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Scott Webb (Host): Endometriosis is a painful condition for women, but diagnosis often just requires a simple medical history and a consultation with your doctor. And there are numerous safe and effective treatment options. And joining me today to discuss endometriosis and the benefits of minimally invasive surgery is Dr. Katie Towles. She's an OB-GYN with Franciscan Physician Network. This is the Franciscan Health Doc Pod. I'm Scott Webb. So, Doctor, thanks so much for your time today. What exactly is endometriosis?

Katie Towles, MD (Guest): Endometriosis is a condition where the lining of the uterus that is shed each month with a period, grows outside of the location of the uterus. The tissue can grow on the outside of the uterus, it can grow on the ovaries. It can grow on the lining of the inside of the pelvis, like by the bladder or the bowels. And typically someone is diagnosed with endometriosis when they're coming in with a problem. And oftentimes it starts with pain during periods and some patients also come in with other issues such as fertility issues. And then we find in that workup that they have endometriosis.

Host: So, pain is the main symptom, but there are other symptoms too, right?

Dr. Towles: So, oftentimes pain is the symptom that's bringing women in to get evaluated, whether they're having really bad cramping during their menstrual cycles or they start to have pain outside of their cycles, and then some women even end up developing painful intercourse at some point in the process of their health.

Host: Right. And so, women come in, whether it's because of pain or fertility issues, whatever it might be. And so what is the process for diagnosis? How is it diagnosed?

Dr. Towles: So, endometriosis is actually primarily a clinical diagnosis We can get a reasonable assumption of endometriosis purely based on what a patient is telling me. So, I go over a very thorough history of how their menstrual cycles started, when things became painful. I do a thorough evaluation of how their cycles are regulated. How intercourse is, if they happen to be sexually active. When it's a fertility patient also asking other questions, but for most patients, I’m asking what have they done already to help with their discomfort? Have they used medicines over the counter? Have they seen other doctors, have they changed their diet?

So, I'm asking a very thorough history and usually by the end of a first visit with a patient, I can be pretty certain if we're going to see endometriosis as a diagnosis. The initial treatment for suspected endometriosis is also what we call empiric therapy. Meaning we're going to initiate a therapy. We don't need to have confirmation with say a surgery. So, I'm able to with a very brief workup to start a treatment for what I suspect is endometriosis, and if somebody gets relief from that treatment, I can be pretty sure that they have endometriosis. Now with those symptoms that bring people in, there are many things that can cause those same symptoms and not even be endometriosis. So, part of the when I'm discussing this with a patient is thinking about other things that cause similar problems.

Host: And on that subject, what are some of those other similar things that can, you know, sort of manifest in the same ways for women as endometriosis?

Dr. Towles: When I'm discussing somebody's history, one of the things that sometimes can stand out is active infections, especially in younger girls. So, I'm assessing somebody's risk for infections in the vagina or uterus something   as common as a sexually transmitted infection can cause really bad periods and menstrual changes and can actually be around for quite some time. And unless we test for it and assess for it, we may not know that that's an issue. Cysts on the ovary is something that can bring women in with pelvic pain. And so we usually can assess for that as well. Somebody who's had a history of pelvic surgery say, if they've had a really bad appendicitis in the past and they might have scar tissue on the inside of their abdomen, that might be causing pelvic pain as well.

And there's also a condition of a muscular nature in the pelvic muscles themselves, where they’re very tight and unable to be relaxed that can cause pelvic pain that can be considered or suspected endometriosis. And these all usually can be teased out really well with a very thorough history and then some exams and usually some very minimal testing.

Host: Is there an age group or an age range for women that can suffer from endometriosis.

Dr. Towles: Most typically the patients I see are going to be in their late teens and early twenties. However, there are a fair number of patients that we see who have started to explore their fertility. And that workup is just slightly different, that when we figure out that they do have endometriosis, when they look back, that there were probably some signals earlier on in their life, but they weren't bad enough to bring them in to a physician or to be concerned about it. So, when I get teenagers in or late teens, I'm always very diligent to get them treated if I do suspect endometriosis, because getting them treated as soon as possible can prevent some of those fertility issues.

I do see the endometriosis tends to kind of get a little bit better in the early twenties. But we still get a fair number of patients who are in their late twenties, early thirties, really exploring some more serious therapies when they've known that they have endometriosis.

Host: Yeah, of course the goal is to be as minimally invasive, as possible to have patients respond to therapies as easily as possible. But for those patients who don't, where surgery is needed and indicated, what are the benefits to the minimally invasive surgery that you do?

Dr. Towles: Absolutely. When we take a patient who we strongly suspect endometriosis, we've ruled out most of the other causes that could be treated in other fashions and they're not responding to medications or they're wanting to pursue fertility because the treatment options for endometriosis are typically suppressing the ovaries. So, preventing those from ovulating, which would not allow somebody to get pregnant. So, if somebody is pursuing fertility, oftentimes what we'll do is offer a surgery, which I usually refer to it as a scout surgery or surveillance surgery. Let's see what's going on the inside of the pelvis.

And so what we usually start with is called a diagnostic laparoscopy. Now there are some patients that you may have a much higher suspicion of having pathology or having something wrong on the inside of the pelvis, like scar tissue. And so we might be really going in there to kind of clean up the pelvis. And that would be somebody who's had a prior ectopic pregnancy, or they've had an infection that went to their uterus. And they might have scar tissue in their tummy. They might have had a really bad appendicitis and had a complicated course with that needing and these are all big red flags for having scar tissue in their belly.

So, when we're doing minimally invasive surgeries, we oftentimes employ the DaVinci robot platform. And what that is, is a specialized laparoscopy. So, this is a way to do pretty serious surgeries through little tiny incisions on the belly, and especially with endometriosis, which can get very complicated and very involved, we get to see these tissues really up close in 3-D fashion, and we can take care of things that otherwise would have had to be done with an open procedure by a specialist, with a much longer recovery. This innovation on a really standard surgery has made things a lot better for patients.

Host: Yeah, it sounds like it. And in a way it sounds a little bit like a colonoscopy to me that it is both diagnosis and treatment. Yeah, which is really great for patients. Right?

Dr. Towles: Yes, it is. Some patients, even when things are normal, you go in there and you can't see endometriosis. A lot of patients will get a benefit. Not only psychologically where at least there's nothing major going on and I can move on with something else. But we oftentimes see something that gives confirmation and validation to their disease process. And sometimes you have stuff that you can fix on there. You've got scar tissue that might loosen up some of the pelvic organs, make things more comfortable, make the fallopian tubes work better. And sometimes you are able to find something that is really going to encourage a patient to go see a specialist. Especially the fertility patients where they really need to get more specialized care. So, a lot of times you can get a lot of information from a surgery that you can't get and certainly you wouldn't want to do that as a first-line therapy for somebody presenting with suspected endometriosis.

Host: Yeah. As you mentioned earlier, that sometimes just a, a great medical history and just speaking with a patient and some basic therapies can do the trick, which is great. Yeah, and you've mentioned fertility a couple of times here. Is this surgery safe for women who want to get pregnant in the future?

Dr. Towles: Sometimes the surgery actually is the first line therapy. So, I've had patients before who have had a long course of infertility. They've been trying for a year or two, they've got regular periods, but very painful. And they've kind of tried everything. And when we're doing our workup we're making sure that there's nothing else as a cause of that, that they're ovulating very regularly that their husband or partner has adequate sperm counts. We're looking at all these medical things and again, the thorough history. And then if they're really wanting to pursue fertility, there are some women that that's the best option is to go with the surgery first to see what is going on. And the patients who have tried with some of the medical therapies to help with fertility, if stuff's not working, that's also, a reasonable course of action. That's a pretty low risk surgery when you're doing this in a minimally invasive fashion. And our patients are generally young and healthy. And so the risks are pretty low. And for them, the benefits could be pretty high.

Host: Yeah, that's always good. A low risk high reward. What's the recovery time like? When can patients go home after the robotic surgery?

Dr. Towles: The recovery time is dependent on the type of surgery. Now, not all laparoscopic surgery even needs to be a robotic type of surgery. Some can do just regular laparoscopy. The more invasive surgeries such as hysterectomy, there's going to have a little longer recovery time, two or three weeks. But when you're doing these for the context of endometriosis, typically women are back on their feet within about four or five days, being pretty normal. End up having a little tenderness on the tummy, kind of what people have said before that they kind of feel like they did way too many stomach crunches. So, more of like a post-exercise discomfort. So, we get women not really needing pain medicines very much and that helps with recovery even more. They can be much more functional at home. So, that's why you can expect for recovery.

Host: Doctor, as we wrap up, anything else you want to tell women about endometriosis? How simple, really the process is for diagnosis, their treatment options. Anything else?

Dr. Towles: My biggest recommendation is if these really having a concern for endometriosis, or if they're having really a lot of difficulty with their menstrual cycles is to talk to your doctor. I think women are afraid of being told that they're infertile or they're afraid that they're going to be told they have cancer or something else wrong, but there's so much that we can do to make cycles much better, with or without medicine and with or without surgery. And it really just takes starting at that discussion with your doctor.

Host: Yeah. Start with your primary, possibly your OB-GYN. You know that as you mentioned, you know, this is just a lot of things that we all sort of live with either because we're not doctors or there's a fear factor or whatever it might be. But for so many people, quality of life could be improved if we just ask the right questions, you know?

Dr. Towles: Absolutely.

Host: Yeah. And so let's hope that people do that. And Doctor, thank you so much for your time today. You stay well.

Dr. Towles: Absolutely. Thank you very much.

Host: For more information, go to Franciscanhealth.org and search endometriosis. And if you found this podcast helpful, please share it on your social channels and be sure to check out the full podcast library for additional topics of interest. This is the Franciscan Health Doc Pod. I'm Scott Webb. Stay well, and we'll talk again next time.