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Endometriosis

Gynecologist Maria Victoria Vargas, MD discusses endometriosis and how affected women should respond to this condition.
Endometriosis
Featuring:
Maria Victoria Vargas, MD
Maria Victoria Vargas, MD is a gynecologist with The GW Medical Faculty Associates and an assistant professor with The George Washington University School of Medicine & Health Sciences. She completed subspecialty training focused on minimally invasive surgical procedures. 

Learn more about Maria Victoria Vargas, MD
Transcription:

Melanie Cole (Host):  Endometriosis can be a painful, but a manageable gynecological condition. Welcome to the GW Medical Faculty Associates Podcast.  I'm Melanie Cole, and today's topic is Endometriosis.  My guest today is Dr. Maria Victoria Vargas.  She's a Minimally Invasive Gynecological Surgeon with the GW Medical Faculty Associates and an Assistant Professor with the George Washington University School of Medicine and Health Sciences.  Dr. Vargas, let's start with a definition.  What is endometriosis?

Dr. Maria Victoria Vargas (Guest):  Endometriosis is when the uterine lining implants in places where it shouldn't be.  One way that we think this happens is through what we call retrograde menstruation. When you have your period, some of it actually comes out into the abdomen through the Fallopian tubes and the lining that's shed implants in the pelvis, on the ovaries.  And essentially, when you're having a period, you're also having that, in those little implants that are located where they shouldn't be, and that causes a lot of inflammation and pain for patients.  

Host:  Who is most affected by endometriosis?  And while you're discussing that — because it can even present itself in the younger age — why does it often go undiagnosed or misdiagnosed?  Why is it so hard to diagnose?  

Dr. Vargas:  It is very hard to diagnose.  The average delay in diagnosis is about seven years.  It often manifests really early on when women initially start getting their periods.  They usually complain of very painful periods.  You'll often hear that they're often started on birth control pills to help manage those symptoms early on, but no one ever really explains why. It's hard to know all the reasons why people don't get diagnosed early on.  The diagnosis is surgical, so you have to have surgery for diagnosis. That's one reason why people will often treat it with medication before they go to surgery.  I think a lot of women say that they mention this to their doctors, but their doctors say that it's normal to have painful periods. It's sort of something that comes up. They're kind of — they feel blown off by their doctors, and they don't bring it up again.  Sometimes then they switch to a new doctor so that they can get new information.  It's one of the most common stories I hear from patients that I see when I first diagnose them with endometriosis.

Host:  Wow. Is it hereditary?  Is there a genetic component to it?

Dr. Vargas:  Yeah. We don't fully understand the hereditary component, but if a family member like your mother or a sister has it, you're six times more likely to have it.

Host:  That's so interesting.  What are some of the complications?  People are really concerned that it can cause infertility, so if someone is diagnosed with endometriosis maybe in their teens and then around in their 20s they want to start thinking about getting pregnant, is this a complication?  And also, can it lead to endometrial cancer?

Dr. Vargas:  It's one of the most common — it's funny.  It's one of the most common misconceptions about endometriosis.  It does not lead to endometrial cancer, but there is a higher rate of very rare ovarian cancer in women that have endometriosis.  It's very rare.  It's just something to be aware of as you get a follow-up in the future.  If your doctor sees an ovarian mass, it's something to be evaluated, usually surgically depending on the size.  

In terms of the infertility component, it is one of the more common symptoms of endometriosis aside from all the pain that you get from it is infertility.  It may be one of the only symptoms that you have from it, and it's something that should be discussed as soon as the diagnosis is made. It tends to be more common with severe endometriosis, which typically requires surgery just because of the pain that is associated with it.  A lot of times the surgery for the pain can also help for the fertility, but some women that have severe endometriosis and even some women with mild endometriosis do require in vitro fertilization or assisted reproductive technology to conceive. 

Host:  Then let's talk about the main goal of medicational intervention first for endometriosis.  You mentioned birth control before, and people are hearing about medications like Orilissa.  Speak about medicational intervention.  What is it intended to do, and what medications would you try first?

Dr. Vargas:  Historically, the first-line is either a progestin-only pill, which may or may not be contraception and/or just regular, combined estrogen/progesterone birth control pills.  That's the first line of treatment for most women.  The intention is to help reduce the pain, but it also helps suppress the endometriosis.  We don't fully know that it prevents it from getting worse, but from a biological standpoint, that makes sense.  That's what I try to explain to patients who are afraid of the hormones.  They're very safe, and they're really important in the case of endometriosis because they do potentially prevent it from causing more damage and scarring long-term.  

Once you had a trial of either the progestin-only pills or combined estrogen and progesterone pills and if you fail — your pain is not sufficiently improved with that — you can move to Lupron, which is a trade name for a GnRH agonist/antagonist, which essentially suppresses the ovarian hormones from the level of the brain.  It causes a temporary medical menopause that's completely reversible, but it works.  It sounds a little bit scary to patients, but it actually works really, really well to suppress endometriosis pain.  Once people fail the estrogen or the progesterone pills they usually are more amenable to these things that may sound a little scary.  Your doctor should explain it really clearly, so you understand what it is because I know it sounds scary to patients, but it's very safe. 

And then, Orilissa is a pill form of the Lupron.  Essentially, what's good about Orilissa is that you can have a lower dose of it, and also, it's a pill.  If you really don't like the side effects, you can stop it more easily whereas the Lupron is an injection that lasts for 12 weeks.  You have less control over the medication.  Orilissa is pretty new.  I think it was just recently FDA-approved for endometriosis, so we're just starting to prescribe it.  I think it's a really good alternative to Lupron in that it gives patients more control, and also, the dosing can be adjusted. 

Host:  What a great explanation, Dr. Vargas.  Thank you for that.  When does surgery become the discussion?  If they've tried hormonal therapy, estrogen, progestin, combination birth control, Lupron, whatever they've tried, what does the surgical discussion look like, and what treatments available do you have?

Dr. Vargas:  I discuss surgery with patients from the very beginning so that they understand and are fully aware that it's something that could be the next step for them depending on where they're at in their treatment with the endometriosis and how they're doing.  I discuss it in the very first appointment because it's the only way to diagnose the endometriosis, and for women that want — let's say you want to get pregnant and are in a lot of pain, medical options really aren't available to you because any medical option that you take is going to prevent you from getting pregnant. It's something that I think women should be aware of from the very beginning as an option.  

What I recommend, typically, is to remove the endometriosis through a technique called excision so that you actually treat the endometriosis, not just biopsy it, send it to Path for a diagnosis, but actually remove it and help prevent the pain. We've shown pretty good results with endometriosis excision with an improvement of pain in up to 70% of women and improvement in fertility in a good portion of women as well.  

There is an alternative technique, which is to ablate the endometriosis, which means you don't remove it, but you use electrosurgery to try to deactivate it.  The thing is that there is no way to know that that's effective, whereas removing it you get the formal diagnosis, and you actually remove the abnormal tissue.  Most surgeons that are treating endometriosis promote the excisional approach to treatment. 

Host:   At what age would that be a discussion?  Is the excisional treatment — would that be something that you might try on teens or do you want them to wait a little bit longer?

Dr. Vargas:  Yeah, that's a hard question.  For young women, I discuss it from the very beginning as an option, as I said.  Every time you do it — let's say there's endometriosis on the ovaries, some normal ovarian tissue has to be removed, and that decreases fertility for the future.  Even though I discuss it, it's not like I jump to it.  I definitely say this is an option, but I encourage people to try medical management first, especially if they don't have an immediate desire for fertility and they're not in significant pain, and they haven't tried anything for their treatment.  Typically, I recommend some sort of medical treatment to start and explain that surgery is an option — that's fertility-sparing.  Also, I explain that you may require more than one surgery to treat it because unfortunately, the pain can come back, and so some women do require more than one.  

The key is to minimize the number of surgeries and to use it as a tool really when it's necessary. Medical management is there and should definitely be discussed as a first, initial step, but surgery is also an important component of the treatment, and patients should be aware of it from the very beginning. 

Host:  Dr. Vargas, your best advice for young women or women in their 20s or 30s that have not been diagnosed or have had the pain for years and have just really not known what to do about it and maybe taken pain killers, whatever, because it's a very uncomfortable situation.  

Dr. Vargas:  Yeah.

Host:  What do you want them to know about getting diagnosed and the treatment options for endometriosis?

Dr. Vargas:  Oh gosh, I really feel for these women.  This is something that I'm really passionate about, the fact that women get blown off when they are in such severe pain.  Some studies have confirmed that there's a significant quality of life decline and work productivity decline from this diagnosis.  I just want you to know that there are specialists out there that specialize in this.  They can help you.  They know what to do for you.  They're called minimally invasive G-Y-N surgeons, and you should look for someone that specializes in endometriosis if you're not getting the treatment you feel like you need from your doctor.

Host:  That's great information.  Thank you so much for coming on and sharing your expertise, and as you say about a condition that sometimes really gets overlooked and can be quite painful. Thank you so much again, for joining us. You're listening to the GW Medical Faculty Associates Podcast.  For more information, please visit GWDocs.com, that's GWDocs.com.  This is Melanie Cole.  Thanks so much for tuning in.