March is Endometriosis Awareness Month, a time to throw a spotlight on a condition that affects an estimated one in nine Australian women aged 18-44.
Endometriosis is a chronic condition that can cause pain and affect fertility, where tissue similar to the inside lining of the uterus appears in the pelvis, in ovaries, and occasionally in other places.
Symptoms can also include heavy menstrual bleeding, sexual, bladder and bowel problems.
Dr Marilla Druitt is an obstetrician and gynaecologist and visiting medical officer at St John of God Geelong Hospital. She has a special interest in endometriosis and pelvic pain, and minimally invasive surgery, and helped develop the national guidelines for endometriosis with RANZCOG released last year.
Dr Druitt says endometriosis can be symptom-free until a couple is having trouble conceiving, but can also present with period pain, and is occasionally diagnosed when surgery happens for another reason.
“Researchers are looking for a non-invasive way to diagnose endometriosis, but at this stage, the gold standard is with a laparoscopy,” Dr Druitt says.
“We can see the tissue and can treat it at an operation. Interestingly, the amount or stage of endometriosis has not been shown to correlate particularly well with the amount of pain or difficulty with conceiving.”
Dr Druitt says endometriosis can affect fertility due to a number of factors, including delaying conception due to chemicals released, adhesions obstructing fertilisation in the fallopian tubes, and sometimes painful sex.
“Pain is also always multi-factorial, and women with endometriosis can suffer period pain, pain with using their bowels and bladder, sexual pain, and pelvic floor muscle pain,” she says.
“If they are not trying to conceive, the one class of agents we have as medicines – hormones – are used for ovarian suppression and no periods. Medicines seem as good, if not better than surgery for the treatment of pain associated with endometriosis.”
But Dr Druitt says her consistent message is that a holistic approach is harder work, but ultimately it will lead to a better quality of life.
“Women with endometriosis, and those with all the pains and no endo’, almost always can benefit from a holistic approach to their care,” she says.
“Pelvic floor pain physiotherapy is excellent for tight sore muscles, Pain Neuroscience Education and helping bladder and bowel symptoms.
“Cognitive behavioural therapy with pain psychologists has also been shown to decrease pain.
“We should treat irritable bowel syndrome, which often co-occurs, as it’s hard to fix one pain if you don’t fix all pains, and the low FODMAP diet and – believe it or not – gut directed hypnotherapy – have great evidence for effectiveness for IBS.
“Exercise treats pain, melatonin has evidence for sleep, and improving mental health should always be considered from the outset – not one then the other.”
Dr Druitt says a big step in treating pain at St John of God Geelong Hospital has been the appointment of specialist pain nurse Patsy Holland.
“She helps with difficult to manage pain, provides an interface with rehab and other services, and this addition to interdisciplinary care is the gold standard for pain management.”
And recent national guidelines for endometriosis were long overdue, she says, and she hopes they will lead to earlier diagnosis, more recognition of the condition, and drive improvements in clinical care and research.
“Women often wait years for a diagnosis, and for some this does not matter if their symptoms are well treated. Either way, the message is that pelvic pain that interferes with your life is not acceptable.”
Dr Druitt is currently involved with Deakin University’s randomised controlled trial – the HAPPI study – which is a mind-body intervention for people with endometriosis and pelvic pain. The trial is halfway through recruitment. Details can be found here.