Gynecologist Jeannette Lager, MD, MPH, associate director of the UCSF Endometriosis Center, offers a thorough update on this painful condition impacting around 10% of U.S. women. She notes essential elements of the history and physical exam, including tips on assessing pelvic pain, then discusses treatments, ranging from NSAIDs and hormones to surgical options. Learn to align therapeutic choices with patient goals and better appreciate all the factors influencing pain perception – and relief.
great thank you so much for that introduction. And um I'm glad that all of you are here to hear about endometriosis and chronic pelvic pain, it's one of my passions. Um and so I'm excited to share that with you. I have no disclosures. Um and I do appreciate you taking your time out of your busy days to listen. We're gonna go over a few things. We're gonna talk about endometriosis. Dispensary and chronic pelvic pain, discuss the initial management for treatment, um rationale for imaging and then when to refer patients. Um As um as you mentioned, we we do have a comprehensive endometriosis center um and so I'll go over a little bit of that evaluation, the treatment modalities and then answer any questions that you put in the Q. And a chat at the end. So dismantle area in general is painful. Menses. Primary is when it is in the absence of pathology, whereas secondary, of course is when there is a reason for the dismissal area. It's very common in young women from the time in young patients when from the time when they start their period As high as 50 to 90 um can lead to students that end up missing school. Um they administer pain medications um even before seeing a physician for evaluation and can be associated with nausea, vomiting, difficulty sleeping among other symptoms. The secondary dispensary as I mentioned is related to um some ideology. One of the most common is endometriosis and that's what we're focused on. But because this memory is so common among patients even from the time of their first menses. Um the time to diagnosis can be quite long. So on average, seven years ranging from 3.5 to 12.1 endometriosis. Um as you likely know, is when the ectopic endometrial glands are noted in other areas outside of the endometrial cavity. So most often that's in the pelvic area near the ovaries, behind the uterus by the bladder, um sometimes near the bowels. Um Occasionally we can see it near the diagram. And um rarely patients can even have plural endometriosis. It's estrogen dependent. Um and um it's an inflammatory condition that can affect women in all stages of life. The prevalence is very difficult to estimate because delay in diagnosis. Um some patients don't necessarily present. Um so it's about 10% is what we estimate in the us and it has an incredible economic impact. Um Where patients will have enough pain that whether they're missing school or work and can cause a decrease in employment productivity of 16.9% and up to 87 billion dollars. Um So, and this is just a laproscopic image of the uterus. You can see the bilateral fallopian tubes. The white off down at the bottom is um the ovary and the bowels are at the bottom. Um And what happens with endometriosis is that as these inflammatory um signals occur with each menstrual cycle, The endometrial glands that are outside of the uterus cause chronic hemorrhage inflammation. And this can lead to areas of fibrosis and ultimately distortion of public architecture. So in the image to the right, you can see that there are some areas where you can see the dark patches of endometriosis. Um it can sometimes be um what they would describe is powder burn lesions. It can look like clear vesicles and later I'll show you pictures comparing to adolescents who can have very subtle um images. But um you can see the different types of endometriosis here. What can also happen is um where a distortion of public architecture, where the ovaries can be in a kissing appearance. So they're actually stuck together. Um there can be obliteration of the posterior cul de sac because all of that area of endometriosis, fibrosis um can often meet there and can destroy the public architecture. The most common theory as to why endometriosis occurs is Sampson's theory, which is a theory of retrograde menstruation so that when a patient starts the period that the endometrial cells travel through the tubes um into the pelvis that we do know that people do. Do you have retrograde menstruation That's that's been noted prior to this. Even prior to that kind of a diagnosis of endometriosis. Um but that's the most common theory have some challenge this theory because there are patients who present even premenstrual with endometriosis. Um And so it's thought that it may be also related to a malaria in embryonic rest or some sort of preceding occurrence that happens prior to menstruation. So even um related to endogenous estrogen from the parent from the mother. That they can have an increase of endometrial cells for that reason as well. Or that it may be vascular lymphatic spread. And as we mentioned um that this can cause the alterations which can cause disease. Risk factors for endometriosis include obstruction of the menstrual outflow similarity in anomalies, um prolonged endogenous estrogen exposure. So if a patient has never been pregnant before um if they have early monarchy um late menopause D. Es. Exposure in utero um a history of childhood trauma, lower B. M. I. And shorter menstrual cycles. Protective factors include multiple births. Kind of the opposite multiple births, extended intervals of lactation where there are Minarik and late monarchy. The most common symptoms that patients present with our dismantle area, pelvic pain, despair. You Nya, sometimes they'll present initially within an excel mass, especially if they don't have many other symptoms that may be finding it when they have an ultrasound for a different reason. Um Same thing with infertility, they may come in for an infertility evaluation, not have any symptoms related to their period but then are noted to have an enemy trauma and then less commonly related to endometriosis lesions that are in the bowels or near the bladder. They may have dyskinesia to syria, he materia, rectal bleeding or shoulder plane related to um referral pain of the enemy traumatic lesions of the diagram. There are no clinically useful biomarkers to diagnose endometriosis. Um We know C. 1 25 is often elevated but can be elevated in many many other inflammatory conditions. Um The ultra Senate M. R. I can sometimes identify cysts that are endometrium Aziz. Um However those are limited to the size of endometriosis Lesions. M. R. I usually doesn't pick up lesions that are smaller than five. And um it can also be tricky because a cyst that appears to be an enemy trauma could also be a hemorrhagic cyst. Um But if it is persistent because those both can be very similar if it's persistent and often is an enemy trauma. So it's um close to diagnostic but the definitive diagnosis is laparoscopy and biopsy of the surgical specimens. Um First line treatments include hormonal agents, usually what most patients who have already tried and sets or other forms of analgesia and then um really the whole gamut of hormonal um medications are options. So that could be the marina I. U. D. Combined oral contraceptives, progesterone only pills. Next plan on depo Provera um maneuvering or the vaginal ring and all of those will help improve the symptoms of endometriosis. Um And the decision of which to start with and which one to do a trial of is directly related to kind of patients medical conditions in history and then um what what they prefer to use as well. So as we talk about the first line treatments um you know I think it's very even though the gold standard is laparoscopy we can also manage and treat patients for endometriosis without a surgical diagnosis. And when patients have um the majority of the symptoms they have a negative ultrasound. To rule out other um anatomical pathology. Um I think that it's very reasonable to give them a presumptive diagnosis of endometriosis and move forward with treatment options. So um and sets hormonal management and then I'll go into further detail about some of the other treatments. So the question of when to refer patients to the endometriosis center. Um That can be really any time when it feels like um you would prefer to have an opportunity to have the patient talk to us as well. Most of the time when we see patients um they have already had a trial of and said hormonal management. They may have tried five different birth control pills in I. U. D. Um They might have tried only you know a couple of different hormonal regimens before they're referred. If a provider is comfortable doing a trial of one of the Gr NH agonists or antagonists. I think that that's very reasonable to um the issue with the Gr NH agonist and antagonist is sometimes they can be a little bit difficult to get approved or they need preauthorization. Um So that can sometimes take a little bit of time to take care of that. Um But I think that any form of management that a provider feels comfortable with um makes perfect sense. And then referring when it's out of the providers comfort level or um scope. Um Typically we'll see patients who usually have ultrasounds prior to coming to see us as well. Um But um but that's that's generally where when we usually will see the referrals the other time that we'll see referrals to. Sometimes that the patient has um really negative experiences with birth control pills or hormonal medications and they strongly desire surgical diagnosis um prior to starting hormones just because of their negative experiences. Then sometimes they'll be referred to us as well. Um And I think that's that's very reasonable as well. We can always discuss risks and benefits of surgery with the patient. Yes. Other considerations for management is just because pelvic pain. Um The ideology of pelvic pain is so broad and the diagnosis can be multifactorial. That if it seems like it's more likely painful bladder syndrome which often overlaps with endometriosis, then um it would make sense to do or for all the urology. Prior two referral here and then um G i if it's related to I. B. S. Sometimes patients will have back pain or they have other musculoskeletal issues where um Petey can be helpful um There are pelvic floor physical therapist to that kind of focus on the pelvic floor and so that can be very helpful for patients and then if they have other overlapping chronic pain um conditions, then pain management or pain anesthesia can be helpful when um they get referred to us. And I'm sure that this is the same thing that you're doing when you're evaluating patients is that we, you know, we always take a history of their pain um with pelvic pain, it's particularly important to hear a detailed story of when um when they first started having the pain, was it from the time they first started having menses, um what have they taken so far? What makes it worse and better? The quality of the pain and the location. So, if it's more valve are pain, I think that's very helpful information when we're thinking about a focused exam. If it's disparity ania with deep penetration, um If the pain is only during their cycles. If oftentimes patients who have pain for a long time, they'll start by having pain during their cycles and then it'll become outside of the time that they have their period. Um If there's any temporal association with other events. And I think the other thing that can be helpful is just too, they can keep a pain diary or a calendar to note when they're having the pain Um taking this history, I think can be helpful too because it helps us think about um what their goals are of care. So, for example, if they have very severe pain that they rate as a nine out of 10 and it's causing them to miss work or school in a way that they weren't able to before that maybe one of their important goals of care is to get back to doing their normal job um when taking a medical history, it's important to cover any other pain syndromes. So sometimes patients will have fibromyalgia to try to differentiate some other symptoms of fibromyalgia with their endometriosis symptoms, psychiatric psychiatric history can really increase their pain sensitivity. And so um if they have high anxiety that's untreated or depression, that can make their pelvic pain much worse um and then asleep history because it may be that they have a pre existing sleep condition um that is separate from the pelvic pain and endometriosis pain. So just making sure that that's treated as well, and then it's helpful to know what treatments they've done so far, what the outcomes were of each of the treatments, whether it helped. Um If it made the pain worse um side effects to the medications and I think that can be really helpful as we think about what we recommend for each patient. Um If they have significant side effects, try 10 different birth control pills, then, you know, it would I would likely not recommend birth control as one of the first recommendations for that patient, but then, you know, it might be that they only took each birth control pill for a week or two weeks. Um and I think that that is hard to really get a good trial of that specific birth control pill. So that would be another aspect of taking an opportunity to kind of talk them through all of that. If they've had previous surgery it's very helpful to have the details of the surgery. Um patients will sometimes have just a diagnostic laparoscopy. So um a surgeon will look in see if there's endometriosis or not and um then take out the camera and that's the end of the procedure systems. That can be a really quick surgery. Um And so it's helpful to see the op report. Um surgeons will often give their patients pictures from the surgery. Um So that that that's really helpful to see and to see the extent of endometriosis. Um With a patient who has had a conversion to an exploratory laparotomy from a laparoscopy that tells me that there was probably significant adhesions or may be related to previous surgeries like a C. Section or trouble or other surgeries or they might have a history say of tubo ovarian abscesses and because of that they have a significant adhesion. So um usually the operative report and the details of that can be very helpful. Um And they might have something like if they for example had a history of heavy menstrual bleeding. We're done with childbearing and had an endometrial ablation which is a procedure that treats the middle part of the uterus and heats affected decreased bleeding, they may still have pain that they had thought was related to the bleeding, but the pain is persistent because an ablation doesn't always help with the pain aspect. Um And so that can be helpful to understand and think about their history Abuse. The history of abuse is very common in patients with chronic pelvic pain. Up to 47% of patients will have um a history of abuse. It can be helpful to just get the details of um physical, sexual or emotional abuse, whether it's current or it's happened in the past. And that information can be very important to inform trump our trauma informed care. So um to know what might be traumatic or trigger touring with the procedure to use the appropriate language with each patient have a chaperone in the room, talk about where the chaperone would be in the room, um for the exam, discuss the exam in advance what components of the exam we'd be doing and also, for example, if we're doing a trans vaginal exam or ultrasound um to kind of talk them through any imaging that we did. So they know what that we would do so that they know what to expect. Um Some patients who can't tolerate exams at all. Um We can always plan to either do an examiner anesthesia or with pre medications. Um it's helpful to talk about the current treatment regimens. So not only the treatments that they've done in the past, but what they're doing currently um including any medications, narcotics hormones, any topic, als um A lot of patients who see a natural path or have um another integrated medicine provider may offer, you know, they may be taking supplements for that reason. They may use illicit substances, they may be getting their prescriptions from a family member of friends. So it's helpful to just know what medications are on, how they obtain the medications and then any other treatments, osteopathic treatments, acupuncture, um and how much their activity is limited and how those medications kind of manage that. And I think that when we talk about um the current treatment regimen and what the outcome of what they're doing currently can be very helpful to talk about expectations moving forward. So if a patient has had pain, for example, for 20 years, it's rare to be able to treat that pain and have it go away in a month. It always, it often has overlapping um reasons for the pelvic pain and just takes time to kind of work towards place of less pain and maybe not no pain at all, but at least to decrease their pain. Um For the exam, um we'll do a detailed exam and we don't always do the exam on the first visit, especially because a lot of patients come from so far away. We utilize a lot more telemedicine to be able to do consultations with the patients. So um and I think that that's great especially for the patients so that they don't have to drive four hours or five hours to get to mission bay. Um And so um we this may be either the first visit or this could be a separate visit and um to do a general exam um at the time of the abdominal exam to just look really carefully to see if there's any scars masses popping at the back and the flank for any tenderness. Um If there's areas that are perhaps trigger points for the patient, that can be really helpful and it's helpful when we think about treating trigger points. Um during the exam the scars can be really helpful because sometimes um They they're very good descriptors of surgical history. Um so if a patient may have had an appendectomy but it was 18 years ago, um we'll see that that it's an open incision and and that's helpful when we're kind of thinking about surgical planning. Um Then after the abdominal and back exam would be a visual inspection of external genitalia. And particularly with someone who has evolved academia um to look carefully for other diagnoses such as like in sclerosis um or other other reasons that that they could have the pain, they could have fissures or some sort of vaginal trauma that can be helpful from that initial inspection and then a neurologic exam. Often what I'll do is I'll take a cotton swab and break it in half so that there's one side that's a little bit sharper and then the cotton swab side and to do a careful exam on the external genitalia. Um to see if sensation is equal. Um You can check reflexes and then um also to identify any areas of pain for the speculum mixi um looking for any discharge, any signs of atrophy trauma infection, do a wet mount if appropriate. And then also to look at the location where the cervix is if the cervix is um asymmetric or um you know very very anterior. Those are all signs that they could have um significant heterosexual endometriosis. Um So that can be helpful information as well. Then um after I do the speculum exam I'll do a single single finger digital exam. So usually just one finger and I try to let the patient know that it's just gonna be one finger. Um And um start with the perennial muscles. So kind of going from most distill too deep so perennial muscles. And then I'll have the patient contract and relax because um we that can give us an opportunity to check also for public floor. This inertia which public floor of physical therapy can be very helpful for. And then I go to um basically 3:00 and 9:00 to check operator muscles. Um 5-7:00 for the para formas muscles which is the whole um kind of basket weave of the large pelvic floor muscles. And then behind that para formas and then bladder tenderness which can be either related to endometriosis. That can be painful bladder syndrome. Um To move the cervix to check for cervical motion tenderness which may not be related to pd but can be related to the enemy traumatic lesions on the uterus, ankle ligaments. Um rectal and rectal tenderness. Then after the single finger digital exam will do a bi manual exam to evaluate the uterus and exa and then um sometimes a recto vaginal exam which can be very helpful if the uterus is um retracted back and very retro flex. Which we often can see with Stage four endometriosis is where the ovaries are kissing and parents behind the uterus the uterus is still tipped back. Um And so um to examine for obliterate cul de sac or uterus april modularity, as I mentioned that most patients will have had an ultrasound performed before I see them. Um Often normal. Sometimes it will be um ovarian cysts. And if there is an endometrium a that increases the likelihood that they'll have an obliterated called a six by five. Um And it also allows for diagnosis and valerian anomalies. We often consider doing a dedicated M. R. I. And we've worked closely with the radiologists here and have a multidisciplinary team and we meet regularly twice a month to review images together. Um And so they have a special protocol to evaluate for areas of deep infiltrating endometriosis and um depending on what the findings are and what the patient's symptoms are. We can also do a rectal and vaginal contrast. If a patient has either, let's say, a lesion that was noted on colonoscopy, it can be helpful to do rectal contrast um if they have rectal bleeding that can be helpful. Um and um sometimes we'll see lesions that are posterior to the cervix or lateral to the cervix and the foreign cities that are endometriosis. And so the vaginal um contrasts can also help to kind of delineate those borders. Right? So when we think about treatment options, um the goals are symptom relief suppressing um disease progression or future fertility. And I think that this is when it's important to kind of talk to the patients about what their main goals are because for some patients, for example, fertility maybe either number one goal and so they might have minimal pain or even if they have pain they really want to focus on fertility. Um So any sort of hormonal contraception or hormonal management that gets in the way of fertility would be um We wouldn't use it as one of the treatment options. Um Some patients desire future fertility but have so much pain that they would rather address the pain first and then follow with their desires for pregnancy. Um And then there's then we always think about the conversation of especially for example after surgery or how to suppress disease progression. It is often multifactorial. So it depends on what we see on the physical exam from their history and what treatments um discussed with the patients if further imaging as appropriate as we're making those decisions that you're gonna proceed with any referrals. Um We also go through the same, we have a great team of neurologists, um colorectal surgeons, pain anesthesia, pain psychology, Integrative medicine on our teams. And so um well sometimes refer to different different folks in the in the Integrative Center and then also consideration of public floor p team. And so we have a pelvic floor physical therapy group that sees patients in our office. Um but we also will refer out ideally it's great for patients, especially if they don't live close to UCSF to be able to see somebody that is closer to them and we'll give them resources of outside public floor physical therapists um or they can see our pelvic floor physical therapists and our pelvic floor physical therapist also do tell amid if there isn't anybody that is near them or is not covered by their insurance. And before I discuss treatment options in further detail, I just want to review a few theories of pain because I think it can be helpful to direct treatment options In the early 1960s. A new theory of pain was developed by Ronald Mail Sack and Patrick Wall to account for um the importance of the mind brain relationship in pain perception and it's called the gate control theory of pain. This theory accounts for the physiologic basis for the complex phenomenon of pain. And it does this by looking at the two major divisions. So there's the peripheral nervous system, all the nerves that are outside of the brain and spinal cord, including branching nerves in the torso and extremities and then the central nervous system, which includes the spinal cord and the brain. So if you look at this image, you know, let's say somebody gets hit in the hand, the painful stimulus will send a response to via that a delta and C fibers to the dorsal horn and then it then travels to the secondary neuron and up to the brain. And then the brain detects pain. Conversely if there is um deep touch or pressure. Um This can travel through the proscenium corpus school and then travel to the dorsal horn as well. And that can have a negative or an inhibitory effect on the interpretation of pain. Um So this is why sometimes when someone gets hit on the hand and you kind of rub the hand or put pressure on it, it's using a different sensor and it actually can inhibit the message to the brain. So this can be helpful because activation of touch sensors can then modulate the sensation of pain additionally. Um the neurotransmitters from a painful stimulus can release neurotransmitters to make it easier to feel the sensation of pain which then leads to pain sensitization pain, sensitization is acute pain when when a patient has acute pain that's not managed over time, this long term pain can continue to be amplified. Now this is different from the sensation of touch. So for example, when you first put your socks on in the morning, you can feel a sensation of the socks but as you go through your day that that sensation is diminished and you forget that you even have socks on. Um But pain is actually the opposite where if a patient experiences pain that there is important because it can, the continued pain can amplify the pain and so they may have pain that continues. That's either leads to hyper analgesia. Um Or it can also lead to centralist sensitization. Where that stimulation continues, releases more of those neurotransmitters which um then travel up to the secondary neuron to the brain and then have increased hyper algae zia related to that. So if we look back at the image for the gate theory, um the yellow is the peripheral sensitization and where it can occur when people will be hypersensitive and have hyperplasia. And central sensitization is where the red arrow is. So anywhere above, including the spinal cord can be um hyper responsive and patients can experience more pain. This there is important as we kind of think about the different treatment medications. So um we've talked about hormonal management. Um and I just wanted to review the other areas where we think about treatment. So um First line hormonal agents, birth control pills, vaginal ring. All of those second line hormonal agents are generated hormone agonists and antagonists, both of them down regulate the hypothalamic pituitary ovarian access and can cause hyper estrogen is um so along with that patients will often have hipaa estrogenic side effects like hot flashes, sometimes mood changes. Um And that can range from 25-45% that patients will have things like basil motor symptoms. Um We don't usually recommend it in um patients that we suspect primary dismissed area just because those are often adolescents and um it can affect their bone density, but we do consider it as a second line if the other medications are not effective. Um this can work really well for patients, but all of them have most, most patients don't stay on this long term and are on it for a period of time for management. Other um second line medications include dana's Ole, which is a energetic medication that will inhibit LH surge in stereo stereo to genesis. Um But some patients do not tolerate the androgenic side effects of it, which include acne, muscle cramps, weight gain spotting her statism and voice deepening and then aromatase inhibitors such as letrozole can be used for severe and refractory pain complementary theory therapies have been promising but there is limited data on them. Um exercise heat and if you think back to the gate control theory you know heat pressure. All of those things can help to decrease the pain response. Dietary supplements have limited evidence but may be beneficial. There's some evidence that anti inflammatory diets can be helpful. So I often recommend that to patients when looking at kind of the multiple treatment options for each patient and then things like a tens unit acupuncture herbal preparations. All of those have demonstrated some improvement and dismantle area in some studies but we you know like many herbal treatments. There's not a lot of data it's a little bit less regulated. So um the safety and efficacy efficacy data are unclear. Um Physical exercise activity. Um There's very little data but there's also very little harm for those. Um Physical therapy and occupational therapy can be helpful. Um Especially public for physical therapy can be super helpful. Osteopathy um trigger point injections sometimes um based on the physical exam. If the patient has specific trigger points that can make a big difference. Um For example there could be patients that will have just a trigger point on their abdomen um near their c. Section incision. It's it's often on one lateral side or the other and a trigger point injection with in analgesia like lidocaine with or without steroids can make a huge difference. And I've had patients that have had a couple of trigger points and a pain that they've had for years will improve and go away. Um So there are some studies that show that that can be beneficial studies that have looked at physical therapy and trigger point injection. They they seem to be pretty similar um but can be used together. Um And along with that sometimes the pelvic floor physical therapist, if they have a lot of muscle spasm, we can also do Botox up the pelvic floor and that can help in conjunction with physical therapy to improve public pain. Behavioral treatments include things like CBT, which, you know, is can be a focused cognitive behavioral therapy where they can focus on pain management um psychotherapy just depending on what other factors are contributing to their pain and if their pain is related to disparity union and public pain, sometimes there can be other issues and communication relationships. Um it can contribute sex therapy can be very helpful as well. Pain sensitization as we think about the different interventions for pain to think about it if it's more of a peripheral sensitization if it's more central. Um and then using the medications accordingly. Um as far as pain management medications, um and pharmacologic management. Um the World Health Organization had originally created an analgesic ladder that was created in 1986, Talking about kind of a three step increase for pain Severe pain being opioids um you know, starting with M sets and other medications. And in 2020 it was revised to make it more of um uh bi bi directional um ladder because patients may kind of move up and down along the ladder and maybe do two different um different diagnoses and that if patients don't have pain relief that it may be that there's a minimally invasive treatment um or invasive treatment that may be helpful to address their pain and then it may be a step up when they're in their period operative period of recovery and then I'll go back down as their pain improves. So um so you know, this is not a perfect paradigm. Um But I think that it's helpful as we think about um treatment of medications and and as we all are aware um opioids are a significant problem in our country. And so um avoiding opioids for mild pain. This is obviously important. Um Other medications that have shown a benefit are anticonvulsants like gabapentin or pregabalin. And um antidepressant medications like tricyclics can be very helpful for neuropathic pain. Um Srs and there's great good evidence for snr eyes as well. Some a german medications can be things like topical medicine like cast facing cream if someone has um I thought estrogenic um symptoms that are related to their pain using a topical estrogen or using anti spasmodic surgical approaches. I think um Whenever I talk to patients about surgical approaches approaches is it's important to talk about what their expectations are what their priorities are for the surgery and um That's that's exemplified and you know, sometimes we talk about conservative surgery versus someone who's had public pain for a long time and really wants definitive management. Um and there's one retrospective study of 240 women um that either had just uh Laparoscopy with excision versus hysterectomy vs. Hysterectomy with direct to me. And the rate of re operation changes significantly with each groups of 58% with laparoscopy alone. Um 19% risk for re operation for hysterectomy and then it goes down significantly for hysterectomy with you for ectomy. But when we think about that, we also take into consideration um the effects of having surgical menopause and euphoric to me. And I'll always discuss with patients that when ovaries are removed for benign disease, that the overall all cause mortality increases with the new for ectomy. Um So we'll usually discuss the person benefits of each of those if we're talking about definitive management, some patients have significant deep infiltrating endometriosis where um the lesions are invading into the bowel or the bladder. And so I think that it's really important to talk to patients about the risks associated with the procedure if they have had multiple procedures. Each procedure, um the risk of resolution of pain, the likelihood of complete resolution of pain or need for re operation increases. So the shorter amount of time with each surgery. Um there's the risk of increased adhesions associated with repeat surgery. Um So I think that it's important to kind of talk through all of that with patients. And then um if they do have a lesion, for example, in the rectum or in the bladder. We also talked about a multidisciplinary approach. And working with our urology are colorectal colleagues and having them see those providers as well. Pre surgical to kind of discuss um what their patient's desires are and risk for, you know, bowel resection, risk of class and even if it's temporary um so that they can decide what is the best approach for that particular patient. Um So as far as surgical management that can be diagnostic laparoscopy alone, generally we don't do um a diagnostic laparoscopy alone will will treat if we see areas of endometriosis. So that can be excision or ablation of endometriosis. Adhesions license. So taking down any adhesions performing ovarian cyst ectomy. And then if the patient is strongly desires fertility, um Chroma perturbation, which is where we insert dye into the cervix into the uterus and then look to see if the dye passes through the tube. So evaluating for trouble, patton C. And um these images you can you can see um compared to the previous image laproscopic images. This show's really shows that distortion of the architecture where the two ovaries are almost a kissing parents. This I wouldn't call exactly kissing, they're not quite touching, but what what's right in between them is the bowel adhesion and the bowel that's pulled up to the back of the uterus. So often with patients who have stage four endometriosis will see this. Um Then next picture shows just the adhesions of the uterus to the bowel. And then um the third picture shows all of the para ovarian adhesions and then um the ball fat that's connected to the poster aspect of the uterus. Um diagnostic laparoscopy. An excision of endometriosis is considered conservative surgery, so leaving all of the organs in place as much as we can, You know, rarely with an ovarian cyst ectomy depending on the location and the size will need to do enough for ectomy. Um Otherwise more definitive surgery is hysterectomy or plus or -4 ectomy. And one of the goals of search is really just to kind of return normal anatomy back to its normal location um rather than being kind of tacked up like you see in in C and really awesome. An additional note about adolescents. Um I had mentioned that I'm going to show a few images with adolescents. The lesions can be really subtle. So sometimes you can just look like clear the secular lesions. Sometimes they can be tiny brown powder burn lesions and so they can be a little bit more difficult to identify. Often will do perennial stripping or excision and send them off to pathology, even if it's a subtle appearance of endometriosis. And um in adolescents. Sometimes a diagnostic laparoscopy can be performed just to identify and diagnose that it is indeed. Um endometriosis and someone who say has um secondary dismissed area but it's not clear on what the diagnosis is. Um To proceed with things like pagination antagonist or agonist. Um After laparoscopy we often consider continued hormone treatment. Um So this is usually a discussion that I have with patients is um what to do after surgery. You know does that mean that I can get off all of my hormones? You know? Not not necessarily sometimes um They may decide that there were some benefits of it makes more sense to stay off of hormonal management. Um But Srm the reproductive medicine recommends long term medication suppression for 6 to 24 months. Especially if somebody for example is planning to get pregnant in a year. Then I recommend that they go on hormonal suppression until they decide to get pregnant. Um And then we'll also consider and discuss putting in a leaving a gestural I. U. D. At the time of the surgery so that um to help manage it and and you know we we can put I. E. D. S. In the office of course. But if they have significant pelvic pain that can make it much worse so far already um in the operating room it's easier to place it then and if they do you want to resume sexual activity. Usually they can resume sexual activity to accept or surgery or whenever they feel comfortable. Um patients that have had chronic pelvic pain and endometriosis benefit from ongoing education and support um integration and multidisciplinary services. And so here's a couple of resources online for patients that can be helpful. Um And um it's not we don't always have groups but we do. Our dr Kinney is the integrated Medicine gynecologist and she does do some um chronic pain and endometriosis groups. So that's something else that the patients can participate in. And then this is just a list. It's not exhaustive of our endometriosis team. We have an amazing group of providers that all work together to take care of our patients. And that includes the G. Y. N. Minimally invasive spine surgeons and nurse practitioners. Um The physical therapists and we have several physical therapists that are focused on pelvic floor physical therapy. I mentioned. Dr Kuniyoshi is an integrative medicine gynecologist um and she has a team of acupuncturists as well. Um G. I. Colorectal surgeons like dr sir and um the Euro gynecologist that we work closely with um the reproductive endocrinologists and infertility doctors who we often will share patients that desire future fertility and they're great resources um pain medicine and pain anesthesia who have pain psychologists in their department as well. And then our incredible radiology team that reviews all of the images and can kind of our super helpless. We're thinking about surgical planning um and our pathologist. So um we're fortunate to have such a great team of providers that work together to focus on patient care, mm hmm.