109. Endometriosis Treatment: Beyond Birth Control & Hysterectomy

Endometriosis care is too often reduced to “birth control or hysterectomy”—but women deserve better. In this second part of our endometriosis deep dive, Dr. Monica Minjeur explores treatment strategies that go beyond symptom suppression. We’ll talk about how bioidentical hormones, anti-inflammatory support, and cycle-informed care can help while you await surgery, and most importantly—how to find a true expert surgeon for excision so you don’t end up needing multiple repeat procedures. You’ll walk away with the exact questions to ask your doctor and a clear vision for your fertility and your future.
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Transcript

Speaker: 0:02

Welcome back to Cycle Wisdom, where we empower women to restore natural menstrual cycles, to improve health and promote fertility. I'm your host, Dr. Monica Minjeur, and I'm so glad you're listening today. Today's episode is going to be a continuation of the discussion about endometriosis and reviewing treatment options, including both medical and surgical interventions. If you've not done so already, make sure to go back to last week's episode where I discuss all you need to know about endometriosis symptoms and diagnosis. Today's conversation will be a continuation of that episode. So let's dive in and start with some steps that you can take in order to advocate. Once you suspect that endometriosis may be a key role in your symptoms. So let's start out again with discussing that ultrasound is oftentimes normal, but your pain isn't. And so it's important to continue on and keep going. Track strategically, log the location of your pain, bowel or bladder symptoms, pain with intercourse, any irregular bleeding, and work with a trained fertility awareness instructor in order to have this crucial detail in order to bring that along with you to any doctor's visits. When you see your physician ask if my imaging is normal, but my symptoms are severe, what's our next step? Also make sure that you know your options. Oftentimes women with significant pain are told that they should just go on birth control or something called a gonadotropin releasing hormone analog. Now, these medications oftentimes will suppress symptoms, but they don't diagnose and they don't remove lesions. Instead, restorative reproductive medicine focuses on restoring function. Improving your symptoms for the long haul and helping you to achieve your fertility goals. So my number one tip is to start with building a team. This team is going to be headed up by a restorative reproductive medicine physician or healthcare professional. It's going to include a surgical expert, which we're gonna talk about more today. And it likely also will include pelvic floor physical therapist, and possibly nutrition support, and all of these people working together can help with improving pain and having better fertility outcomes. So let's start with talking about options while you're waiting for surgical intervention. And this is so important because many women are told, we'll just go on the pill and wait, and then when you want to get pregnant, we can stop the pill. And if you're still having problems, we can send you to IVF. Now, obviously in the world of restorative reproductive medicine, this flies in the face of everything that we would suggest because while surgery is the only definitive way to diagnose and remove lesions, there are many other evidence-based ways to reduce pain, bleeding, and inflammation in the meantime without going on the pill. So one of the most common things that we prescribe in our practice is going to be that bioidentical progesterone. Again, we're helping to work support the luteal phase and to help balance that estrogen dominance, which oftentimes drives inflammation. So again, we often will expect that this is going to be something that we see and find on hormone levels, but we always want to identify clearly. What are the labs showing us? And if it looks like you would benefit from that progesterone support, we would prescribe this bioidentical progesterone to be taken after you've ovulated up until the time of your next menstrual cycle, because that's when progesterone normally should spike in our cycles. This helps with reducing endometriosis associated pain and is oftentimes first line medical therapy. If you are someone that deals with excessively heavy bleeding, there are also ways that we can manage this. There is a prescription strength medication called tranexamic acid or list, and short courses of this medication during heavy days can actually decrease the menstrual blood loss. And help to prevent anemia or low blood counts while you await surgery. We also pay attention to your iron stores helping to replace iron if your iron levels or ferritin are too low, and this will oftentimes help with your fatigue, exercise tolerance, and general energy levels. If pain is a problem, we can focus on analgesics, things like anti-inflammatory medications, Tylenol, and also dealing with other things that can help, like pelvic floor, physical therapy, heat, tens unit, gentle movement, optimizing sleep. All of these things working together to help with relieving pain in ways that are specific to your pelvic pain that you're experiencing. In addition to this, we always talk about lifestyle changes. So what kind of foods are you eating? Can we help with decreasing the inflammatory foods? Can we get rid of some of the ultra processed foods and try and add in more fiber? Try and add in more of the Omega-3 rich foods. All of these things have been shown to help decrease inflammation, and we know that endometriosis is a chronic inflammatory condition. Other things that help with decreasing inflammation may include supplements, things like n-acetylcysteine. We also oftentimes discuss or prescribe low dose Naltrexone, and again, low-dose naltrexone has been found to modify the immune system and decrease inflammation. And so if you want to hear more about that, go back and listen to episode number 88 where I talk all about low-dose naltrexone because we do oftentimes use this again while we're waiting for definitive surgical treatment. As we are waiting for you to see a surgeon, we are always talking about tracking your pain, adjusting medications, helping to support your body with inflammation in real time. And although these therapies can help to reduce symptoms and make things more manageable, they don't remove the lesions, which is why we still advocate for timely evaluation. By an especially trained endometriosis surgeon when indicated. So why does it matter and how do I find the right surgeon? And you know, my normal local gynecologist said they can do endometriosis surgery. Why might I want to consider getting an expert opinion? So one of the endometriosis surgeons that we frequently refer patients to, Dr. Patrick Young, recently did a study where he looked at and evaluated women that required repeat surgical excision or repeat evaluation for excision of endometriosis. And what he found was a stark contrast, depending upon the surgeon's level of expertise and how detailed they did with the first surgery. So the general population as we look across the US. About 50% of women end up going back for a repeat endometriosis surgery, either because of suspected or known or diagnosed endometriosis, 50%. Think about that. If you had a flip of a coin that if you did a surgery and half of the time you're gonna need to go back for another surgery down the road. That's just unacceptable. However, if we compare that to surgeons who are specially trained to excise endometriosis, who do meticulous evaluation and who remove every single lesion they find, we find that those women need repeat surgery less than 5% of the time. Now, I don't know about you, but I don't wanna sign myself up for multiple surgeries, and if I'm going to go through the process of having any surgery done, I would much rather trust. A surgeon who says there is only a less than 5% chance you're gonna need to come back for a repeat rather than the general population of 50%. So an expert makes all the difference in these cases because endometriosis oftentimes will be on places other than just the reproductive organs. And endometriosis can infiltrate not only the uterus and ovaries, but also bowel bladder. Ureters, which is what carries your urine from your kidneys down to your bladder. The diaphragm, pelvic nerves, and incomplete treatment oftentimes will leave disease behind. Now, this can create persistent pain. It can create new pain. Recurrence and may not change the course of your fertility. And so true. Excision of endometriosis by a high volume endometriosis surgeon is associated with improved pain outcomes, less need for repeat operations, and improved fertility potential. Especially when it's combined with expert level care from your medical treating restorative reproductive medicine physician. These surgeons will prioritize fertility preservation using meticulous technique to protect ovarian tissue, minimize damage, reduce scar tissue, and have close coordination with your restorative reproductive medicine physician both preoperatively and postoperatively. So when it comes to finding an expert and how do you determine if this person is an expert? I have some questions that I want you to ask in a consultation and that will really help you to dig out, is this person the right fit for me? Now, before you just start cold calling surgeons, always ask your restorative reproductive medicine physician for referrals within networks because they oftentimes will know where are the good surgeons. We want surgeons who are welcoming of complex referrals routinely are collaborating with pelvic floor physical therapists, GI physicians, urogynecologist, and bonus points if they're publishing their outcomes or are willing to share their outcomes. The downside to this is that many times there is a long wait list for these expert level physicians, and many times people need to travel in order to get to those individuals. So it is. Absolutely challenging to find. How do I find that balance? But it is absolutely worth the travel, worth the time to have what we call one and done surgery. So here's a few questions that I want you to consider and ask if you are looking to get a referral to a restorative reproductive medicine surgeon. So question number one, how many endometriosis excision surgeries do you perform annually? And along with that, do you perform excision? Rather than ablation or cautery. Now, the reason this is important is that if your surgeon is extensively cutting out and removing those endometriosis lesions, rather than just burning them off, we know that the excision has better outcomes. Less chance for scarring. And typically when they're removing those lesions, they are also stitching those lesions back together so that there is nothing that's going to create scar tissue. And this helps to preserve fertility for the long run. Ideally, we're looking for a surgeon that's performing at least 80 to a hundred surgical cases per year because we know that that means that they're going to be higher quality and they're more focused on just those excision cases. Question number two, how often do you manage other involvement of organs like bowel, bladder, ureter, or diaphragm? And do you have other people that you can call in if needed? Now, most of the expert trained endometriosis surgeons will absolutely work with other surgeons when needed. It's not bad if they have to call in another surgeon. It just means that they want that expert level of care in order to make sure that no other organs are harmed in the process. So sometimes this means that patients have two separate surgeries, one in order to just diagnose what's going on, literally to go in with a camera and take a look around to see how extensive is this involvement? Is this something that I'm going to be able to manage just on my own? Or am I going to need to coordinate with another highly trained surgeon, somebody who's skilled in managing bowel complications or bladder issues? And that's okay. And I just want people to be aware that sometimes that happens as two separate surgeries, and sometimes it's just a one and done, but really important to at least know and understand how your particular surgeon manages that. Question number three, how are you going to make sure that we are managing my fertility for the long run? What steps are you taking to preserve your ovarian reserve and minimize adhesions? Now, this is important even if you don't have fertility on your mind, because we always want to make sure that we're preserving fertility to the long run because that also helps with ovulation function. Which helps with menstrual symptoms and other symptoms that you may have, even if you haven't had kids yet, or even if you're past that stage of having children. We want to make sure that we are preserving fertility wherever possible. Too often I find that women are sent for surgical evaluation. And they find that there is significant endometriosis perhaps on an ovary. And so that surgeon chooses, rather than to meticulously cut away all of those areas of endometriosis, the surgeon may choose to just remove the ovary in order to remove the pain. And while this does happen in rare cases with our endometriosis trained surgeons, we always are doing everything within our power in order to preserve fertility rather than to just remove the diseased organ. Question number four for your surgeon. How are we going to manage things before surgery and what does the things look like after surgery? What is my postoperative plan? Are those lesions all going to be sent for pathology so that everything that was removed is identified? And what are we going to do to help coordinate and manage my pain? Getting my cycles back on track. And oftentimes this can be deferred to your restorative reproductive medicine medical consultant who is working with you, but we want to make sure that we have the whole picture plan in place. And then final question number five is what are the complication rate? How often do you see that you need to have repeat surgeries and how are you measuring success other than just seeing an improvement in pain? Now, all of the expert level endometriosis surgeons that we refer to are able to answer all of these questions and have been able to identify when there are issues where might we need higher level of care. So things I want you to watch for that may be a red flag is if your surgeon says, well, we'll just burn off those spots. This is considered an ablation. This is not excision of the lesions, and again, ablation is sometimes utilized, but typically has more poor outcomes and oftentimes leads to additional repeat surgeries because all of that endometriosis wasn't cut out. There may still be a base left to it. If your surgeon says your ultrasound or your MRI is normal, so you can't have endometriosis again, that's a big red flag. As we have discussed. Endometriosis oftentimes is very subtle changes. It may just be a discoloration. Sometimes it can present as a clear blister looking lesion, and so just finding it there on imaging is not always the case. Other things that we get concerned about is if a surgeon tells you, well, if you wanna have kids, just go straight to IVF Surgery Won't help many, many, many documented studies show and prove that removing endometriosis, again, in a very systematic and expert level way, will reduce inflammation and absolutely does improve outcomes as far as live births. If your team does not have a plan as far as pathology or identifying what is actually being seen when they excise that, or if they default to just saying, well just go on birth control. We'll suppress it as long as we can. Again, these are not restorative approaches. Your surgeon should be able to coordinate along with you. What are we doing? Around the time of your surgery in order to make sure that we're not only managing your symptoms, but moving everything towards that restorative standpoint so that you don't have to deal with these symptoms long term. Imagine if your endometriosis pain wasn't minimized, your imaging was identified and read by someone who knew exactly what to look for, but also didn't rely on just that for diagnosing your endometriosis. Imagine bringing a clear symptom map to a team of expert level healthcare professionals who will coordinate skilled surgery when needed and help your cycle to heal this way forward is possible. Please know that severe menstrual cycle pain, although it can be common, is not normal and does not need to be your way forward. We can help work together to create a plan that helps restore your quality of life, your fertility, and brings you hope.

Speaker 2: 17:34

If you're ready to work with our elite team of healthcare professionals, go to our website, radiant clinic.com to schedule a free discovery call and learn more about our package based pricing for comprehensive care. We are currently able to see people for in-person appointments in our Cedar Rapids, Iowa Clinic, or can arrange for a telehealth visit if you live in many different states across the us. Check out our website for current states that we can serve medical clients and let us know if your state is not listed to see if we can still cover you there as we are constantly expanding our reach. Please note that our fertility educators are able to take care of clients no matter where they live. Thank you so much for listening to this episode. Please share this podcast with someone in your life who would benefit from our services. Remember to subscribe to this podcast for more empowering content that I look forward to sharing with you on our next episode of Cycle Wisdom.