laparoscopy

BLOG #7 QUESTION: ARE THERE ANY ‘ALTERNATIVE THERAPIES’ THAT MAY HELP?

/ topendodoc

Disclaimer: The help I offer in this post is based mostly on observation of my patients whom I have had an opportunity to manage  and interact with over an extended period of time. I do not have any scientific evidence to support the conclusions I have drawn, and you should be sure to consult your individual provider(s) for personalized management.

DIET:
I recommend a diet emphasizing two components. First, your diet should reduce plant and animal sources of estrogen and estrogenic substances. Animals treated with ‘hormones’ to enhance animal growth rates and size may possibly contain estrogenic stimuli to existing endometriosis. There are also plant sources of ‘isoflavones’ and ‘phytoestrogens’ that may have the same potential effect. Think soy products, yams and the like.

Secondly, your diet should be of the ‘anti-inflammatory’ variety. There are a wide variety of these diets available to you online and I encourage you to look them up. The purpose of this component is to reduce the body’s inflammatory response to endometriosis. In theory, a reduction in the inflammatory response to areas of ‘endo’ might slow adhesion formation, swelling, vascular engorgement and micro-cellular influx.

SUPPLEMENTS:
The list of supplements my patients have tried is too extensive to discuss in detail here. However, I would like to mention:

Fish oil (be certain it is pharmaceutical grade): is a good source of omega-3 fatty acids. The anti-inflammatory benefits of omega-3s are well documented. Also, I prefer fish oil in liquid form. If your GI tract does not object, I would gradually increase daily intake up to 2 tbsp/day. Be sure to clear this with your regular doctor before initiating.

The B Vitamins:  are important aids to the metabolism of estrogens, and may also help in the conversion of fatty acids into the beneficial forms of prostaglandin.

HERBS:
I have followed many patients who have used herbal preparations on a regular basis and reported a better quality of life. Try them cautiously for intervals of time off and on to determine their value for you personally. Check with your primary care physician before initiating and be sure to rule out any interactions with current medications you may also be taking.

ACUPUNCTURE:
I have observed an inconsistent response to acupuncture in the patients that I have managed. Yet, I would suggest a trial for anyone anxious to see if pain relief or pain reduction can be achieved. I have never had a patient who tried acupuncture and had their endometriosis “disappear;” however, I have suggested it to patients as a means of possibly improving quality of life until ‘gold standard’ treatment can be obtained.

FloralHOMEOPATHY:
For many years I have shared an occasional ‘endo’ patient with a Homeopath in Atlanta for whom I have great respect. Most of these patients have ultimately chosen ‘gold standard’ treatment. Yet, I can think of several who have bragged on their experience with homeopathy and wanted me to recommend it to others. By all means – give it a try. I have never cared for a patient whom I thought was injured by homeopathy, although, I have managed a few who wish they had not delayed surgical excision of all disease.

AROMATHERAPY:
For help with massage, calming, and meditative approaches, give it a try.

 

 

MASSAGE THERAPY:
Massage therapy comes in many forms, but I have observed many patients who have received benefit from one technique or another.

‘Pelvic floor’ physical/massage therapy can be an important adjunct to the gold standard treatment of ‘endo.’  Thankfully, it is not required by all patients. I will discuss pelvic floor changes in patients with endo in a later blog. For now, let me just state that after endometriosis is removed, the spasm in pelvic floor musculature may persist. A good pelvic floor therapist can usually reverse these changes over a period of time if there are no other ongoing reasons for this muscular spasm.

Caution: deep pelvic and lower abdominal massage is of some concern in specific situations. Yes, I do believe that deep massage is necessary in many kinds of back, hip and shoulder pain to achieve muscle relaxation, but if a large ovarian cyst is present, there is a small risk of cyst rupture. This happened to one of my patients who was attempting to delay definitive surgical treatment. She experienced an immediate increase in pain at the time of the massage and required an emergency Laparoscopy.

HEAT/COLD APPLICATION: COLD!
In my experience, most people suffering from an acute exacerbation of their pain benefit most from application of cold as directly to the area as possible. Cold tends to reduce blood supply and thereby reduce localized tissue swelling. Remember that ‘refrigerator cold’ is usually fine. ‘Freezer cold’ can be too cold and can actually create frostbite. Be careful.

HEAT/COLD APPLICATION: HEAT!
Heat can improve blood supply and speed healing where inflammation and swelling have occurred. Again, please be careful. Extremely high temperatures (such as achieved when a person puts a hot washcloth over the abdomen, covers it with a plastic moisture barrier, and then places a heating pad on top of that) can cause a permanent skin mottling in the area due to “fat dystrophy.” This is due to fat degeneration under their skin. Sadly, for some, the pain they experience with endometriosis is so intense that they choose a treatment that by itself is painful and destructive. They tell me ‘it is better than doing nothing.’

Alternating between cold and heat is a technique used for centuries to aid healing.

I will discuss my observations regarding pain relief approaches in a blog to come. Stay tuned!

Disclaimer: any and all material(s) presented herein are offered for informational purposes only. Such material is not intended to offer or replace medical advice offered by your personal physicians or healthcare professionals. No information herein should be considered as party to any doctor/patient relationship. All contents herein are © copyright by Robert B. Albee, Jr., MD except where otherwise explicitly noted. All rights reserved. This material may not be reproduced or utilized in any form, including electronic or mechanical, photocopying, recording, or by any information storage and retrieval system except for personal or teaching use with prior permission. Thank you.

BLOG #6 – QUESTION: HOW SHOULD I FIND A TRUE EXPERT TO TREAT MY ENDOMETRIOSIS?

/ topendodoc / Leave a comment

DSC_1686-1

Relative to most physicians who have not had gynecology-specific advanced training (such as an ‘Ob/Gyn’ residency), all gynecologists should be considered as general experts in endometriosis care, but with varying degrees of experience. Here are some hints to help you find the expert among the experts:

Start by doing your research!

  • If you know women who have been treated for ‘endo’, ask them about their experiences with specific doctors.
  • Google “‘endo’ experts” in your zip code, state, and geographic region to establish a list of possibilities.

Visit on-line ‘endo’ sites such as:

Acquaint yourself with valuable ‘endo’ advocate resources such as:

  • Nancy Peterson & Nancy’s Nook for Endometriosis on Facebook
  • Endometropolis on Facebook
  • World Endometriosis Research Foundation on Facebook
  • caseyberna.com
  • salliesarrel.com
  • EndoIreland on Facebook

Ask your regular gynecologist if he/she knows of anyone in the area specializing in treating patients with endo. Be sure that they understand that you are seeking to be treated by what we term LAPEX – Laparoscopic Excision, the gold standard, if that is appropriate for your situation.

Look for gynecologists demonstrating evidence of advanced surgical training.

  • Member of the AAGL (formerly known as the Association of Gynecologic Laparoscopists)
  • Certified as ‘ACGE” by the AAGL
  • Certified as ‘COEMIG’ (Center of Excellence in Minimally Invasive Gynecology) by Surgical Review Corporation
  • Establish a list of prospective doctors to evaluate further

Unfortunately, a broad and vastly mistaken assumption exists that all surgery for endometriosis is performed by surgeons of similar experience and skill. This completely overlooks the wide disparity that actually exists and does not address the issue of completeness in removing all disease at the time of surgery, ignoring the excellent results of truly skilled excisionists with adequate experience in recognition and total resection. Finding a true specialist can be critical.

When choosing your physician, consider the following:

  • Do not be afraid to see multiple doctors. The time and money that you spend will be rewarded in the end if your ‘endo’ is successfully treated. Traveling for appropriate ‘gold standard’ treatment is common because referral centers and/or true endo specialists are not found in every state.
  • Look for a doctor that is interested in you and will spend the time you need answering your questions. If you feel that your doctor is too busy, he/she probably is.
  • Make a list of questions that you would like answered by the doctor and/or his/her staff in order to help your selection process. See my suggested list of questions below to select the ones that you believe are appropriate for you.

Dr Albee’s list of questions intended to help you find the expert among experts:

  1. Do you prefer to treat ‘endo’ patients by surgically excising the disease – or by suppressing the disease with drug therapies?
  2. Do you believe in complete excision of all ‘endo’ in most cases?
  3. If you believe in surgical excision, do you remove all abnormal peritoneum or just what you think is ‘endo’?
  4. If you believe in surgical excision, can you do it Laparoscopically (this is ideal)?
  5. Do you send all tissue to the pathology department for evaluation and confirmation?
  6. How many patients have you treated by surgical excision in the last 6 months? (high volume is important: 0-2=small experience base, 3-12=worth considering, 13 or more=great experience and dedication)
  7. If you find invasive disease involving the urinary bladder, bowel or ureter, how do you proceed? (‘stop and refer to specialists’=acceptable, ‘stop and organize team to accomplish removal of all disease’=better, ‘proceed to treat the areas using available specialists on-call’=best)
  8. Do you provide your patients with complete record copies including operative reports, pathology reports and photographs?

Knowledge is power and when it comes to picking your doctor, deciding whether or when and which surgery is right for you, fighting for excision and adopting practices and lifestyle adjuncts that you can do for yourself as a partner in your own care, you are your own best advocate.

Stay tuned for Dr Albee’s thoughts about alternative medicine approaches, palliative measures, nutrition and lifestyle for the ‘endo’ patient!

Disclaimer: any and all material(s) presented herein are offered for informational purposes only. Such material is not intended to offer or replace medical advice offered by your personal physicians or healthcare professionals. No information herein should be considered as party to any doctor/patient relationship. All contents herein are © copyright by Robert B. Albee, Jr., MD except where otherwise explicitly noted. All rights reserved. This material may not be reproduced or utilized in any form, including electronic or mechanical, photocopying, recording, or by any information storage and retrieval system except for personal or teaching use with prior permission. Thank you.

Blog #2: My Suggested Treatment Plan

/ topendodoc

In most cases, I favor treating patients definitively (I will list the exceptions to this recommendation in following commentary).

This means that I recommend all endometriosis is completely excised from the body. Up to this point in time, the only way that I am aware of that this can be done is by surgical excision. While I favor doing this Laporoscopically (using small umbilical and accessory ports for instrument insertion), this treatment can also be done by laparotomy (open incision). The energy source used for excision is best left to the experience and confidence of the surgeon, but I use the carbon dioxide laser as my energy source (why will be the discussion of another blog; see also http://centerforendo.com/dr-albee-on-excision).
china6There is one critically important aspect of excising all disease that is often overlooked by surgeons. Subtle ‘endo’ can hide in peritoneum that looks atypical, but does not have one of the ‘classic’ appearances of ‘endo’. In order to have low recurrence rates, surgeons must not leave any disease behind. This means that the surgeon must be committed to removing abnormal/atypical peritoneum even when it does not have a ‘classical’ appearance. For more on this discussion, refer to one of my academic papers on the subject: https://www.ncbi.nlm.nih.gov/pubmed/18262141.

Definitive treatment in my experience is the most effective treatment because it:

– Results in the longest intervals of time before retreatment is required (our data continues to indicate that 80-85% of our patients are currently free from any clinical indication of recurrent ‘endo’);
– Results in a significant improvement in ‘quality of life’ and pain reduction scores on follow-up surveys; and
– Fertility rates improve in stage 2, stage 3,and stage 4 cases after excision

The emotional burden of being told that you have an incurable disease is enormous. I do not tell patients that I am going to cure them, but I do tell them that if they have any more ‘endo,’ they will be the exception and not the rule (understanding that not all pelvic pain is the result of endometriosis and there are often comorbidities which also need to be addressed). Please note my above figure on our percentage of clinically disease-free patients after excision.

In following blogs, I will discuss the current objections to definitive treatment, and the reasons that I feel it is not more commonly used. But up next, let’s talk about ‘when I do not recommend definitive treatment.’ Stay tuned!

Disclaimer: any and all material(s) presented herein are offered for informational purposes only. Such material is not intended to offer or replace medical advice offered by your personal physicians or healthcare professionals. No information herein should be considered as party to any doctor/patient relationship. All contents herein are © copyright by Robert B. Albee, Jr., MD except where otherwise explicitly noted. All rights reserved. This material may not be reproduced or utilized in any form, including electronic or mechanical, photocopying, recording, or by any information storage and retrieval system except for personal or teaching use with prior permission. Thank you.

Blog #1 July, 2017 “The Great Treatment Debate:” first, lets define some important terms…

/ topendodoc / 1 Comment

Let’s use two large treatment categories:

  1. Definitive Treatment
  2. Non-definitive Treatment

‘Definitive Treatment’ includes all treatments intended to completely remove all areas of endometriosis.

  • Laparotomy with excision of all areas (using the technique and energy source chosen by the surgeon)
  • Laparoscopy with excision of all areas (using the technique and energy source chosen by the surgeon)
  • Hysterectomy/Oophorectomy only if all areas of ‘endo’ are also completely removed at the same time
  • Possible future techniques using external energy sources to remove ‘endo’

‘Non-definitive treatment’ includes treatment options intended to control the disease.

  • Observation: is really not in either category, but is still a ‘non-treatment’ choice if a patient’s diagnosis is uncertain, examination is normal, and pain is easily manageable
  • Disease Suppression:
    • Simple ovulation inhibition
    • Progesterone therapy
    • Anti-estrogen therapy
    • Advanced ovulation inhibition resulting in medical castration
    • Aromatase Inhibitors
  •  Disease Reduction:
    • Laparotomy with removal of some, but not all, ‘endo’
    • Laparoscopy with removal of some, but not all, ‘endo’

The standard treatment for ‘endo’ today has not changed significantly during my professional career. This approach is predominately ‘non-definitive.’ It begins with simple suppressive treatments, using stronger suppressive treatments when pain or infertility persists, and may include surgery with some disease removal, then ultimately leads to hysterectomy when the disease remains uncontrolled.

Sadly, I see many of these hysterectomized patients who actually needed only to have their ‘endo’ actually removed – excised – to achieve a satisfactory quality of life. Even worse, if all ‘endo’ is not removed at the time of hysterectomy, pain may continue despite the absence of the uterus or even ovaries if the patient is placed on hormone replacement (basically a good idea in the castrated woman of premenopausal age).

Why has the non-definitive treatment of the disease remained standard? Blog #2 will continue this discussion, along with my approach to treatment. Stay tuned!

Disclaimer: any and all material(s) presented herein are offered for informational purposes only. Such material is not intended to offer or replace medical advice offered by your personal physicians or healthcare professionals. No information herein should be considered as party to any doctor/patient relationship. All contents herein are © copyright by Robert B. Albee, Jr., MD except where otherwise explicitly noted. All rights reserved. This material may not be reproduced or utilized in any form, including electronic or mechanical, photocopying, recording, or by any information storage and retrieval system except for personal or teaching use with prior permission. Thank you.