Treatment of endometriosis
In choosing the right therapy, it is important to adapt it individually to the patient. The main complaints should be identified and the therapy selected based on the patient’s needs and preferences. Thus, the patient is an essential member of the treatment team. In the selection of the treatment it plays a big role, in which age one is, whether immediately a pregnancy is aimed as well as which pretreatments already took place and which were their side effects. The severity and type of endometriosis and the presence (or absence) of symptoms also have an influence on the therapy.
We ask all patients to fill in a short questionnaire and send it to us so that the doctor can get an idea of their situation and symptoms before their first appointment. Endometriosis is a disease that affects women throughout the years up to the menopause – and in extremely rare cases even beyond. Endometriosis can thus be described as a chronic disease. If it is detected early and treated specifically, it can cause little damage. The symptoms of endometriosis can change over time, just as the preferences and needs of the women affected change depending on the situation.
Thus, it is important to dynamically address the changing ailments and changing needs and provide appropriate care for those affected. During the consultation, we will work together to develop a treatment plan for you and your individual situation. Our Endometriosis Nurse will accompany you throughout your treatment and support you in coping better with everyday life with endometriosis.
Our aim is to provide you with personal advice and support you individually in dealing with the disease.
We discuss complex cases with experts from other disciplines, at the pelvic pain board or directly with our colleagues at the fertility center.
Medication
Anti-inflammatory painkillers (NSAIDs)
An essential treatment approach (and often the first step) is to treat the symptoms of endometriosis with anti-inflammatory medication – so-called non-steroidal anti-inflammatory drugs (NSAIDs). These agents not only combat pain, but also inhibit the inflammatory response associated with endometriosis. There are various NSAIDs that contain mefenamic acid, ibuprofen or diclofenac as the active ingredient, for example.
Many endometriosis patients report that they avoid taking painkillers whenever possible and only take them if the pain can no longer be tolerated. Since the painkillers mentioned can also have side effects, it is certainly correct that they are not taken without reason. However, experience has shown that the effect is better if these medications are taken at an early stage, so that a more severe pain and inflammation situation cannot develop in the first place.
In addition, pain that is not treated for a long time can become chronic. Chronic pain can adversely alter nerve sensitivity in the long term, which can be partially prevented with pain medications. It should therefore be ensured that the painkillers are taken at the first onset of period pain and in a high enough dosage.
If, on the other hand, the medication is taken late, it usually takes a lot more of it to break through the pain peak.
Hormonal therapy
Endometriosis is a hormone-dependent disease. Many of today’s therapy recommendations are also based on the connection with hormones. Regulation with hormones can prevent endometriosis from growing, which has a positive effect on pain. Taking a combined contraceptive pill (pill with estrogen and progestin) reduces the influence of the body’s own estrogens and thus puts endometriosis on a “diet”, so to speak. Continuous use of the contraceptive pill can improve its effect (so-called long cycle). The absence of menstruation further prevents the spread (or recurrence after surgery) of endometriosis. This is because bleeding into the abdomen or endometriosis cysts occurs with each menstrual period, which can cause pain and scarring. However, the greatest effect is achieved with so-called progestogen pills (“mini-pills”), which are completely free of estrogens. This not only takes the drive, but actively brakes it. Depending on the progestin form, additional effects can be developed, such as an additional direct inhibition of inflammation and pain. The progestogens can be given not only in pill form, but also by means of a so-called hormone coil. In contrast to the pill, there is no risk of forgetting to take the IUD. The IUD can be left in place for up to 8 years and offers an excellent treatment option.
Finally, GnRH (gonadotropin-releasing hormone) analogs, which centrally stimulate the body’s own estrogen production, are the second line of treatment. at the level of the pituitary gland. The main side effect of this therapy is menopausal symptoms. These can vary from woman to woman and disappear completely after the end of the active period. As nine out of ten women undergoing this therapy suffer from hot flushes/sweating and around half of the women treated suffer from headaches, mood changes/depression, sleep disorders, vaginal dryness – less frequently also hair loss, acne and joint and limb pain – this therapy is often combined with a small addition of oestrogens – a so-called “add-back” therapy. Thus, the therapy can be carried out for a longer period of time without the manifestation of side effects. Undesirable effects on bone density can also be reduced in this way.
After discontinuation of the GnRH analogs, the natural cycle resumes. Recently, so-called GnRH antagonists have also become available.
Other supporting methods
Nutritional counseling/gastroenterological therapies/bladder problems
The inclusion of nutritional counseling and gastroenterology for intestinal complaints and urogynecology for bladder complaints can be helpful. Avoidance of pro-inflammatory dietary components and exclusion of coexisting irritable bowel syndrome or irritable bladder symptomatology are important for proper management of the disease. Drinks or foods can cause irritation or bloating, which can be improved with appropriate advice and changes in dietary habits.
Physiotherapy
If, during the examination, there are indications of a muscular component to the pain in the muscular pelvic floor (so-called “myofascial pelvic floor pain syndrome” = pain caused by problems in the musculature/muscular membranes of the pelvic floor), specialized pelvic floor physiotherapy can lead to an improvement in the pain. Active cooperation in the therapy is central. The support of a physiotherapist experienced in pelvic pain is a great help for many patients.
Infertility treatment
Pain is not always the main concern for all endometriosis patients, but infertility is often also a factor.
Whether pregnancy can be achieved through surgery (endometriosis removal) or artificial insemination depends on several factors. The inclusion of reproductive medicine is of great importance for these issues. With the correct treatment selected individually to your situation but also needs, very good results can be achieved, sometimes by surgery or artificial insemination alone, sometimes by the combination of both.
Surgery
In certain cases, endometriosis should be treated surgically. Surgery is usually minimally invasive by means of laparoscopy (= laparoscopy) under general anesthesia. A larger abdominal incision is only necessary in very rare cases. It is important to us that operations – even supposedly “simple” diagnostic laparoscopies (= laparoscopy for clarification) – are carried out by surgeons experienced in the field of endometriosis, as endometriosis is like a chameleon and can take on different forms. In this way, we ensure that the diagnosis can be made even in the case of very small endometriosis lesions. The tissue removed is then examined under a microscope for fine tissue examination.
It is important to us to know as precisely as possible where endometriosis is suspected before a laparoscopy using ultrasound and other examination procedures – e.g. on the ovary, the uterine ligaments, the intestine or the peritoneum.
With the help of such a “map”, the doctor can explain exactly where the disease is located and which surgical steps are necessary.
Laparoscopy is used to confirm these findings and determine the severity of the endometriosis (classification according to the “American Society of Reproductive Medicine – rASRM” grades 1 to 4 and according to the #Enzian classification depending on the affected compartment/organ).
In the case of mild infestation, the endometriosis can be removed directly and completely. In severe cases, organs (bowel, urinary bladder) and important structures (ureter, diaphragmatic dome, vagina, etc.) are typically affected, which usually requires a procedure involving other specialties (visceral surgery and urology).
By precisely clarifying the extent of the disease BEFORE surgery, as described above, the procedure can be better planned and any necessary specialists can be called in at an early stage. From the patient’s point of view, it has the advantage of being fully informed and knowing exactly what to expect during and after the operation. During surgery, the tissue altered by endometriosis is removed and adhesions are loosened. Complete removal of endometriosis foci is important because there is evidence that incomplete removal may even lead to increased pain perception by increasing activity of nerve fibers remaining in the foci. This operation can help in situations where the pain cannot be controlled by all of the aforementioned means, but cannot replace hormonal therapy in the long term.
The correct management of endometriosis is considered complex and differs from patient to patient, which is why the right therapy is not always found right away. However, we accompany and support you on your way out of pain towards regaining a high quality of life or fulfilling your desire to have a child.
Other treatment methods
Pain therapies
It is known that endometriosis can lead directly to pain due to the chronic inflammation in the abdominal cavity and the resulting adhesions. Complex physical processes in the brain and nerve cells can cause pain that persists over time to “burn” into the brain and become chronic. Pain can be felt in such a situation even without a recognizable stimulus. Specialized pain management can address chronic pain. The feeling of being helpless in the face of pain can lead to anxiety and despair. Teaching them skills to do something about the pain themselves is central to chronic pain therapy in particular. It is equally important to normalize the altered body perception caused by the constant pain and to modulate the increased sensation of pain.
Complementary medicine therapies
In addition to conventional medical treatment, we also offer supportive complementary medical treatment options. These are not only used when hormonal therapy is not an option for the patient, but should also be seen as a supplement to conventional therapies. For this purpose we cooperate with the Institute for Complementary and Integrative Medicine. The anti-inflammatory and hormone-regulating effects of some herbal preparations can be used as well as methods of traditional Chinese medicine (TCM).