Cheryl Martin (Host): This podcast is for informational purposes only and is not intended to be used as personalized medical advice. 

It's estimated that more than 11 percent of women here in the United States between the ages of 15 and 44 have endometriosis. It's especially common among women in their 30s and 40s, and it can make it harder to get pregnant.

Here to tell us what endometriosis is, its symptoms, the different treatment options available and more, is Dr. Carlyn King, an OBGYN at Skagit Regional Health. This is Be Well with Skagit Regional Health. I'm Cheryl Martin. Dr. King, so glad to have you on.

Carlyn King, DO: Hi Cheryl, good morning.

Cheryl Martin (Host): First, please explain what endometriosis is in simple terms for those who might not be familiar with it.

Carlyn King, DO: Of course. Endometriosis is a condition where the cells that normally are on the inside of the uterus or the endometrial cells, somehow migrate outside of where they belong. And so, these cells can implant along the fallopian tubes, the ovaries or commonly sort of the slippery surface overlying the pelvic floor called the peritoneum.

Cheryl Martin (Host): What are some of the common symptoms of endometriosis that women should be aware of?

Carlyn King, DO: The most common symptom with endometriosis is pelvic pain. And pelvic pain can have a lot of different causes, but it's estimated that about 70 percent of women with chronic pelvic pain actually have endometriosis as the cause. Other symptoms that might cause a patient to think they have endometriosis could be things like pain with intercourse, pain when using the restroom, both urination and with bowel movements and even pain in between their menstrual cycles can be common.

Cheryl Martin (Host): So, how is endometriosis diagnosed and what steps should a woman take to if she suspects that she has it.

Carlyn King, DO: So the first step is to meet with a gynecologist or even your general practitioner to discuss the symptoms you may be having related to painful menstrual cycles or pain with intercourse. Oftentimes, a history and just hearing the symptoms that a woman is dealing with, might clue a practitioner into the possible diagnosis of endometriosis. In many cases, for women who have symptoms that are suspicious of endometriosis, we often make a clinical diagnosis by history alone. Although to confirm the diagnosis of endometriosis, we often have to do surgery and directly observe those endometriotic lesions. Surgery is not always necessary for women who are dealing with endometriosis symptoms, and for many women, we can treat their symptoms without doing surgery.

Cheryl Martin (Host): So, do we know what causes endometriosis?

Carlyn King, DO: The predominant thought for what might be causing endometriosis is a multitude of factors working together. And so there is a genetic component, a predisposition from your genes that you're born with, that you inherit from your parents. But we've also been trying to study and figure out why some patients who have those genes do or don't get endometriosis.

There's currently research going on about the idea of different, levels of rare metals like cadmium in your blood. There's also research looking into different bacteria that might inhabit your genital tract and whether that may increase the risk of developing endometriosis. And so the short answer is we don't really know what causes it, but we found some common risk factors, to look for and try to delineate which patients are at risk.

Cheryl Martin (Host): So, what can potentially happen if endometriosis is left untreated?

Carlyn King, DO: Endometriosis is a progressive disease and that's the biggest problem because there's often a delay in diagnosis of endometriosis. Many women feel that menstrual cycles are supposed to be painful and that they just expect to have cramps with their menstrual cycles. But most women who have really painful, debilitating menstrual cycles, that's not normal.

And this can lead to a delay in diagnosis. With endometriosis, the reason that's a problem is each cycle that you have, the endometriosis lesions grow and bleed and cause further scar tissue. So over time, if your endometriosis is left untreated, you can develop more significant scar tissue in your abdomen or your pelvis, your pain symptoms can get progressively worse, and it can even lead to worsening infertility over time.

Cheryl Martin (Host): I'm glad you brought that up because I wanted to ask, how does endometriosis affect fertility and what options are available for women who want to conceive? Because I know of women who were not able to conceive because of endometriosis.

Carlyn King, DO: Great question. Endometriosis in its early stages often does not interfere with the ability to conceive, but there's so much variability between the symptoms that a patient may have. The severity of the disease and whether it may be contributing to infertility. And so we do know women with endometriosis, do have higher rates of infertility.

The most common way that we see that is when there's large endometriosis lesions that are located within the fallopian tube structures or near the ovaries; those lesions inhibit your body's ability to release an egg as usual. And when you can't ovulate or release your egg like usual, then you can't conceive easily.

Endometriosis can also block the fallopian tubes or cause it to be more difficult for the egg that your body releases to migrate where it's supposed to into the uterus, and in that way becomes a little bit more difficult. And we even see data that endometriosis that's on the ovaries actually releases some inhibitory molecules that can be toxic to embryos.

And so women who have endometriosis on the ovaries, what we would call endometriomas, those are cysts that contain endometriosis; those women we find have lower fertility rates even when they're undergoing infertility treatments like IVF.

Cheryl Martin (Host): Do you have any numbers on, let's say, the percentage of women when you look at all the infertility problems? Where does endometriosis rate on that list?

Carlyn King, DO: Endometriosis is actually one of the rarer causes of infertility and that's good news for most women with endometriosis because we have an ability to intervene early and try to keep the disease as minimal as possible. But the nature of endometriosis is that it is a chronic, ongoing and progressive disease that doesn't have a cure.

And so early diagnosis, knowing that the symptoms that you may be having are not normal and seeking care for it is really important in this case. If we treat it early, we may be able to prevent the progression of the disease and reduce the risk of things like infertility.

Cheryl Martin (Host): Talk about some of those treatment options for managing endometriosis symptoms. 

Carlyn King, DO: When I diagnose a woman with endometriosis, or we have a conversation where I suspect she may have endometriosis, most commonly we'll talk about how we manage the symptoms. The symptom we talked about being the most common is pelvic pain and especially pain related to your menstrual cycles. We commonly treat that using NSAIDs, or nonsteroidal anti-inflammatory medications, things like ibuprofen or naproxen.

Those medications do well to reduce the pain with menstrual cycles, but they don't treat the endometriosis itself. And so to combine that approach with pain management, we often manage your menstrual cycles and we do that using hormonal contraceptives. The most common and most effective treatment that I've found in practice is actually using a normal birth control pill, a combined estrogen and progesterone birth control pill, but you take it in a way where you skip the placebo week or that last week of pills in a pack.

By skipping that week in the pack, you actually never have a menstrual period. And if we suppress women from having that menstrual period, we actually reduce the symptoms significantly of endometriosis. 

Cheryl Martin (Host): That's great. Now, are there any lifestyle changes or dietary recommendations that can help alleviate symptoms? 

Carlyn King, DO: So, we do know that endometriosis, being a chronic pain disease, is often associated with inflammation, and so although there is current research being done on lifestyle modifications and dietary changes that may help, there's no one diet or modification that's recommended.

We often focus on medical management and trying to control your menstrual cycles to prevent the progression of the disease. But also chronic pain conditions are really common in women more often than not. And so in those sorts of conditions, we see inflammation as a major mediator of pain. So following low inflammation diets, working on keeping your diet free from many additives that can cause inflammation in your body is one approach that many of the more holistic practitioners will take for patients with endometriosis to try to reduce the symptoms.

Cheryl Martin (Host): Now what about surgical treatment?

Carlyn King, DO: Yeah, so I mentioned that a birth control pill is the most common treatment that we start. There are many other birth control options. Sometimes we'll use even long-acting options like IUDs or Nexplanon. We sometimes use the DepoShot. These are just other hormonal treatments. There are some hormonal treatments that simulate menopause, and in the same way, the goal of those is to suppress the menstrual cycle so that the symptoms improve.

There are some more side effects with the more advanced treatments for endometriosis, things like Depo Lupron or Orlissa, and it's important to talk to your healthcare provider to make sure that choosing a medication or trialing a medication like that is right for you and used at the right time.

When medications don't control your symptoms adequately, surgery is often the next step. And it depends on where you're at with your symptoms. For some women we'll offer surgery fairly early on in our conversation. Other women have a goal to try to avoid surgery as much as possible. And so depending on what symptoms you're dealing with and what your response may be to our initial therapy, surgery is often considered.

The benefits of surgery are that we get a definitive diagnosis. We know exactly how much endometriosis and where the endometriosis is. The current best practice in endometriosis treatment is excisional surgery. So we find any lesions that may be there and we actually remove them from your body. And by doing that, we reduce inflammation, we reduce pain and many women show improvement in their symptoms significantly after surgery.

The other interesting thing about surgery is that women who are struggling with infertility and have endometriosis may experience about a six-month period after their first surgery where their fertility rates are increased. And so that's really exciting for women who are struggling with infertility to know that we have this option that actually can improve your fertility rates.

One goal, of course, in endometriosis, knowing that it's a long-term disease, would be to avoid repeat surgeries. We don't want to put patients through surgery over and over, so medical therapy is still necessary even when we're going through surgical treatments.

Cheryl Martin (Host): And when you say medical therapy, you're talking about the hormonal?

Carlyn King, DO: Exactly, yes, the cycle control options that help reduce the progression of the disease.

Cheryl Martin (Host): Okay. Just final thoughts, any other advice you would have for women who are living with endometriosis?

Carlyn King, DO: So my first thought is that, if you think you may have endometriosis, you need to get a care team together. Find a gynecologist you can talk to that you trust, that you can talk to about your symptoms and find a management plan that controls those symptoms. It is not normal to be debilitated during your menstrual cycle.

Many women with endometriosis often miss school or work because of their symptoms and that is not normal. That's a sign that something is not happening the way it should be. So you should seek medical care and work towards getting the diagnosis so that we can treat things and prevent progression. And the other factor I would say is, as you mentioned at the top of this podcast, the rate of endometriosis is up to about 11%.

I mean, that means one in 10 women, is also struggling with endometriosis. There are robust communities out there, support groups and discussions of which medications have worked and which haven't. And so I would encourage patients to seek those communities out and build your support structure as you’re starting to deal with some of these issues because it is a long road. It's a chronic disease, but the symptoms can be managed and we can give you quality of life back.

Cheryl Martin (Host): Dr. Carlyn King, this has been great. Thank you for sharing your expertise on endometriosis. Great information. 

Carlyn King, DO: Thank you so much for having me, Cheryl.

Cheryl Martin (Host): For more information, visit SkagitRegionalHealth.org. And if you found this podcast helpful, please share it on your social channels. You can check out our entire podcast library for other topics of interest to you. This is Be Well with Skagit Regional Health. Thanks for listening.