Supportive Therapies That Help Ease Endometriosis Pain

Endometriosis Supportive Therapy: Can Endometriosis Be Treated Without Surgery?

Endometriosis is an extremely painful chronic condition that often leads to infertility or subfertility and affects about ten percent of women worldwide. It is characterized by growth of endometrial-like tissue, which normally lines the inside of the uterus, outside of the uterus on pelvic organs, the abdomen, bowel, and beyond. This tissue is not the same as the endometrium, displaying very different behavior and unique molecular profiles.

Eventually, personalized “theranostic” (therapy and diagnostic) tools will exploit these unique molecular profiles and lead to far better diagnosis, therapy, and monitoring approaches. Research is accelerating in this area and is already very pervasive in other diseases such as cancer and various immuno-inflammatory conditions. Meanwhile, the only therapies that are available to actually treat endometriosis, not just mask symptoms, are hormonal options and excisional surgery. However, there are major limitations to the argument that hormonal therapies work very well to treat endometriosis rather than simply reduce symptoms. That leaves surgery.

So, to the question “can endometriosis be treated without surgery?”, the answer is a resounding NO. That is not to say that hormonal and other treatments, including anti-inflammatory and perhaps anti-histamine agents such as Zyrtec, whether mainstream or integrative-holistic, don’t help. They might. The following sections unpack this to offer a roadmap of options.

Understanding Endometriosis

The exact cause of endometriosis is technically unknown, but it is influenced by genetic, genomic, hormonal, immunologic, and environmental epigenetic factors. In other words, it is multi-factorial. This means the reason you may have endometriosis could be different from why your friend or even your sister does. Endometriosis can also behave very differently because different factors are probably in play in different people. This makes a standard treatment hard, if not impossible, to recommend to any given patient. This landscape is changing with the advent of bio-molecular pathway research, which is expected to lead to highly individualized targeted treatments, but that is not part of what is broadly available today.

Diagnosis of Endometriosis

Diagnosing endometriosis is very challenging because the symptoms can mimic other conditions. This is part of the reason that diagnosis is often delayed by 5–10 years and intentional or inadvertent gaslighting is rampant, depending on which specialist is consulted. A doctor may be evaluating through a general practice, intestinal, urologic, neurologic, or other specialty lens when forming opinions.

Rule #1 is to listen to the patient, which is almost never done to an appropriate extent. Today’s medical system limitations often lead to five-to-ten-minute visits with a semi-interested and overworked provider who may be under-informed regarding endometriosis.

When rule #1 is broken, appropriate evaluation and testing are less likely to be carried out. Ideally, a clinical suspicion leads to testing that may include ultrasound or MRI, various blood tests, and assessment for associated conditions. None of these will reliably lead to a diagnosis of endometriosis but they can guide appropriate specialist referrals to get to the root cause of pain, such as endometriosis.

Rule #2 in medicine, in general, is to get a diagnosis before recommending treatment. Treatments can be ineffective when aimed at the wrong condition or, worse, can lead to complications and side effects. In the author’s strong opinion, this is often violated in endometriosis care. A common standard is to offer hormonal therapy to see if it might work because the diagnosis might be endometriosis and endometriosis is, in part, fueled by hormones. Whether this is reasonable depends on individual circumstances and choices.

Rule #3 proposes that patients should be offered treatment options after informed consent about potential risks versus potential benefits based on the best possible scientific evidence. This is not always done very well and certainly depends on the trust factor with selected specialists, since scientific evidence is subject to interpretation—something most patients do not realize.

Conventional Treatment of Endometriosis

Traditional treatment for endometriosis often involves medication or surgery. Medications can include anti-inflammatory pain relievers and hormonal therapies. In the near future, medications will likely include targeted biomolecular non-hormonal therapies, but they are not here yet. Pain relievers mainly reduce symptoms and are not intended to treat the disease itself, though they can help as part of overall management. Here, the focus is on treatment.

Hormones aim to either shut down ovarian function (in other words, cut off estrogen) or at least regulate the menstrual cycle, and progestational agents are used to potentially reduce the growth of endometriosis tissue.

Surgery is used for definitive diagnosis as well as treatment by removing any lesions or implants that are found. In some cases, medications and surgery can be used hand in hand, but the order in which they are used and the nature of the proposed hormonal therapy are important considerations.

Hormonal Treatment

International guidelines are confusing and inconsistent regarding hormonal therapy for endometriosis, and recommendations can therefore vary between practitioners. Without detailing every option, several principles matter for decision-making.

The only way to definitively diagnose endometriosis is through biopsy, which is usually done during surgery. Starting treatment that can cause extreme side effects and potential long-term harm without first obtaining a definitive diagnosis can be imprudent; if hormones are offered based on suspicion from history, examination, and perhaps imaging, it is wise to seek a second opinion from an endometriosis specialist. This approach falls within international guidelines but can cause significant misery and potential harm if not managed by experts. Medical therapy essentially attempts either to reduce or eliminate estrogen exposure or to increase progestational agents in order to eliminate lesions. Reducing estrogen levels is not straightforward, since different types and sources of estrogen exist, and endometriosis lesions themselves can influence local estrogen production. Endometriosis cells also differ from normal endometrial cells by being relatively resistant to synthetic progestins or natural micronized progesterone. While hormonal therapy is known to reduce pain when endometriosis is the cause, objective pathology studies show that it fails to significantly retard growth of endometriosis tissue. It also cannot eliminate scar tissue or fibrosis caused by endometriosis, and that fibrosis alone can be a source of pain. While unproven, under some circumstances it may be prudent to use less toxic hormonal therapy options to potentially reduce the risk of recurrence after surgery.

Surgical Treatment

When symptoms, history, physical exam, imaging, and laboratory evidence all point to endometriosis as a strong possibility for pain and/or infertility, minimally invasive surgery should be considered to confirm the diagnosis. If endometriosis is found, medical hormonal therapy may make sense as part of a highly individualized plan guided by an endometriosis specialist.

The caveat is that surgery, even when minimally invasive, carries potential risks and complications. These risks can be minimized in the hands of an expert surgeon, but they should be weighed in a risk–benefit discussion.

More importantly, assuming an expert excision surgeon has been identified, surgery remains the cornerstone of effective treatment today. While not completely proven for many reasons, excision of lesions and scar tissue (fibrosis), rather than burning them away (fulguration), appears to be a better and safer approach. To explore surgical considerations, see additional resources such as those provided by gynecologic oncology and endometriosis centers, including us here at Lotus: Surgery & Advanced Excision.

Integrative Holistic View of Endometriosis

Since the cause of endometriosis is incompletely understood but highly multifactorial, and because the reason it is present in any given individual may vary, either surgery or hormonal therapy or both may fail. Failure is relative and may mean no immediate pain improvement, persistent subfertility, or recurrence years later. These scenarios are very different and require different approaches. It is also important to consider whether associated conditions have been addressed, such as SIBO or other microbiome irregularities, and other inflammatory immune-modulated diseases. Pelvic floor physical therapy is not just a symptom band-aid but a critical co-treatment for pelvic floor function before and after surgery.

If expert excision surgery and supportive hormonal therapy, when used, fail to alleviate pain, supportive pain management can still improve quality of life. Options can include mainstream pain and anti-inflammatory medications like non-steroidal anti-inflammatory drugs (NSAIDs), nerve block injections, electrical stimulation modalities, and more holistic approaches including acupuncture, acupressure, mind–body biofeedback approaches such as HeartMath, and herbals and aromatherapy.

Taking this further, nutrition and lifestyle choices, along with well-selected and targeted supplements, can be implemented proactively at any point. This goes well beyond simply eating right, exercising, and de-stressing.

Upcoming bio-molecular therapies will target specific biological pathways that are becoming better understood. Many pathways are already identified, and many are not. The challenge is that there are not yet mainstream medical therapies that can target these pathways safely and effectively. Experience from other genomically modulated inflammatory diseases, such as cancer and autoimmune disorders, shows that these treatments take time to develop and deploy safely. Meanwhile, many of the genomic, metabolic, and epigenetic abnormalities that influence endometriosis are known or at least partly known. With few exceptions, while it is too early to safely use pharmaceutical agents to modulate these abnormalities broadly, factors such as nutrients, specific exercise, toxin avoidance, and even state of mind can influence the same pathway abnormalities without added risk.

Nutrigenomics and Epigenetics

Toxins or stress can adversely affect health, while healthy diet and exercise can positively influence it, in large part through metabolomics and genomics and their derivatives. You are born with your genes and, so far, you cannot alter that deck of cards. Some genes may be unfavorable and increase the risk of endometriosis and other diseases. However, not everyone with certain genetic risks develops disease. A classic example involves identical twins who inherit the exact same genetics yet may look a little different (for example, eye or hair color) and often develop different diseases. The question is why.

Anything and everything you eat, drink, are exposed to via skin or breathing, or even think about or emote can affect genes through epigenetics. Substances and neurochemicals—good or bad—can turn genes on and off. The reality is more complex, and multiple genes often affect a single process. Nonetheless, inflammatory and oxidative states can be actively modulated. While it is not known which specific food, thought, or toxin turns a specific gene on or off, there is an understanding of how gene-controlled pathways can synergize and work together to create health or facilitate disease.

Conclusion

Surgery is a cornerstone for definitive diagnosis of endometriosis and serves as a very important part of treatment. The path to success involves a correct diagnosis, attention to detail, and a highly individualized treatment plan. This can only be carried out in consultation with specialists in both medical and surgical management of endometriosis.

Finding the right clinician or team is not easy, but it is a crucial step forward to seek the best fit. The more complex the situation—such as possible advanced disease or repeat surgery—the more important it becomes to have an excision surgeon with master-level skills. Ideally, a specialist is not only a surgeon but is also capable of guiding you through any additional treatment options you may need, both mainstream and holistic. While a master excision surgeon and integrative endometriosis specialist can be hard to find, many have a team that can fulfill these needs.