The Message of Pain

USC Physicians are Championing Less Invasive Treatments for the Pain and Infertility Experienced by Women with Endometriosis

by Alicia Di Rado

One of the great enigmas of women’s health hides within the uterus, in the organ’s rich inner lining known as the endometrium.


During a woman’s cycle, the endometrium builds and thickens, readying to nourish a fetus if the woman becomes pregnant. If no pregnancy occurs, the uterus sheds the endometrium through menstruation.
But this monthly cycle is not so simple for the millions of women with endometriosis, a mysterious but common condition in which reproductive tissue grows where it does not belong.

 


The endometrial tissue sometimes grows elsewhere, on the ovaries, fallopian tubes and the uterus’s surface. The tissue responds to female hormones even outside the uterus, so it continues the programmed cycle of build-up and breakdown. But without a way to exit the body, internal bleeding results.


Physicians believe that endometrial bleeding and build-up in the wrong areas contributes to scarring and inflammation, which leads to pain. Over time, the scarring might interfere with the movement of an egg to the uterus, which could cause infertility.


Pain and infertility are the typical banes of this disease, which has no cure. And despite advances in medicine, some physicians still suggest the old standard treatment for endometriosis’ sometimes debilitating aches, even in young women: removing the uterus.


Not Claire Templeman, M.D., assistant professor of clinical obstetrics and gynecology and surgery at the Keck School of Medicine of USC.


“Taking out the uterus doesn’t remove the disease,” Templeman says. “I would say I’ve removed the uterus less than 1 percent of the time, and usually it’s because of other factors.”


Tackling endometriosis with both passion and compassion, she strives to ease patients’ pain. Templeman offers women a message that is more hopeful than those of years past: “We do have better ways of treating endometriosis, even if we still don’t really know what causes it.”


One theory suggests that a component of retrograde menstruation is involved, says Templeman, whose research specialty is endometriosis. In that case, endometrial tissue flows backward instead of exiting during menstruation. Another theory is that the immune system plays a part: While a healthy woman’s immune cells could grab and destroy endometrial tissue that remains in the wrong place, the immune system of a woman with endometriosis might be compromised and fail to flush out the endometrial tissue. As a result, the tissue implants where it falls and it begins to grow.


Today, physicians are diagnosing women with endometriosis at an earlier age, says Templeman, who often sees it in 16- to 18-year-olds. “Doctors are more aware of it, especially those of us who see adolescents. When we see patients with abnormal menstruation and pelvic pain, we are more likely to think endometriosis.”


For women who in generations past might have had to struggle for years with inexplicable pelvic pain before being diagnosed, a hysterectomy was the standard course of treatment.


But for Templeman, there are other options to consider.


If the disease is not hidden deep in the pelvis, hormones often help. Templeman says a typical approach to someone with pelvic pain and possible endometriosis is to prescribe analgesics such as ibuprofen or Vioxx and a three- to six-month course of estrogen-progestin birth control pills. Other physicians prescribe medications such as Lupron, which suppress estrogen stimulation of the endometriosis implant and cause a temporary early menopause.


If symptoms persist despite analgesics and birth control pills, Templeman recommends laparoscopy to confirm the diagnosis and remove the lesions at the same time. She makes two or three small incisions in the skin, inflates the abdomen with carbon dioxide and inserts a long, tiny camera into the area. She passes slim instruments into the abdomen through the incisions, cutting away and removing pain-causing lesions from organs.


Endometriosis can even develop on the intestines or rectum. When this happens, Templeman partners with Howard S. Kaufman, M.D., associate professor of surgery and chief of colorectal surgery, in one procedure to remove lesions in reproductive and colorectal areas.


Women often travel from far-off areas to undergo procedures at USC because of the surgeons’ unique expertise. Templeman, for one, trained in both laparoscopic gynecological surgery and pediatric and adolescent gynecology.


That background has taught her how endometriosis’ pain can hamper the lives of otherwise vibrant young women—an awareness that prompts her to send patients to physical therapist Julie Reynolds, D.P.T., for help.


Reynolds starts by listening to women discuss their symptoms. Pain in the lower back differs from pain in the thighs or bladder, she explains.


“We look at the muscles in the hip and back, connective tissue, joints and more,” Reynolds says. “Our goals are to decrease pain and restore function and tolerance for movement. We want to give women a lifelong pain-prevention program.”


Reynolds works with patients in six-week cycles, suggesting yoga-like exercises for retraining muscles, strengthening and keeping good posture. She uses biofeedback and teaches how to breathe through pain. She also gives women practical advice, teaching how to use ice and heat and encouraging good dietary habits such as drinking fluids and eating fiber to prevent pain-causing constipation.


“These women are usually very motivated,” says Reynolds. “They don’t want to continue being in pain every month.”


Templeman hopes that new investigational treatments might someday help, too. Laboratory researchers are studying drugs called aromatase inhibitors to reduce the levels of estrogens in women with endometriosis; they also are looking into drugs that stifle the growth of new blood vessels, possibly choking off growth of new endometriosis lesions.


For today, though, Templeman believes that better diagnosis of endometriosis is a good start.
“We want physicians to think about the possibility of endometriosis when they hear about pelvic pain,” she says. “Dealing with the endometriosis can help preserve women’s quality of life.”


For more information about research and treatment of endometriosis, or to learn more about The Doctors of USC, call 1-800-USC-CARE (1-800-872-2273).