In this podcast, experienced Endo-Gynaecologist, Advanced Laparoscopic Surgeon and General Gynaecologist Dr Dan Krishnan will be discussing the topic of endometriosis, including what endometriosis is, the treatment options, recent developments in treatment, when a GP should refer and more.
This podcast is the first in a four-part series called ‘The Woman in Pain’.
Please note this is a machine generated transcription and may contain some errors.
*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.
Today I’d like to welcome to the PodMD studio Dr Dan Krishnan
Dr Dan Krishnan is an Endo-Gynaecologist, Advanced Laparoscopic Surgeon and General Gynaecologist providing care in Ashfield and Liverpool.
Dr Krishnan spent two years at the prestigious Sydney Minimally Invasive Gynaecological Surgery (SMIGS) unit, an AGES-accredited fellowship focusing on Endometriosis Excision at the Sutherland Hospital where he now holds a Staff Specialist position. Upon completing his fellowship and obtaining his FRANZCOG, Dan decided to venture further into complex pelvic surgery at Westmead Hospital as a Gynaecological Oncology Fellow. He also holds a part time Staff Specialist position at Liverpool Hospital, where he leads Endo-Gynaecology Clinics and Endometriosis Excision Surgeries.
Today, we’ll be discussing the topic of Endometriosis, which is the first in a four-part series called ‘The Woman in Pain’.
*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.
Dan, thanks for talking with us on PodMD today.
Dan : Thank you for having me.
The topic of today’s discussion is endometriosis. Dan, can you describe for our listeners what endometriosis is?
Dan: So to put it simply, endometriosis is a chronic condition that causes severe pelvic pain or infertility in women. So that is the condition itself. Now, why does this happen, or how does this happen? Basically, it is the fact that there’s endometrial tissue, which is usually the lining of the uterus, that lies outside and spreads around the pelvis. Now, as a result, this spreading of endometrial tissue or lining of the uterus outside the uterus and sticking around the pelvis causes a lot of complications to women, most commonly pain, but sometimes can also cause severe adhesions in the pelvis that can cause infertility.
How would a patient with endometriosis typically present?
Dan: So the two most common symptoms would be one pain and secondly infertility. Rarely, sometimes we see patients with bowel symptoms or urinary symptoms that can be related to endometriosis itself, but their most common presentation will be pain. And sometimes we find endometriosis as part of her infertility work up.
What are the risks or effects of the condition?
Dan: The biggest problem is that it causes chronic debilitating pain in patients with this condition. It can compromise fertility and sexual function and women it impacts families, partners, carers. It affects social and economic participation of women due to this condition. It can also affect physiological, mental and psychosocial health in patients of reproductive age, which is younger women.
What are the treatment options?
Dan: The first thing I’d like to start with treatment and management options for endometriosis is lifestyle change. I advise all of my patients to have a 10% weight loss if they are overweight, I send them to an exercise physiologist to help them with this. I send them for physiotherapy to help them with pelvic pain, and there’s a lot of Women’s Health physiotherapy specialising in pelvis out there, that can really be beneficial for women with chronic pelvic pain.
The other most important thing is this is this early psychological psychology referral for patients with this chronic condition. So the first step is always going to be modifying those lifestyle factors, putting in place non-medical options, making sure they have all started because as we all know, lifestyle factors, physiotherapy, psychology, weight loss, these are processes that take some time and needs to be started early on, because we have a referral pathway in place and changes can be implemented.
Once I start with the lifestyle changes, my first line for treatment would be simple analgesia for pain relief. I generally commence my patients with regular Panadol anti-inflammatories. Sometimes buscopan, it is really important to avoid opiates or any other stronger pain relief in the first instance with endometriosis patients. As a side effect of Constipation can be extremely non beneficial for patients with pelvic pain. Together with analgesia, I start a huge Constipation management regiment in patients, starting with a high fibre diet hydration movicol lactose if required to help with bowel motility and I encourage all my patients to have a strict bowel chart so we know how their pain is related to their bowel motions. I also recommend them to have a cycle chart to advise me whether day one is most painful or the last day of the cycle is most painful. Just to have a diary of pattern of what pain is for a specific patient.
I then go into medical and hormonal management of endometriosis. And most of our medical specialists, GPs, gynaecologists would be very familiar with hormonal suppression of endometriosis. It’s usually with the combined oral contraceptive pill. All progesterone only pill which are very specific to endometriosis and other forms of hormonal management would be, the Mirena intrauterine contraceptive device that really helps with long term management of endometriosis.
I also advise patients that it is important to track their cycle so that they can optimise their premenstrual analgesia requirement and regiment to put be put in place when they’re expecting a menstrual cycle. Of course, my favourite and the most challenging part of endometriosis management is surgical excision. As an endometriosis excision specialist, I can highly guarantee that surgical excision will significantly improve pain in patients where lifestyle change and medical options do not benefit any longer.
It is also important that surgical excision is done completely by an expert so that disease is not left behind in the pelvis, and if so, patient is well aware that there is a percentage of disease left behind that may need to be resected at a later stage or with adequate informed consent be resected bearing in mind the complications of radical endometriosis, excision may carry. So that, in short, is the treatment options for endometriosis. Certainly, it seems very concise, but going into detail of lifestyle, analgesia, hormonal, non-hormonal and surgical excision for endometriosis is really important and it is important to tailor this to patients. As all of their symptoms and signs are different.
Have there been any developments in treatment in the last years or are there any in trials or development now?
Dan: So the most significant change in endometriosis recently is the type of investigations available to stage endometriosis preoperatively, one of the most important things that we find is to diagnose or stage, although not 100% accurate, preoperatively with the patient to give them information of the extent of disease, the first thing outside of a pelvic abnormal pelvic ultrasound or a routine pelvic ultrasound would be something called a deep infiltrating endometriosis ultrasound.
It is a highly specialised tertiary gynaecological ultrasound that that can take anytime between 1:00 to 2 hours to perform and it is performed by a specialist gynaecologist who has undertaken extensive training in ultrasound. The results of this specific ultrasound will tell us the stage of endometriosis, with particular interest to the bowel and other aspects of the pelvis that may require extensive surgical excision, not only by a gynaecologist, but sometimes a colorectal surgeon and a urologist.
So that we find extremely helpful to diagnose patients, to provide detailed, thorough informed consent process to book surgeries in this extremely complex patients and to provide adequate risks and complications, including a percentage number for each, so that patients can make a decision to what extent they would like the surgery to be performed.
Another really developing investigation for endometriosis would be a pelvic MRI. We found pelvic MRIs utility and endometriosis extremely helpful, particularly with bowel endometriosis or bladder endometriosis that may be missed occasionally with a routine pelvic ultrasound. The other most important factor for endometriosis is the importance of completely excising the disease. Initially, ablation was the mode of therapy for endometriosis when this was done surgically. However, in recent most evidence, it is really important to achieve good outcome that the endometriotic tissue and nodule is resected in completion.
The other new thing about endometriosis or recent development of endometriosis is specifically trained endometriosis excision specialists via a new pathway of advanced laparoscopic surgery such as myself, where I completed a two-year fellowship specialising in endometriosis excision, and it is really important that for good surgical outcome patients have surgery by a high-volume endometriosis excision surgeon. It’s just. So that the depth and adequacy of resection is maintained , adequate pathology is used to diagnose specialist inspection of the slides is used to diagnose endometriosis and not to under diagnose disease. And it is also really important to suppress the patient post operatively adequately, so these are the few changes in recent years with endometriosis.
Are there any warning signs a GP or their patient can look out for?
Dan: So the most important thing for GPs to know is that menstrual pain is never normal, and I think early referral to a specialist specialising in pelvic pain and endometriosis is vital. Painful intercourse is also never normal, and it can start as early as painful periods and painful intercourse can start in very young women and should be never taken lightly by general practitioners. The other most important population of patients would be patients who are pain free but are having trouble conceiving and this could, like most, could be likely to be due from endometriosis. So, infertility or subfertility in patients should raise warning signs to GPs. And of course, patients with pelvic pain at any age should never be normalised.
What is the likelihood of recurrence of the condition?
Dan: Approximately 20 to 40% of patients would have post-surgical recurrence of endometriosis and how do we find this? There is no improvement in pain. There is no improvement in fertility or pain is suppressed for a few years and then restarts after a few years of surgical therapy. There could be sometimes ultrasound findings of recurrence of endometriosis which could be incidental or from symptoms.
And because these are quite common, what we recommend in our endometriosis practice and unit is to continuously monitor patients for a few years after surgery to make sure the symptoms do not recur, and if they do, to be suppressed immediately compared to before. I would like to raise because of the likelihood in the raised recurrence rate of endometrium it is absolutely vital to suppress the menstrual cycle after surgical resection, the failure to suppress menstrual cycle of the surgical resection would increase the rate of recurrence of endometriosis in sometimes can make the entire process of endometriosis excision a complete waste of time, as disease will come back very, very rapidly.
When should a GP refer to a specialist like you?
Dan: So a GP should refer to a gynaecologist specialising in endometriosis whenever they have a patient reporting painful period. I find there is the starting point of endometriosis. Before starting patients on analgesia and pain medications, I think it is really important to immediately seek specialist consultation. Basically, any woman in pain, any woman with abnormal symptoms of menstruation, and any woman of reproductive age with abnormal bowel or urinary symptoms need to be referred to a gynaecologist.
What role does the GP play in the treatment of the condition?
Dan: The first step is identification. It takes a long time for a patient to seek a gynaecologist help in Australia, I think the average time is somewhere between 7 to 12 years before it is diagnosed by a laparoscopy, so the role of GP is in the identification of these patients to avoid the delay of referral to a specialist, to shorten the time between symptoms and surgical diagnosis. So I feel the biggest role of a GP is to have a clear picture of endometriosis very early in a patient’s presentation.
Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on endometriosis?
Dan: So I have 5 myths of endometriosis that is not true that I would like to state here for all GP’s out there.
Period pain is normal. No period. Pain is never normal.
The second part is if you don’t have pain, you do not have endometriosis. This is not true as well. Patients with infertility, sometimes their only presenting problem would be endometriosis, so endometriosis may not always cause pain in patients but can cause infertility.
Point #3 having a baby will fix endometriosis. This is entirely untrue. Pregnancy is never the answer and certainly does not suppress or cure endometriosis.
#4 if you have endometriosis, you cannot have children. This is also untrue. Patients with endometriosis with adequate treatment and resection to succeed in having a family.
#5 hysterectomy will cure the disease. This is not true. A hysterectomy does not cure endometriosis. Endometriosis excision cures the disease.
Thanks for your time and the insights you’ve provided.
Dan: Thank you