Personalized High-Tech Endo Excision
Endometriosis is highly variable in extent and location, so you want personalized treatment options. Just like diseases differ, so do individuals and their specific situation. We have the highest tech and the most advanced surgical skill-set, but individual needs call for different answers to help you defeat endo and thrive. ~Dr. Steve Vasilev
Endometriosis is extremely common, affecting as many as 1 in 10 women. Yet it is extremely underdiagnosed, leading to unnecessary pain and suffering for years. Endo occurs when the tissue that normally lines the inside of the uterus (endometrium) grows outside of it inside your pelvis and abdomen. The exact cause of endometriosis is not known, but most theories center on how one’s cells, hormones and immune system works. It may also be due to ectopic endometrial tissue, aberrant endocrine signaling or genetic factors. Women can develop endometriomas, or “chocolate cysts” with old blood and endometrial tissue.
Pelvic endometriosis can be categorized as superficial peritoneal, ovarian or deeply infiltrating. These lesions contain fibrous tissue, cysts and blood in addition to endometrial glands and stoma. The sizes of the lesions vary. It can cause painful periods, infertility, pain during intercourse and excessive vaginal bleeding. Less common symptoms include bowel and bladder dysfunction, low back pain or chronic fatigue. Severe pain does not always equal severe endometriosis. Some patients have minimal pain with actual significant disease and vice versa.
- Superficial endometriosis (on surface)
- Deep Infiltrating endometriosis (invading tissues)
- Ovarian endometriosis (endometrioma)
- Metastatic endometriosis (spread to other areas)
Endometriosis can affect not only your pelvic organs and delicate structures, which include your bladder, ureters and rectum, but also outside your pelvis higher up in the abdomen. There it can involve your intestines. Endometriosis can spread literally anywhere in your body, including, rarely, to distant organs like the lungs (metastatic).
Endometriosis Prevention and Detection
While the near future may bring molecular genetic insights into targeted prevention, today there is no reliable way to prevent endometriosis. In fact, there is a genetic predisposition which is not well understood. If you have a relative with endo, you have a 5-7x risk of being affected. What those genetic switches are will be uncovered soon and prevention and treatment will be enhanced. Meanwhile, you can do a lot towards reducing the chances it will affect you and maybe decrease endometriosis progression. The following are integrative insights into endometriosis reducing lifestyle modifications and is as natural a strategy for endometriosis treatment as possible.
Through regular intensive workouts, you’ll be able to “whip yourself into shape” and most importantly, get to a low percentage of body fat (low BMI or body mass index). By reducing the amount of body fat less estrogen is made in those fat cells and you reduce the total amount of estrogen circulating in your body. Since estrogen feeds endometriosis, the less estrogen circulating in your body, within physiologic normal limits, the better. To emphasize, the best exercise for this is high-intensity interval training (HIIT) or “burst training”. Ideally, you should work with a personal trainer or someone in the gym for safety, but you basically want to go all out for 30 seconds and then rest for 90 seconds and then repeat over and over. This type of exercise builds muscle, which burns more calories from your diet and increases human growth hormone (HGH).
Whole food plant based diet
By eating lots of vegetables as the “base” of your diet, rather than sugar and relative junk, you will lose weight and reduce the estrogen in your body through less fat production as well as helping you maintain regular cycles. When your cycles are regular there is less chance that your body is in estrogen overload. The best animal protein is wild-caught fish like salmon. Maintaining healthy fiber in your diet also helps bind and flush excess estrogen.
Unfortunately, alcohol causes estrogen spikes in your body. So, limit the drinking. This is also a good cancer prevention strategy over the long run.
Simlar to alcohol, consuming a lot of caffeinated drinks per day (more than one) can cause estrogen levels to rise. So, limit this or look for less caffeinated solutions like some teas.
We are exposed to more than 30,000 toxins per year. Some of these can act as estrogens on your body and disrupt normal hormone function. Sources include commercially raised meat and dairy products (especially processed meats), products with insecticide or pesticide residue, unfiltered tap water, many food additives and personal items such as conditioners, lotions, shampoos, soaps and even toothpastes.
This is controversial and, GMO arguments aside, the plant estrogens in soy can theoretically stimulate endo growth. Generally, you would have to consume gallons of it, but at least limiting soy products may help reduce total estrogen in your body. All of the above are helpful to try and avoid more invasive medical or surgical endometriosis treatment options.
Diagnostic Scans and Biopsies
Imaging scans (Ultrasound, CT, MRI) are normal too often unless there is a pelvic mass which can possibly be an endometrioma. This is one of the reasons that diagnosis in the United States can be delayed by many years, if not decades, after the onset of symptoms. If you have persistent pelvic pain with normal scans, it is possible that you have endometriosis. The physical examination and detailed history of pain and overall assessment is important in helping determine if surgery should be performed for a diagnosis by biopsy.
Excision (biopsy) of an implant during minimally invasive surgery is the only way to make a certain diagnosis of endometriosis. Rarely, a needle biopsy guided by ultrasound or CT scan can make the diagnosis. The reason it is rare is that a needle is very small and even if you place the needle accurately in an abnormal area seen on imaging the amount of biopsy tissue is tiny. The pathologist may simply find inflammation and fibrosis or scarring and no active endometriosis. This does not mean it is not there and was only millimeters away from the area the needle biopsied.
Some blood tests, like the CA-125 “ovarian cancer tumor marker”, may be elevated in endo. This does NOT mean you have cancer because CA-125 can be elevated in any inflammatory disease. Endometriosis is inflammatory. With the advent of “omics”, including genomics, metabolomics, proteomics and other research areas, promising blood tests are being developed. So far, none are accurate enough to help in the diagnosis or follow-up testing of endometriosis.
Treatment of endometriosis is partly dependent on where it is located (pelvis or outside the pelvis) and what the stage is. Staging is a classificiation of the severity of pelvic endo.
Stages of Endometriosis:
According to ASRM (American Society of Reproductive Medicine), there are four stages of pelvic endometriosis. This does not always correlate with the symptoms. Someone can have high stage and less pain than another person with lower stage and more pain. But this staging helps determine treatment and the type of surgery that might be best for you. The following is simplified but the general groupings are as listed.
Stage I or minimal endometriosis:
There are small patches or implants either on or around the organs in the pelvis.
Stage II or mild endometriosis:
There are more implants than in Stage I but damage to the pelvic organs is still pretty minimal and there’s not much scarring or adhesions. Altogether, when summed up the implants are not more than 5cm (couple of inches).
Stage III or moderate endometriosis:
Implants are more widespread and are beginning to infiltrate (grow into or invade) the organs in the pelvic region, including pelvic side walls (where the blood vessels, major nerves and ureters are located) and peritoneum. There is more scarring and adhesions and endometriomas (“chocolate cyts”) of old blood in a blister on the ovary, can be seen.
Stage IV or severe endometriosis:
The disease is definitely infiltrating or growing into and affecting several organs in the pelvic region as well as the ovaries. This may be the bladder or the rectum. Anatomy is severely distorted with scars and adhesions and there is fibrosis (like concrete) between organs. Larger and more endometriomas can be seen.
Endometriosis Surgical Treatment
Surgery for endometriosis is used for two reasons: 1/ diagnosis of endometriosis and 2/ treatment of endometriosis. Treatment is either for pain, for a suspicious pelvic mass (possible endometrioma) that might be a tumor, or for reproductive concerns like infertility. Using minimally invasive surgery through very small incisions you can get to the bottom of your pain and to make a definitive diagnosis of endometriosis. Without biopsy proof, you may be getting treated for the wrong disease. Also, early excision of significant implants can go a long way towards years of symptom-free life. Having mentioned that, it is important for your surgeon to use surgery within a well-defined strategy and to time the surgery properly. Each time surgery is done more scars can develop and the more risky the next surgery becomes. So, while this can be a phenomenal help, surgery is not without risk and this has to be balanced against the benefits you might get from it at any given point in time.
What type of surgeon for endometriosis?
The type of surgeon you need for endometriosis treatment depends on your individual situation. Are you trying to determine if you have endometriosis? Do you know you have endometriosis from prior surgery and biopsies and it’s back, causing pain? Do you have a pelvic mass that may be an endometrioma but your doctor is unsure? Do you have fertility issues and are trying to get pregnant? These may all be related but are all different in terms of the type of surgeon you need or what team of surgeons you need.
In general, to get a correct diagnosis a general gynecologist can often do that. However, if you are being treated without biopsy proof of endo, get a second opinion with either a reproductive endocrinologist (a subspecialty of ObGyn) or a fellowship trained endometriosis surgeon. If you know you have endo and need an excisional surgery for endometriosis treatment, consider a fellowship-trained gynecologic endo surgeon and/or a gynecologic oncologist. The more the disease is advanced and the more the pelvis is likely to be very scarred and anatomy distorted, a gynecologic oncologist should be involved for the treatment of endometriosis.
Why should a “cancer surgeon”, a gynecologic oncologist, be involved in endometriosis treatment? Because gynecologic oncologists have an advanced skill set to operate not only on gynecologic organs but also on surrounding intestine, rectum, ureters and bladder; all of which can be affected with endometriosis in advanced cases. Also, endometriosis is associated with an increased risk of ovarian cancer as well as degeneration of endometriosis itself to clear cell cancer or sarcoma. These are things you do not want missed and are especially important to be evaluated for as you get older with a diagnosis of endometriosis. Your life is worth at least an opinion about all of this sooner than later from the right expert, a gynecologic oncologist.
If your main concern is about fertility issues with a diagnosis of endometriosis, a reproductive endocrinologist opinion would be very helpful. At the Gynecologic Oncology Institute, we can help you find the right specialist if we are not the right fit for your needs. We collaborate and work with many general gynecologic surgeons, fellowship-trained excisional surgeons and reproductive endocrinologists to help you build your team to beat your endo. We also provide integrative holistic support and can guide you in this regard as well.
Minimally invasive surgery starts with laparoscopy, or “keyhole” surgery through small incisions instead of a big vertical or horizontal “bikini cut” C-section type of incisions. A camera instrument and operating instruments are inserted through these incisions, which can number from one belly button incision to four or more, depending on how many and what type of instruments are required. The instruments are scissors and graspers that are “straight stick”, which means they can only open and close in one direction. This is reasonable for relatively easy endometriosis surgery excisions but lacks finesse for more difficult surgery with advanced endometriosis and scarring.
The laparoscopic camera usually used is pretty sophisticated and offers good visibility, but in most cases lacks 3-D (three dimensional) view and is not generally able to be magnified. In some centers, 3-D laparoscopy with magnification is available but not very common. Why is this critically important? It is not possible to predict how bad the endometriosis will be or how much scarring there is or what organs might be involved. So, once again, for basic excisions or biopsies or even basic hysterectomies it is adequate.
For more advanced surgery losing that 3-D third dimension is like operating with one eye closed. You lose the depth perception that is very important for delicate surgery in difficult spaces. Try closing one eye and doing things around the house. It’s harder to do isn’t it? Picking things up is not as exact. You can certainly compensate, as people do when they lose an eye, but it’s harder to judge what is further from or closer to you. So, given a choice, using both eyes is better and 2-D laparoscopy screens mimic having one eye closed. This is part of why robotic surgery adds safety to endometriosis excision.
Robotic surgery excision
Robotic surgery for treatment of endometriosis by excision is the 21st century tool of choice. It is laparoscopy on steroids, so to speak. While there are expert laparoscopists who argue that robotic surgery does not add anything beyond laparoscopy, the arguments used are usually cost-benefit business-related mumbo jumbo, some of which is only true when centers are not used to using robotics. But this is not your problem anyway. You want the best equipment and the best surgeons possible to help you beat endo. Robotic surgery for treatment of endometriosis has many features and clinical benefits. These are only some of them:
- Less tissue injury internally due to finesse wristed instruments
- Less blood loss because of the instruments and better visibility
- Less trauma to your abdominal wall because the instruments do not move as much
These features lead to:
- Shorter recovery time
- Less scarring
- Fewer complications, transfusions and readmissions
- Fewer “conversions” to a big incision due to inability to finish the surgery via minimally invasive approach
- Better ability of surgeon to excise endometriosis
Drawbacks of robotic surgery include a slightly longer time to complete the surgery (mostly the setup time before surgery starts), it is more costly (but your co-pays are the same as laparoscopy), and it is not easy to learn. Many surgeons take robotic surgery training, but you do not want a rookie surgeon for complex endo surgery. Select wisely. We realize some studies are published which still claim no difference compared to laparoscopy. It’s important to realize that studies do not capture all the differences between patients and statistics are complex. Without video proof, it is hard to tell if the surgery was even the same quality and extent. So, as mentioned, laparoscopy is certainly a reasonable tool for many cases but do you want to take a chance that your case may be a bit too difficult for a surgeon with one eye (2-D) and without wrists (straight stick instruments)? As noted, at GOI we approach cases individually but have the robot available for your safety and best outcomes.
Medical endometriosis treatment is largely based on hormonal options and/or pain symptom management. At this time we focus on what we do best, which is our very specialized and advanced surgical help, as well as counseling about cancer risk. We will collaborate with your gynecologist or reproductive endocrinologist but do not provide medical therapy for endometriosis. If you do not have someone that can manage the medical and hormonal part of your endo care, we can help you find someone to be part of your endometriosis-fighting team!
Integrative Natural Support
For mild symptoms of endometriosis, there are integrative natural support options to consider and here is an example of some of them:
This spice contains a bioactive ingredient called curcumin, which is a strong anti-inflammatory. Pepper helps its absorption. It’s best to use the root or spice and just add to your salads or as part of curry dishes.
This natural root also reduces inflammation and helps reduce nausea that may be caused by the pain of endometriosis. You can make ginger tea by boiling 1 tablespoon of grated ginger into 2 cups of water for 10 minutes. After straining it, add honey. You can also get some ginger pieces and simply chew on them as needed.
This natural herb from daisy-like flowers is also an anti-inflammatory. But beware that it is also a diuretic, so it can make you feel the urge to pee often. You can make chamomile tea by steeping 2 teaspoons of dried chamomile mix in 1 cup of hot water for five minutes, straining it and adding honey for sweetness if desired. Chamomile supplement capsules also exist if it’s inconvenient to make tea.
Bromelain is an enzyme which helps digest protein and has been used as a digestive aid and anti-inflammatory agent. It can be taken in capsule form, but fresh pineapple pulp is a great source.
Endometriosis Treatment Outcomes
It is difficult to cure any disease when the exact cause is unknown. Such is the case with endometriosis. As we enter the molecular age of targeted therapy, this will change. However, today anyone with endometriosis is likely to see it recur after any medical or surgical therapy. So, the best plan is to make sure the diagnosis is correct, consider removing significant disease with minimally invasive surgery (especially deep infliltrating endo), then focus on ways to minimize estrogen excess in your body. This may include medical treatments listed above or simply being as fit and lean as you can be. Often repeat surgery is required, but you want to limit the number of times this is done to limit scarring from the surgery itself, which can also produce pain. Also, the more surgeries are performed and the more scarring (adhesions) that are potentially created, the more complications are increased. Working with a master surgeon is crucial.
Robotic Surgery Endometriosis Excision Outcomes
Regarding the surgical expertise and outcomes with robotic surgery, from focal to widespread endometriosis, we stand very unique on the West coast. The following information is crucially important in selecting your surgeon.
Basic robotic surgery training and expertise in pelvic surgery is becoming more common for many conditions, including cancer and endometriosis treatment. However, currently, radical robotic multi-quadrant excisional surgery is not standard of care because an advanced skill set for this is not sufficiently prevalent among the majority of surgeons. This expertise is slowly evolving with a relative handful of committed surgeons practicing nationally with adequate experience, who embrace the technique with strategies and tools to minimize risk of conversion to laparotomy while achieving as close to “complete” R0 or CC0 excision as possible. This “R” and “CC” based scoring is something we use for ovarian cancer when life is on the line, not just pain reduction. But the concept is the same, that being to remove the endometriosis as close to “complete” as possible.
Our surgical experience with complex and re-operative robotic surgery spans over eight years and thus far, the results include low conversion rate of <1% with a high rate of complete CC0 macro-cytoreduction and practically all achieving more than "optimal" cytoreduction status with minimal CC-1 remaining disease (almost microscopic and superficial only). In selecting your surgeon it is critically important to understand the following. While today's imaging with CT and PET-CT is good, it is not perfect to predict the extent of disease or distribution. Therefore, the endometriosis distribution can be pan-abdominal and pan-pelvic. In other words, it can be anywhere and involving any organ. Literally, ALL possible situations need to be anticipated and prepared for to optimize outcomes with the lowest morbidity (complications), lowest conversion rates to a big incision and to get the best possible resection success. At the Gynecologic Oncology Institute, we have the specialized tools and advanced expertise to provide a very unique surgical benefit to you even in very advanced endometriosis situations. As noted, we are not alone nationally but are in a unique position regarding the ability to provide minimally invasive surgical options, even in the face of very advanced disease.
Beyond Life With Endo
Beyond beating endometriosis there is quality of life, which can be equally as important. This is especially true because treatment beyond surgery can extend for a long period of time. To achieve the best quality of life after a diagnosis of endometriosis, a personalized treatment plan is crucial to beat your endo and thrive. In addition, the treatment plan must evolve as time goes on. By focusing on you as an individual, and not just on your disease, we guide you every step of the way. At the Gynecologic Oncology Institute, we specialize in helping you plan out the best outcomes possible based not just on your endometriosis but also on your body, mind and spirit.
Endometriosis Critical Tip
It’s crucially important to get the diagnosis straight and get it right early. If you have pelvic pain, at any age, do not “grin and bear it” with no answers from your doctor. Get a second opinion. If it looks like you have endo, the earlier endometriosis treatment starts, with or without minimally invasive or robotic surgery excision, the better the outcomes and the faster you can get back to a good quality of life!