A Patient-Centred Approach To Treating Endometriosis

During an insightful talk at the recent Fertility Show Africa, Dr Sulaiman Heylen – a reproductive medicine specialist and director of Cape Fertility in Cape Town – explained a patient-centred approach to treating endometriosis, a disease that is one of the most common causes of female infertility.

While most gynaecological problems are treated successfully by today’s medical specialists, endometriosis is a disease that is often diagnosed late, misdiagnosed and /or incorrectly treated.
Dr Heylen’s talk highlighted three problematic approaches to the treatment of endometriosis, and outlined the patient-centred approach to treating endometriosis that is used with great success at Cape Fertility.

One problematic approach is a focus on medical treatment for endometriosis to the exclusion of the surgical option and does not consider assisted reproductive therapies (ART) such as IVF (In Vitro Fertilisation).

Another problematic approach is only considering surgery to treat endometriosis. Fortunately open surgery is no longer necessary and instead laparoscopy is an option. Laparoscopy is a minimally invasive surgery during which a small incision in the navel allows medical specialists to look inside the abdomen and the pelvis, to inspect the uterus, the ovaries and the fallopian tubes, and to detect and treat any endometriosis at the same time.

A further problematic approach is simply focussing on one symptom of endometriosis, such as infertility, and treating endometriosis with ART to the exclusion of surgery.

All these approaches are problematic because the treatment of endometriosis should not be based on the classification or even the severity of the disease. It should also not be based on a medical specialists’ preference for medical treatment, or for surgical treatment.

The treatment of endometriosis should be based on the symptoms of the patient and should therefore entail a combination of medical treatment, surgical treatment and assisted reproduction based on the patient’s situation. Because endometriosis is a benign disease, the disease itself does not require treatment.

Treatment is required by the patient experiencing a specific set of symptoms. This means that the treatment required depends on what symptoms the patient has. In the treatment of endometriosis, the question to answer is: “What symptoms do the patient suffer from?” Are the symptoms just infertility? Or pelvic pain? Or painful periods? Or one of the other associated symptoms such as fatigue, depression, eating problems and gastrointestinal problems?

Without such a patient-centred approach, mistakes in the diagnosis and treatment of endometriosis are common. Very often there is already a delayed diagnosis. Often, too, endometriosis is not properly diagnosed, and symptoms like anxiety and depression remains untreated.

In addition, surgery is often offered as a solution without discussing all the treatment options. In many instances, surgery is incomplete. In other cases, surgery can be too aggressive.

Treatment Options For Endometriosis

There are various treatment options for endometriosis, including medical treatment; surgery or laparoscopy; and assisted reproductive therapies (ART) such as IVF (In Vitro Fertilisation).

Which treatment option is right for each patient depends on which of the symptoms of endometriosis each patient required treatment for. For example, the treatment of endometriosis is different for pain than it is for infertility.

For example, the treatment options for pain caused by endometriosis are – in order of priority – hormone treatment; analgesics; and surgery as the last option.

The medical treatment for pain caused by endometriosis can be quite efficient. Surgery should therefore not be the first line treatment for pain, but the last. Oral contraceptives and the Mirena are first line treatments for pelvic pain related to endometriosis, in cases where a patient is not trying to conceive.

Birth control pills are commonly used, including a drug called Visanne. Visanne is very effective as a long-term treatment option in the treatment of pelvic pain related to endometriosis.

The Mirena® is also used successfully as treatment of endometriosis. The Mirena® is a hormone-releasing IUD (intrauterine device) that is used as contraception and also treats heavy periods for up to five years.

Sometimes injectable contraceptives are used, and then there are GnRH analogues such as Zoladex that produce an artificial menopause.

So there are various options for the medical management of endometriosis that is highly effective for the treatment of painful periods and chronic pelvic pain.

Where the symptom of endometriosis that requires treatment is infertility, the treatment options are – in order of priority – hormone treatment; surgery; and ART following the surgery if a pregnancy is not achieved.

Medical therapy is ineffective where infertility is the issue. This is because all the medications mentioned above work as contraceptives, so none of these medical treatment possibilities are an option for women who struggle with infertility.

The first line approach for the treatment of endometriosis related infertility in all stages of the disease is surgery. It is very important, however, if you are trying to conceive, that this surgery is performed by a specialist in the treatment of endometriosis. IVF and IUI (Intrauterine insemination) are good options if pregnancy is not achieved after surgery.

The best time for endometriosis surgery is usually at the time a woman is trying to conceive – not at the time of diagnosis. This is because if a woman does not want to conceive, the pain caused by the endometriosis can be managed with medical treatment without doing surgery.

A few real-life examples will illustrate how important it is for each patient’s endometriosis treatment to be customised.

Example 1 – Unnecessary Surgery

A 25 year old woman who has been married for two years is diagnosed with a 3cm endometrioma on the right ovary during a check-up with her gynaecologist. Fortunately, she is asymptomatic. She is on birth control pills because she’s not planning to conceive in the next two to three years.

A laparoscopy was proposed to remove the ovarian cyst. However, in this case a laparoscopy is not necessary – since the woman has no symptoms, and is not trying to conceive, her first line of treatment should be medical.

Example 2 – Too Much Surgery

A 32 year old woman has been struggling with infertility for six years. She had been diagnosed with severe endometriosis in the form of bilateral endometriomas or endometrial cysts on the ovaries.

In this example, the woman’s treatment involved too much surgery: two laparoscopies by a general obstetrician-gynaecologist (or OB-GYN – a healthcare professional that specialises in female reproductive health) and another two laparoscopies by a specialist in endometriosis.

Because the treatment here was focussed on the disease and not the patient, the end result was that the patient lost all her eggs and her most pressing symptom – infertility – went untreated.

Example 3 – Too Little Or Incomplete Surgery

A 34 year old woman suffered severe pain, but did not have fertility challenges. Surgery was done, but six months later the severe pain persisted because – it was later found – deep endometriosis that had been missed during surgery continued to cause the pain. This is an example of too little or incomplete surgery.

Patient-Centred Approach To Endometriosis Treatment

So, it is important to understand that surgery is not always the first approach for pelvic pain, but rather that medical treatment is the first approach for pelvic pain. However, when a woman is trying to conceive, surgery is often necessary.

What treatment is required is also dictated by the patient’s quality of life. Chronic pain and severe pain for an extended time is not normal and has a very negative effect on a person’s quality of life.

In many cases, however, a patient may require a combination of treatments. It is also important to consider the side effects, the efficacy, the availability and the costs of each option, as well as the patient’s personal preferences, when deciding on the treatment of endometriosis. Each patient’s treatment plan will differ.

What Should I Do If I Think I Have Endometriosis?

If you suspect that you have endometriosis, especially if you are trying to conceive, we would like to invite you to come and meet one of our specialists by clicking here

We offer all the most effective fertility treatments at Cape Fertility, including treatment for endometriosis.

At Cape Fertility, we value each individual patient and we look forward to providing you with individualised and personalised care, affordable quality fertility treatment, and higher success rates at our purpose-built premises, situated in the Claremont Medical Village in the beautiful city of Cape Town.