Monday, June 23, 2014

Endometriosis - should we treat the pain or the infertility first ?

Many patients with endometriosis have both infertility and pain , and often receive poor quality medical care. They are confused as to whether they should treat the pain first, or focus primarily on their fertility. While having a baby is an important long-term goal for them , getting relief from their pain is often far more urgent. Their pain  causes them a lot of distress, and they need a quick solution for this.

When they go to their gynecologist ( most of whom are not infertility specialists ), the doctor prioritizes the management of the pain . Sadly, this ends up harming their fertility in the long run.

Often the pain is suppressed by “ treating “ the endometriosis with birth control pills , danazol or GnRH agonists. These can provide dramatic pain relief, which can be very reassuring for the patient. However, while taking the medicines, she cannot get pregnant, and this medical treatment wastes valuable fertile time, as her biological clock ticks away .

The other popular technique for managing the pain is surgical. While laparoscopic surgery is touted as being “minimally invasive”, the truth is that often this unnecessary surgery reduces fertility as normal ovarian tissue is also removed along with the cyst wall of the chocolate cyst, thus reducing ovarian reserve. This trade-off is very shortsighted, and a few months of pain relief often translates into a lifetime of infertility.

Patients with endometriosis who have both pain and infertility are far better off concentrating on getting pregnant. They should prioritise getting pregnant first .

Once they conceive, they will be pain-free for the nine months of their pregnancy and while they are breast feeding. Pregnancy can also often have a positive impact on the natural history of the disease, and many women find their endo pain goes away after they have had a baby.

But how do they cope with their pain while waiting to get pregnant ? The trick is to learn to manage the pain more aggressively. Sadly, this is not something most doctors teach their patients to do well.

The commonest mistake endo patients make is that they wait for their pain to become unbearable before taking pain-killers. They are scared that they will get addicted to pain killers; and are worried about the long term consequences of taking too many analgesics. Many of them manage their pain so poorly, that they end up having to go to the ER for taking injections , because they pain is unbearable. When this happens 2-3 times, most are very happy to sign up for surgery ! The real tragedy is that the surgery is often not needed. What they need is to learn to manage their pain more intelligently.

Endo pain usually creates problems for the 3-4 days during which they have their periods. This means that most patients know exactly when their pain is going to strike. Rather than wait passively and miserably for the cramping to start , they need to begin taking pain killers before the pain starts. They need to take adequate doses, around the clock, for the 3-4 days of their period. This ensures that they have adequate blood levels of pain killer during their painful periods. This will allow the painkiller to act much more effectively, and make the pain much more bearable.

So why don’t doctors teach them how to manage their pain ?  For one thing, doctors would rather be doing surgery ! For another, they are worried that taking pain killers on a long term basis can have side effects ( such as causing kidney damage) . However, remember that the patient will end up taking medicines for only about 3-4 days every month. ,This means that even if she needs 4 tablets daily, she will take only about 10 tablets during the entire month. This kind of intermittent use, even if it is chronic,  will not cause harm. Taking inadequate doses of pain killers as a result of the fear of side effects is worse, because it results in the pain not being treated properly.

If they take the pain killer properly, their ability to manage their pelvic pain becomes dramatically better . This allows them to take a more patient, mature long term approach, and they don’t go to pieces everytime their period starts. Similarly, learning simple techniques such as using lubricants during sex or trying different sexual positions can help to relieve pain during sex as well.

By using an aggressive approach to treating the pain conservatively , they can focus on getting pregnant , rather than running to the doctor for pain relief.

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