Selected Podcast
Endometriosis Awareness
Anna Lisa Schmitz MD discusses the common symptoms of endometriosis. She shares how it is diagnosed and what is involved in the management of this challenging condition.
Featuring:
Learn more about AnnaLisa Schmitz, MD
AnnaLisa Schmitz, MD
AnnaLisa Schmitz, MD specialties include Obstetrics & Gynecology, Robotic Surgery, Women's Services.Learn more about AnnaLisa Schmitz, MD
Transcription:
Expert Insights is an ongoing medical education podcast. The Carle Division of Continuing Education designates that each episode of this enduring material is worth a maximum of 0.25 AMA PRA Category 1 credit. To collect credit, please click on the link and complete the episode's post-test.
This podcast forum is brought to you to share expertise and insights within our integrated delivery system to help us improve the health of the people we serve and achieve world-class accessible care. This is Expert Insights. Here's your host, Melanie Cole.
Melanie: Welcome to Expert Insights with the Carle Foundation Hospital. I'm Melanie Cole. And today we're discussing endometriosis. Joining me is Dr. AnnaLisa Schmitz. She's an obstetrician-gynecologist with the Carle Foundation Hospital. Dr. Schmitz, it's a pleasure to have you with us today. Tell us a little bit about what you've been seeing with endometriosis, how common it is. Are you seeing a lot of it?
Dr AnnaLisa Schmitz: Yes. Thank you so much for having me today. I appreciate it. And endometriosis is a topic that I spend a fair amount of time in my gynecology practice speaking on. And it's actually quite common in reproductive age women. It can be up to Between 20 to 50% of women that are affected by endometriosis. Some of that variation comes in some of the challenges with diagnosing endometriosis, which I'm sure we can touch on as we go along. But it's actually quite common and really does affect those reproductive age women.
Melanie: Well, let's touch on diagnosis because it is difficult. So tell us a little bit about why it's challenging to diagnose. Who is seeing these women? Tell us a little bit about how that process works. Is it from a primary care provider that the first complaints go or the woman's gynecologist? Tell us a little bit about diagnosis.
Dr AnnaLisa Schmitz: The diagnosis becomes challenging and, unfortunately, many women suffer with endometriosis for a long time and actually have multiple visits to the physician's office before endometriosis is even brought to the table as a possibility. And that's a two-fold problem. One is that some of the symptoms are more vague or more personal or they cross over with other potential diagnoses.
So for example, common complaints are abdominal pain and pelvic pain, but that can cover a lot of other diagnosis. Then also we run into other symptoms that come along with it. So sometimes pain with bowel movements. Even pain with urination in some cases is endometriosis.
Classically, the symptoms that go along with endometriosis are dysmenorrhea or pain with menses and dyspareunia is another common one, so pain with intercourse. So those are some of the most common symptoms of endometriosis. And so hopefully classically, a woman that comes in with dysmenorrhea, they have at least a discussion about endometriosis by their primary care provider or referral to a gynecologist if that's their preference.
Dyspareunia is a more difficult one because some women are reluctant to talk about that with their providers. And in fact, that's usually not the common presenting symptom or complaint when they come to my office. But it is one of the classic symptoms that I ask about and a large majority of women with endometriosis will note painful intercourse.
The other challenge with diagnosis would be the difficulty of actually making the diagnosis. And this is one of those times when it's not actually technically possible for a primary care provider to make a diagnosis of endometriosis. It's suspected endometriosis, absolutely. But technically, the diagnosis of endometriosis is made surgically with visualization and hopefully pathology of endometriotic implants.
So there's no blood tests that we can do to diagnose endometriosis and it doesn't actually show up on ultrasound, unless the woman happens to have ovarian lesions, which would be classic for endometriosis called endometriomas. Technically, an ultrasound would not diagnose those, but it would have a high suspicion for an endometrioma because they have a pretty classic appearance on ultrasound. So it makes it more difficult for a primary care provider to make a diagnosis.
However, to have a high index of suspicion in a woman for reproductive age, especially a young woman coming in with complaints of cyclic pain, in particular pain with periods, then either management or referral to a gynecologist would be ideal.
Melanie: Well, thank you for saying that because that's so important for other providers to notice, that if a woman does present with these symptoms, referral is really the only way to get that diagnosis. So tell us about some of the treatments. What do you do once you do determine that a woman has endometriosis?
Dr AnnaLisa Schmitz: So endometriosis is ectopic implantation of endometrial tissue. So tissue of the lining of the uterus that ends up outside of the uterus and studding the pelvis. And these are small areas, which is why they don't show up on ultrasound. But the treatment, I usually say there's two different ways to approach this. So we can manage endometriosis even without an official diagnosis. And the main management is managing the symptoms that come from endometriosis. And so the symptoms would be the pain with periods, the dysmenorrhea, the dyspareunia, the dyschezia, the dysuria. So managing those symptoms, all of their pain symptoms are typically the difficulties that they're experiencing.
And so our approach to management, the idea is suppression. So suppression of those hormonally responsive ectopic endometrial cells. So all of that endometrial tissue that's implanted outside of the uterus, the idea is to hormonally suppress the activity of those implants. And we do that using any form of reproductive hormone manipulation, so birth control pills. Sometimes just birth control pills on their own are useful, but the other possibility would be continuous birth control pills. So someone that’s refractory to birth control pills might go on to continuous birth control pills.
Another possible option would be the Mirena IUD or levonorgestrel iUD does seem to be helpful with suppression of pain. And other options would be manipulating hormones from a level higher up, so manipulating the gonadotropin-releasing hormone. So those would be agonists and antagonists of that receptor. So your options would be Depot Lupron or Orilissa at this point in time.
The data says that they're in some cases equivalent to birth control, but that actually usually is our second line option for refractory pain with birth control pills. And all of these management options for pain would be options for someone who's not attempting pregnancy. One of initial questions with endometriosis in terms of management has to come in in terms of what is her plan for future pregnancy. If she's coming to us because she has pain and wants to get pregnant, these are not options.
So the data actually says putting somebody on birth control pills for some amount of cycles because she has pain with periods is not going to treat her endometriosis. This is not going to make it go away. It's really just a management option for pain. So there's no value to someone who's attempting of pregnancy being put on birth control pills for a few cycles. It's not going make a difference for her endometriosis. She really needs a referral to a gynecologist for treatment, which would be a laparoscopy.
In that case, visualizing these ectopic endometrial implants, and ideally taking some amount of sampling, so some removal of this tissue to send a pathologist for an actual tissue diagnosis. And then that comes in terms of treatment, in the sense that removing these endometrial implants does seem to improve fertility in these women with endometriosis. The amount that it improves fertility is debatable, but it does improve fertility. Surgical treatment of endometriosis does improve fertility.
Melanie: That's important to note. Dr. Schmitz, for women that are refractory to treatment and not wanting to get pregnant, what could be done next? Speak about surgical options in that case,
Dr AnnaLisa Schmitz: So someone with truly refractory endometriosis, refractory pain, again, the question becomes attempting pregnancy versus not. Attempting pregnancy or desiring pregnancy, then our options are really limited. We can try and work on suppressing pain until she's ready to attempt pregnancy. But if she still wants to maintain her uterus, then our options are pretty much what we've talked about already.
If she's done with childbearing and has tried medical management, has tried a laparoscopy for pain and it's just tired of pain, then our options would be to do a hysterectomy, so removal of her uterus and plus minus her ovaries. We tend to have better pain outcomes with removal of ovaries, but anytime that I'm having this discussion with women, we have to talk about the possibility of recurrent pain, recurrent endometriosis, even with removal of the ovaries with a hysterectomy and ideally a hysterectomy with some visualization capabilities for these endometrial implants. So the best outcomes for hysterectomy for endometriosis would be removal of the ectopic endometrial cells, the removal of these endometrial implants at the time of hysterectomy, which would require typically traditionally a laparoscopic hysterectomy of some sort and then again, plus minus removal of the ovaries, which is a discussion based on multiple other risks and her desires, and how concerned she is about maintaining her hormone level as well.
Melanie: So Dr. Schmitz, tell us a little about what you would like other providers to take from this episode. What would you like them to know about referral when their patients come to them and the need for diagnosis, the challenge of endometriosis and what you feel are the most important bits of advice we've given here today?
Dr AnnaLisa Schmitz: The diagnosis of endometriosis is a surgical diagnosis. So anybody that's not had a surgery has suspected endometriosis, but management can fall into the realm of primary care in terms of hormonal suppression, that's very appropriate. But first two questions, I would say for someone with endometriosis is how much are your symptoms affecting your day-to-day life? So if you have minor dysmenorrhea, treating with NSAIDs, if that's manageable, perfect. You don't really need to do anything more and then kind of going into step-wise fashion in terms of medical management.
And then the other side of things is what is your plan for future child-bearing? If you are actively attempting pregnancy or would like to attempt pregnancy in the next three months, then there is no value to medical management in that case. And those are the people that really should be referred to a gynecologist. So someone that is either refractory to any medical treatment or someone that's attempting or desiring attempting pregnancy in the very near future. Those people need to be coming in to see a gynecologist right away so we can work towards actually treating their disease to help them achieve their goal of pregnancy.
Melanie: Thank you so much, Dr. Schmitz. What great information. That concludes this episode of Expert Insights with the Carle Foundation Hospital. For a listing of Carle providers and to view Carle-sponsored educational activities, please visit our website at carleconnect.com for more information. I'm Melanie Cole. Thanks so much for listening.
Expert Insights is an ongoing medical education podcast. The Carle Division of Continuing Education designates that each episode of this enduring material is worth a maximum of 0.25 AMA PRA Category 1 credit. To collect credit, please click on the link and complete the episode's post-test.
This podcast forum is brought to you to share expertise and insights within our integrated delivery system to help us improve the health of the people we serve and achieve world-class accessible care. This is Expert Insights. Here's your host, Melanie Cole.
Melanie: Welcome to Expert Insights with the Carle Foundation Hospital. I'm Melanie Cole. And today we're discussing endometriosis. Joining me is Dr. AnnaLisa Schmitz. She's an obstetrician-gynecologist with the Carle Foundation Hospital. Dr. Schmitz, it's a pleasure to have you with us today. Tell us a little bit about what you've been seeing with endometriosis, how common it is. Are you seeing a lot of it?
Dr AnnaLisa Schmitz: Yes. Thank you so much for having me today. I appreciate it. And endometriosis is a topic that I spend a fair amount of time in my gynecology practice speaking on. And it's actually quite common in reproductive age women. It can be up to Between 20 to 50% of women that are affected by endometriosis. Some of that variation comes in some of the challenges with diagnosing endometriosis, which I'm sure we can touch on as we go along. But it's actually quite common and really does affect those reproductive age women.
Melanie: Well, let's touch on diagnosis because it is difficult. So tell us a little bit about why it's challenging to diagnose. Who is seeing these women? Tell us a little bit about how that process works. Is it from a primary care provider that the first complaints go or the woman's gynecologist? Tell us a little bit about diagnosis.
Dr AnnaLisa Schmitz: The diagnosis becomes challenging and, unfortunately, many women suffer with endometriosis for a long time and actually have multiple visits to the physician's office before endometriosis is even brought to the table as a possibility. And that's a two-fold problem. One is that some of the symptoms are more vague or more personal or they cross over with other potential diagnoses.
So for example, common complaints are abdominal pain and pelvic pain, but that can cover a lot of other diagnosis. Then also we run into other symptoms that come along with it. So sometimes pain with bowel movements. Even pain with urination in some cases is endometriosis.
Classically, the symptoms that go along with endometriosis are dysmenorrhea or pain with menses and dyspareunia is another common one, so pain with intercourse. So those are some of the most common symptoms of endometriosis. And so hopefully classically, a woman that comes in with dysmenorrhea, they have at least a discussion about endometriosis by their primary care provider or referral to a gynecologist if that's their preference.
Dyspareunia is a more difficult one because some women are reluctant to talk about that with their providers. And in fact, that's usually not the common presenting symptom or complaint when they come to my office. But it is one of the classic symptoms that I ask about and a large majority of women with endometriosis will note painful intercourse.
The other challenge with diagnosis would be the difficulty of actually making the diagnosis. And this is one of those times when it's not actually technically possible for a primary care provider to make a diagnosis of endometriosis. It's suspected endometriosis, absolutely. But technically, the diagnosis of endometriosis is made surgically with visualization and hopefully pathology of endometriotic implants.
So there's no blood tests that we can do to diagnose endometriosis and it doesn't actually show up on ultrasound, unless the woman happens to have ovarian lesions, which would be classic for endometriosis called endometriomas. Technically, an ultrasound would not diagnose those, but it would have a high suspicion for an endometrioma because they have a pretty classic appearance on ultrasound. So it makes it more difficult for a primary care provider to make a diagnosis.
However, to have a high index of suspicion in a woman for reproductive age, especially a young woman coming in with complaints of cyclic pain, in particular pain with periods, then either management or referral to a gynecologist would be ideal.
Melanie: Well, thank you for saying that because that's so important for other providers to notice, that if a woman does present with these symptoms, referral is really the only way to get that diagnosis. So tell us about some of the treatments. What do you do once you do determine that a woman has endometriosis?
Dr AnnaLisa Schmitz: So endometriosis is ectopic implantation of endometrial tissue. So tissue of the lining of the uterus that ends up outside of the uterus and studding the pelvis. And these are small areas, which is why they don't show up on ultrasound. But the treatment, I usually say there's two different ways to approach this. So we can manage endometriosis even without an official diagnosis. And the main management is managing the symptoms that come from endometriosis. And so the symptoms would be the pain with periods, the dysmenorrhea, the dyspareunia, the dyschezia, the dysuria. So managing those symptoms, all of their pain symptoms are typically the difficulties that they're experiencing.
And so our approach to management, the idea is suppression. So suppression of those hormonally responsive ectopic endometrial cells. So all of that endometrial tissue that's implanted outside of the uterus, the idea is to hormonally suppress the activity of those implants. And we do that using any form of reproductive hormone manipulation, so birth control pills. Sometimes just birth control pills on their own are useful, but the other possibility would be continuous birth control pills. So someone that’s refractory to birth control pills might go on to continuous birth control pills.
Another possible option would be the Mirena IUD or levonorgestrel iUD does seem to be helpful with suppression of pain. And other options would be manipulating hormones from a level higher up, so manipulating the gonadotropin-releasing hormone. So those would be agonists and antagonists of that receptor. So your options would be Depot Lupron or Orilissa at this point in time.
The data says that they're in some cases equivalent to birth control, but that actually usually is our second line option for refractory pain with birth control pills. And all of these management options for pain would be options for someone who's not attempting pregnancy. One of initial questions with endometriosis in terms of management has to come in in terms of what is her plan for future pregnancy. If she's coming to us because she has pain and wants to get pregnant, these are not options.
So the data actually says putting somebody on birth control pills for some amount of cycles because she has pain with periods is not going to treat her endometriosis. This is not going to make it go away. It's really just a management option for pain. So there's no value to someone who's attempting of pregnancy being put on birth control pills for a few cycles. It's not going make a difference for her endometriosis. She really needs a referral to a gynecologist for treatment, which would be a laparoscopy.
In that case, visualizing these ectopic endometrial implants, and ideally taking some amount of sampling, so some removal of this tissue to send a pathologist for an actual tissue diagnosis. And then that comes in terms of treatment, in the sense that removing these endometrial implants does seem to improve fertility in these women with endometriosis. The amount that it improves fertility is debatable, but it does improve fertility. Surgical treatment of endometriosis does improve fertility.
Melanie: That's important to note. Dr. Schmitz, for women that are refractory to treatment and not wanting to get pregnant, what could be done next? Speak about surgical options in that case,
Dr AnnaLisa Schmitz: So someone with truly refractory endometriosis, refractory pain, again, the question becomes attempting pregnancy versus not. Attempting pregnancy or desiring pregnancy, then our options are really limited. We can try and work on suppressing pain until she's ready to attempt pregnancy. But if she still wants to maintain her uterus, then our options are pretty much what we've talked about already.
If she's done with childbearing and has tried medical management, has tried a laparoscopy for pain and it's just tired of pain, then our options would be to do a hysterectomy, so removal of her uterus and plus minus her ovaries. We tend to have better pain outcomes with removal of ovaries, but anytime that I'm having this discussion with women, we have to talk about the possibility of recurrent pain, recurrent endometriosis, even with removal of the ovaries with a hysterectomy and ideally a hysterectomy with some visualization capabilities for these endometrial implants. So the best outcomes for hysterectomy for endometriosis would be removal of the ectopic endometrial cells, the removal of these endometrial implants at the time of hysterectomy, which would require typically traditionally a laparoscopic hysterectomy of some sort and then again, plus minus removal of the ovaries, which is a discussion based on multiple other risks and her desires, and how concerned she is about maintaining her hormone level as well.
Melanie: So Dr. Schmitz, tell us a little about what you would like other providers to take from this episode. What would you like them to know about referral when their patients come to them and the need for diagnosis, the challenge of endometriosis and what you feel are the most important bits of advice we've given here today?
Dr AnnaLisa Schmitz: The diagnosis of endometriosis is a surgical diagnosis. So anybody that's not had a surgery has suspected endometriosis, but management can fall into the realm of primary care in terms of hormonal suppression, that's very appropriate. But first two questions, I would say for someone with endometriosis is how much are your symptoms affecting your day-to-day life? So if you have minor dysmenorrhea, treating with NSAIDs, if that's manageable, perfect. You don't really need to do anything more and then kind of going into step-wise fashion in terms of medical management.
And then the other side of things is what is your plan for future child-bearing? If you are actively attempting pregnancy or would like to attempt pregnancy in the next three months, then there is no value to medical management in that case. And those are the people that really should be referred to a gynecologist. So someone that is either refractory to any medical treatment or someone that's attempting or desiring attempting pregnancy in the very near future. Those people need to be coming in to see a gynecologist right away so we can work towards actually treating their disease to help them achieve their goal of pregnancy.
Melanie: Thank you so much, Dr. Schmitz. What great information. That concludes this episode of Expert Insights with the Carle Foundation Hospital. For a listing of Carle providers and to view Carle-sponsored educational activities, please visit our website at carleconnect.com for more information. I'm Melanie Cole. Thanks so much for listening.