Joey Wahler (Host): It can cause pain and affect a woman's fertility. So, we're discussing endometriosis. Our guest is Dr. Luann Racher. She's an obstetrician and gynecologist at UAMS. This is UAMS Health Talk from University of Arkansas for Medical Sciences. Thanks so much for joining us. I'm Joey Wahler. Dr. Racher, hi there. Welcome.

Luann Racher, MD: Hi. Thanks for having me.

Host: Great to have you aboard. We appreciate the time. So first, for those unfamiliar, in a nutshell, what is endometriosis and how common is it among women?

Luann Racher, MD: Yeah. So, unfortunately, very common. It probably affects about 20 million American women of reproductive age. And it is really something that, I think, women oftentimes are struggling at getting the diagnosis for. It is when the cells of the endometrial cavity come outside of the uterus and line the pelvic cavity, and then you have a lot of pain associated with that in addition to some other symptoms as well.

Host: And it's more common as women age and much more so if they're infertile, right?

Luann Racher, MD: We do see infertility with it. Oftentimes it can cause scarring in the pelvis or even if no scarring is present, the inflammatory processes associated with endometriosis can result in infertility.

Host: And so specifically, what are some of the most common symptoms, including how it differs from a normal, heavier period?

Luann Racher, MD: Yeah, that's a good question. So really, whenever we see someone who is suspicious for having endometriosis, the most common complaint that we're going to hear is pain with their period cycle. And so, women who have mild pain, a little bit of discomfort when they are on their period have to take an ibuprofen or an acetaminophen a couple of days during their cycle. That's very normal. But when that pain starts to affect your ability to go to work, to go to school, to do normal activities, and even pain medications like Tylenol or acetaminophen or ibuprofen are not cutting it as far as doling that pain, then there may be something else going on.

Host: And so overall, how can this condition affect a woman's daily life?

Luann Racher, MD: So, what we see is usually it starts with just a very painful cycle or very painful period. And then, eventually, as it progresses, the woman can start to have pain even when she's not menstruating or not having her period. So, we go from having a very painful few days before your cycle starts to very painful periods. And then, it becomes very painful almost every day as that degree of endometriosis increases. So, we can see women who have pain every single day, maybe worse when they're on their cycle. They have pain when they use the bathroom. They have pain with intimacy with a partner. And sometimes it can even progress to just pain with no activity at all. Just existing can be painful.

Host: And so, this can really affect just about everything, right?

Luann Racher, MD: It really can. It can take over your life. And often, we hear from patients that they feel like their lives have been consumed with this disorder. And one of the biggest struggles that women face is getting that diagnosis. And studies have shown that women will see between three to five physicians for this disorder before they actually get a diagnosis of endometriosis.

Host: Wow. And you led me beautifully into my next question, which is about being diagnosed and how you go about arriving at that. But first, why so many different specialists?

Luann Racher, MD: There's probably a lot of different reasons. And I think as women we're often told your period's supposed to be painful. This is a normal part of being a woman. Just use a heating pad and move on. It's just your cycle. It shouldn't be this difficult. But there's not really a great way to measure pain.

And so, unfortunately, we have to listen to what our patients are telling us. And when they are unable to function, we have to have a higher degree of suspicion. And so, it's just being able to recognize when someone is telling you that this really is more than just uncomfortable.

This is actual pain that's affecting my daily life, And then being willing to, to take some extra steps. Another barrier in diagnosis is the only way to truly diagnose endometriosis is with a surgery. And so, you need to be able to see that endometriosis and have a tissue biopsy to confirm that diagnosis. And so, that can also be a barrier to diagnosis as well.

Host: Gotcha. So, speaking of which, how exactly is endometriosis diagnosed? What does that involve?

Luann Racher, MD: So, you can clinically suspect it based on someone's history or on their exam. And so, if you have someone who's giving you the classic history of, you know, it started out with a painful period, it's gotten progressively worse. And now, I have pain almost every day of my life. That is highly suspicious for endometriosis.

There is some imaging that we can do, so you can get a pelvic ultrasound or even a pelvic MRI. And sometimes on that imaging we can see deposits of endometriosis. But for some women who have superficial endometriosis that hasn't caused a lot of scarring in their pelvis yet, you may not even see it on imaging. And so, then it takes a laparoscopic surgery where we put a camera into the pelvis and actually look at the peritoneal lining to see if we can see endometriosis.

Host: And so, when it's diagnosed as being just that, are women typically at least relieved to know what it is?

Luann Racher, MD: That's very common thing that I hear—just knowing that finally getting that validation that you're not crazy, and that you are having pain, and that that's not normal, and that there are interventions that we can do, that can be very validating for a patient. And sometimes the opposite is true too. You may have someone who comes in and has a history suspicious for endometriosis. If you do that surgery and you don't find endometriosis, that can also be validating as well. You can cross that off, but then continue to look for other reasons why they're having that pain.

Host: All right. Well, we mentioned fertility is part of the picture here. So, how is that typically affected by endometriosis?

Luann Racher, MD: So, it can kind of be a couple of different reasons or be associated with a couple of different reasons that endometriosis can cause infertility. So, it is a highly inflammatory state. And so, you get a lot of inflammatory proteins that are secreted into the pelvic fluid. And that can cause difficulties with the implantation. You can also have scarring of the fallopian tubes, where then the tube can be blocked and then that sperm and egg cannot meet up. So, you can see that is a cause of infertility.

So, part of the assessment in someone who's been trying to get pregnant and has been unsuccessful is to evaluate the integrity of those fallopian tubes, make sure that they're open. And if they have a painful period or history that is suspicious for endometriosis, going in laparoscopically and looking for those lesions. Removing those lesions may improve their ability to get pregnant.

Host: And like with many conditions, of course, stress can worsen endometriosis, correct?

Luann Racher, MD: That is very true. So, pain itself causes stress. And then, you have that stress associated with that hyperinflammatory state. And then, you just get into this vicious cycle where then now you have more stress, and that contributes to even more pain and symptoms. And so, yes, stress and lifestyle can definitely play a role. We do encourage all patients with endometriosis to get plenty of rest, to exercise, and to eat a healthy diet. But sometimes that's not enough and many women will need other interventions.

Host: And one more on the stress factor. Naturally, any woman that's going through a prolonged period of trying to get pregnant, there's enough stress there already, to say the least. So now if you add in endometriosis, that just furthers that, right?

Luann Racher, MD: Absolutely. Absolutely can be true.

Host: So, what are the treatment options here?

Luann Racher, MD: So, oftentimes there are medications that we can use that can improve the quality of life. Birth control pills are a good option for treating endometriosis. Not everyone will tolerate a birth control pill, but we know that endometriosis is a highly estrogen-dependent condition.

And so when you have a very estrogen-driven condition, we can kind of hack that and tone down the amount of estrogen that's feeding those lesions by putting the patient on birth control pills or even just a progesterone-only medication. So, hormonal treatment is really a mainstay of the treatment for endometriosis. Anti-inflammatories are also important. And so, that includes things like ibuprofen or other nonsteroidal anti-inflammatory medications.

And then, whenever we start thinking about higher degrees of suppression of endometriosis, there are some medications that interfere with the way I describe it to patients as they interfere with the way our brain talks to our ovary and just tells our ovary to chill and stop making so much estrogen. So, we can kind of be on those types of medications for a short period of time to kind of reset and lower that estrogen rate for about the next six to 12 months and, hopefully, help that endometriosis regress that way.

Host: And once treated, what results can women expect and how long does it take? I'm sure you get that question a lot.

Luann Racher, MD: Absolutely. So when you're treating with medication, women can feel relief pretty quickly if that truly is the source of their pain. And so, if it truly is the inflammation and the active endometriosis lesions, we cool those off, then pain can get better pretty quickly. Same thing with surgery. You go in, you remove those lesions that are causing pain. Oftentimes I'll do a surgery, I'll excise those lesions for a woman, and her postoperative pain is nothing compared to the pain she was having before. So, it's not uncommon to hear that, "I feel much better after surgery, even though I should technically have surgical pain."

But there are other conditions that can run with endometriosis. And so, I tell all of my patients that, while we're going to try these medications and we're going to try this surgical intervention, even if we don't improve things 100%, we need to keep our minds open that we could have some musculoskeletal pain. We could have some neuropathy or nerve pain. We could have some bowel and bladder pain that maybe part of the endometriosis, like downstream effects. But treating the endometriosis directly may not improve those symptoms. So oftentimes, women will still need pelvic floor physical therapy, or even trigger point injections, or even neuromodulators. We don't use opioids for the treatment of endometriosis, but things like Neurontin, or the medications in that family can be very beneficial.

Host: If left untreated, what are the potential dangers of this?

Luann Racher, MD: So, the dangers are, if it's left untreated, it can continue to progress, meaning that you can have more scarring. Maybe you don't have infertility right now, or maybe you don't have infertility due to scarring of the fallopian tubes right now, but if left untreated, that could progress and cause scarring. It could result in worse pain. Sometimes it's kind of like someone pours bubble gum into your pelvis and everything can stick together. So, untreated endometriosis can start to involve your bowels or your bladder. And then, it can make future treatment even that much more difficult once we involve other organ systems.

Impact on quality of life can definitely worsen as time goes on. As far as true danger dangers, there's very few life-threatening risks associated with endometriosis. But untreated pain can definitely lead to depression and anxiety, and also like a PTSD type picture.

And then, it is very rare, but it can happen that endometriosis can turn into a cancerous condition. So just like we can get cancer of the lining of our uterus, we can also get cancer of endometrial cells from endometriosis. That is very common. Thank goodness, it's only about 1% of patients that will experience that. But it can happen.

Host: And in summary here, Doctor, what's your overall message to those joining us about getting this addressed? Because it sounds like the good news is it can be typically very successfully addressed, right?

Luann Racher, MD: Absolutely. I think the biggest take-home is you are your best advocate. And so, if you feel like that you are not getting the answers that you need, if you feel like you have voiced that this is greatly affecting your quality of life, and you're not really getting the interventions or the multimodal treatment that endometriosis requires, then it may be time to seek an endometriosis specialist.

Host: You know, doctors like yourself, always pushing patients to be your best advocate, right? You don't want to have to see five different doctors when you can see hopefully just one.

Luann Racher, MD: That's right. That's right.

Host: Well, folks, we trust you are now more familiar with endometriosis. Doctor, keep up all your great work. Great advice indeed, and thanks so much again.

Luann Racher, MD: Thanks for having me.

Host: Thank you. And to make an appointment at UAMS, please call 501-686-8000. If you found this podcast helpful, please do share it on your social media. I'm Joey Wahler. Thanks so much again for being part of UAMS Health Talk from University of Arkansas for Medical Sciences.