

It is also important to note that all of these options are contraceptives, which prevent pregnancy.  Thus, these are not appropriate options for women who are actively trying to become pregnant.

First line hormonal options include combined hormonal contraceptives (medications that contain estrogen and progestin) and progestin only medications.

Combined hormonal contraceptives are available as pills, weekly patches, or monthly vaginal rings. These methods can be used cyclically to have a lighter, less painful period each month or continuously to completely eliminate menstrual periods.

Progestin-only methods are equally effective and are available as pills or injections.  These medications are taken continuously and usually eliminate menstrual periods.

Second line hormonal options are usually considered when first line options do not adequately control symptoms and include GnRH (gonadotropin-releasing hormone) analogues, progestin intrauterine devices and implants.

GnRH analogues are highly efficacious but are considered second line due to less tolerable side effects and increased cost.  This category of medications includes GnRH agonists and GnRH antagonists. The most commonly used GnRH agonist is given as an injection every 1-3 months.  A newly approved antagonist is now available as a daily pill. GnRH analogues are associated with greater estrogen suppression than hormonal contraceptives and progestin medications, and therefore usually cause menopause symptoms including hot flushes and vaginal dryness.  There is also a risk of irreversible bone loss when these medications are given for longer than their approved duration. GnRH agonists can be used with low levels of add-back estrogen/progestin therapy, which alleviates these side effects and prevents bone loss, without reducing their efficacy in improving pelvic pain.  Add-back therapy with GnRH antagonists is currently under investigation.

Progestin intrauterine devices (progestin IUDs) have also been shown to reduce endometriosis pain and size of endometriosis implants.  However, it is important to note that LNG-IUDs do not consistently prevent ovulation and may not effectively reduce ovarian cyst formation.  Thus, this may not be an adequate option for women with ovarian endometriosis cysts (chocolate cysts). Similarly, progestin implants may reduce overall amount of menstrual bleeding, but typically do not prevent ovulation.

There is no single hormonal therapy method that has been proven to be best for patients with endometriosis. The best option for you is the one that manages your symptoms most effectively with the fewest side effects. You may need to try a few different methods to find the one works best for you. Some people even find that using two methods at the same time, such as a progesterone IUD plus a continuous birth control pill, is more likely to result in decreased pain and suppression of menstrual periods. Your health care provider can help you navigate these options.

Surgical therapy – As you remember, laparoscopic surgery is the gold standard method for diagnosing endometriosis, and the recommendation is to completely remove, or excise, endometriosis lesions during that procedure. There is evidence that the majority of patients with endometriosis report at least a significant improvement in pain following surgical treatment. However, it is important to note that surgery is not a guaranteed cure for pain or endometriosis and should always be considered as part of a therapeutic plan that often includes medical suppression prior to and after surgery to prevent recurrence.

Routine, repetitive surgeries to treat endometriosis are no longer recommended by gynecologic or pelvic pain professional societies. Repeat surgery is not generally recommended unless previous medical treatments for endometriosis have been unsuccessful, a patient has an enlarging ovarian cyst, a patient has severe pain but cannot take hormonal medication because she is actively trying to become pregnant, or if there are signs that endometriosis is causing obstruction of the intestines or urinary tract. However, these recommendations may vary depending on individual patient needs.

There are two primary categories of surgery – conservative and radical. Conservative surgery removes endometriosis implants while preserving the uterus and ovaries, while radical surgery includes hysterectomy (removal of the uterus, sometimes one or both ovaries) along with removal of all endometriosis implants. The right option depends on the patient’s medical history, symptoms, success of prior treatments, and her fertility goals.

Endometriosis surgery is often complex due to the inflammation and scar tissue that often surrounds endometriosis implants and close proximity of endometriosis to other vital organs such as the intestines, bladder and ureters (tubes that drain the kidneys to the bladder).  Therefore, it is important that these surgeries are performed by gynecologic surgeons that have experience and training in complex endometriosis surgery.

Conservative surgery - These procedures remove endometriosis implants without removing the uterus (hysterectomy). This is almost always performed using laparoscopy, a minimally invasive surgery technique that uses a thin camera and small instruments inserted into the abdomen using small “Band-Aid incisions”. Although this surgery requires general anesthesia, patients can go home the same day and return to work in 1-2 weeks.  Laparoscopic removal of endometriosis can effectively reduce pelvic pain in about 75% of women who have endometriosis. However, it is not helpful for about one in four women who have this surgery. And among women who have initial improvement in symptoms, pain and/or endometriosis returns in about 25-50% of women who do not use medical suppression after surgery.

Radical surgery - This refers to hysterectomy (removal of the uterus) and should also include removal of all endometriosis implants. Total hysterectomy means removal of the uterus and cervix, whereas subtotal or supracervical hysterectomy means removal of the uterus but not the cervix.  (These terms do not refer to whether or not the ovaries are removed).  Hysterectomy is generally considered for women with endometriosis who have not experienced pain relief from medical treatment or less invasive surgeries. Hysterectomy eliminates the possibility of carrying a pregnancy, so this is only appropriate for women who do not wish to become pregnant.

It is important to understand that even hysterectomy is not a guaranteed cure.  Pain can persist or recur despite hysterectomy, endometriosis can return after hysterectomy, and recurrent pain is not always due to recurrent endometriosis.  Possible reasons for persistent or recurrent pain include the possibility that endometriosis lesions outside of the uterus that were not removed during surgery or that the pain is due to another reason, such as pelvic floor myofascial pain.

Because hysterectomy alone does not decrease estrogen production, remaining lesions may be stimulated from estrogen produced by the ovaries. Hysterectomy and oophorectomy is the removal of the uterus and one or both ovaries. A total hysterectomy and bilateral oophorectomy (removal of the uterus and both ovaries) is the most radical surgical option and the option with the least likelihood of recurrence, but still is not a guarantee of pain relief.  In some studies, about 8% of women had recurrent pain after hysterectomy with bilateral oophorectomy. Removing the ovaries has the greatest impact on reducing estrogen production, but it also results in surgical menopausal state (in women who have yet to reach natural menopause).  Early surgical menopause is associated with menopause symptoms, such as hot flushes and vaginal dryness.  But it can also lead to osteoporosis (thinning of the bones), increased risk of heart disease, and increased risk of dying at a younger age than women who have not had both ovaries removed. Risks of early surgical menopause are so significant that routine removal of both ovaries is not generally recommended, unless the ovaries themselves are extremely abnormal (e.g. containing large endometrioma cysts, significant deep infiltrating endometriosis, or severe scarring to nearby structures).

Pelvic Physical Therapy - Like many other conditions that cause chronic pelvic and abdominal pain, patient with endometriosis often suffer from associated pelvic muscle dysfunction or myofascial pain (e.g. pelvic floor myalgia, levator ani syndrome). This refers to abnormal contraction and shortening of the pelvic floor muscles. Symptoms of pelvic myofascial pain include many symptoms that overlap with endometriosis, including chronic pelvic pain, painful intercourse, urinary urgency or frequency, and constipation.  Pain is often worsened by physical activity and worse at the end of the day. First line treatment is working with a physical therapist who is certified in the treatment of pelvic floor dysfunction.  This link provides more information on Myofascial Pain and Pelvic Physical Therapy.

Endometriosis is usually treated by gynecologists. While these doctors often coordinate the care of patients with endometriosis, optimal care often requires a team approach. This team might include the following specialists:

• Gynecologists – Obstetrician-gynecologists (OBGYN) are physicians who specialize in women’s health, with a focus on conditions that affect the female reproductive system (uterus, ovaries, fallopian tubes).  OBGYN’s are usually the primary physician who coordinates the care of women with endometriosis.  Subspecialists within OBGYN can often provide specialized care for the complex needs of women with endometriosis.  For example, some gynecologists have specialty medical and surgical training in endometriosis and can provide advanced pain management and minimally invasive surgery for complex and advanced endometriosis.  Reproductive Endocrinology and Infertility specialists can treat infertility caused by endometriosis.
• Advanced practice providers (nurse practitioners, physician assistants) who specialize in reproductive health conditions and often work with gynecologists can help coordinate the long-term care of women with endometriosis.
• Nurse educators – specialists who can educate about the condition and help develop or refine a personalized treatment plans.
• Pelvic Health Physical Therapists- physical therapists who specialize in the evaluation and treatment of abdominal and pelvic musculoskeletal disorders, including chronic abdominal and pelvic pain.
• Pain psychologists– specialists who can help initiate and maintain behavioral and self-care approaches to manage symptoms and who can help address psychosocial challenges associated with dealing with chronic pain and associated symptoms.
• Integrative health practitioners - specialists who use mindfulness and other positive behavioral approaches to improve endometriosis symptoms, promote healing, and improve functional status and overall well-being.
• Colorectal Surgeon, Urologist, Thoracic Surgeons- occasionally your gynecologist will work with other surgeons for surgical removal of endometriosis from organs outside of the uterus, ovaries, or fallopian tubes.  Colorectal surgeons can assist with removal of endometriosis from the intestine, urologists can assist with removal of endometriosis from the bladder or ureters, and thoracic surgeons can assist with removal of endometriosis from the lungs or diaphragm.

These health care providers work with patients with endometriosis to improve symptoms, overall well-being, and quality of life. It is likely that you and your health care team will need to work together to identify the best combination of professional and self-care approaches that works for you.  This plan will need to be reviewed and potentially revised over time as your needs shift.

Monitoring Progress: Bleeding Symptoms

International Pelvic Pain Society

American College of Obstetricians and Gynecologists, Patient Education FAQs

American Society for Reproductive Medicine, Patient Resources

Royal College of Obstetricians and Gynaecologists

Academy of Pelvic Health Physical Therapy, Section on Women’s Health