Beating Endo. Dr Iris Kerin Orbuch

that is right for you. It includes, when needed and at the right time in your treatment process, the excision surgery that is the sole known method for removing endometriosis from the body.

      While we are both sympathetic to the contemporary reader’s tendency to jump to the chapter that seems most personally relevant, we urge you to read the chapters of Beating Endo in order. Understanding the full implications of what this disease can do is the first essential for beating it, and that understanding unfolds almost as a narrative. At the same time, we put in your hands the tools to combat every theft of life endo represents, and we show you how, if you use the tools right, you can take back your life from the disease and live it to the fullest.

      Our own bottom line is that no girl or woman need feel that she is defined by her endometriosis, nor should any girl or woman be robbed of her strength, her comfort, her joy in her own body, and sometimes her fertility by this disease. This book is our prescription for ensuring that.

1

       What Is Endo?

       The Disease Process of Endometriosis

      The endometrium is the lining of the uterus. In an estimated 176 million women worldwide, cells similar to those in the lining of the uterus are found outside the uterus. In these women, the presence of those cells where they don’t “belong” distorts the body’s anatomy, ignites an inflammatory response, and increases the likelihood of autoimmune dysfunction and disease. The result can be a process of progressively accumulating symptoms—although it may not be; there are women with endometriosis who never know it and are never affected by the pain it can cause.

      But if those cells outside the uterus do initiate such a process, the progressively accumulating symptoms can be wide-ranging. This is because the inflammatory response sets off cascading chain reactions of localized and downstream effects that impact the normal physiological functioning of the body. This is one of endo’s distinctive traits. Its varied “spin-off” ailments affect so many of the body’s systems: interstitial cystitis/painful bladder syndrome, pelvic floor dysfunction, irritable bowel syndrome, sensitization of the central nervous system, not to mention anxiety and depression from the physiological changes and the pain they bring—sometimes to the point of debilitation.

      As a result, a woman with endo may see a range of specialists and receive a range of diagnoses, along with prescriptions for medications or procedures that bring no lasting relief. She is equally likely to undergo tests that return a finding of “normal” even though the woman lives every day in pain and discomfort, or to receive a puzzled non-diagnosis—remember the 75 percent to 85 percent of doctors at Amy’s meeting in Sydney who didn’t know endo when they saw it?

      Maybe that’s why medical schools typically have given it short shrift. If you can’t see it and you can’t measure it, it’s hard to teach. And with a lot of medical insurance plans holding doctors to a standard fifteen minutes of one-on-one consultation per patient, maybe there’s just not enough time for even the most compassionate of physicians to dig deep into understanding what might be going on inside a female patient’s body. Let’s face something else as well: The fact that it is exclusively a woman’s disease may be part of the problem. It is perhaps why, in March 2017, the then-president of the American College of Obstetrics and Gynecology could report that “63 percent of general practitioners feel uncomfortable diagnosing and treating patients with endometriosis, and as many as half are unfamiliar with the three main symptoms of the disease.”²

      It is estimated that from seven to as many as twelve years pass between the onset of endo symptoms and its proper diagnosis, during which time the woman or girl with endo may undergo a range of treatments, some of them ineffective, some of them with side effects that outweigh their benefits. We both have seen women who had been prescribed multiple different narcotic pain medications, others who went through gynecological, gastrointestinal, even orthopedic surgeries that brought neither relief nor respite and that turned out to be needless traumas to the body.

      So we are left with a great many women afflicted with endometriosis who simply do not know they have it, and with a great many others who assume it is just something they must put up with—part of the price of being female, nothing specific to put a name to. To a great extent, therefore, endometriosis remains something of an enigma—a disease afflicting millions that nevertheless resides in the shadows of medical science.

      What is well known, however, especially by those who suffer from endo, is what it can do to the lives of the women afflicted with it. We know it too. We’ve seen it up close and personal. As caregivers, as women, as mothers of daughters, we can’t help but feel directly affected by the suffering we witnessed.

      If you have been diagnosed with endometriosis, or if you suspect you may have it, you should know that a positive diagnosis is possible only via analysis of excised tissue; it’s what the medical profession calls “pathological confirmation.” Short of that, there is as of yet no other test to confirm the presence of the disease—no image, no scan, no sampling of fluids. (In chapter 2, however, we will discuss some important signals every woman should pay attention to.)

      For many women but not for all, the principal and defining symptom of endometriosis is pain. In some, the pain is minimal or intermittent or even inconsequential. There are also women who are discovered to have endo lesions—the visible evidence of the disease’s damage that surgeons like Iris can see laparoscopically and excise—but who experience no symptoms and feel no pain at all. In too many women, however, the pain may be anywhere from difficult to utterly incapacitating.

      Unlike so many other medical “conditions,” the pain of the endo disease process does not progress in incremental steps from A to B to C to D, where A is uncomfortable, B is pain, C is worse pain, and D is disabling pain. An endo patient may experience all of those levels of pain, but it isn’t always because the disease is getting worse. It may also be that the disease is affecting so many of her bodily systems concurrently.

      Ask a woman with endo where and when her pain occurs, as we do, and she will locate it just about everywhere and at any time: around the lower abdomen . . . in the back . . . deep in the pelvis . . . on the right side . . . on the left side . . . worse during her period . . . worse during ovulation . . . worse all month long . . . worse before her period . . . worse after her period . . . in the rectum . . . down the legs . . . up the vagina . . . during sex . . . after sex . . . around the ribs . . . up into the diaphragm . . . during bladder and bowel functions . . . in the groin area . . . hard to pinpoint . . . everywhere . . . most of the time . . . all of the time. Some describe the pain as acute, catching them unawares, without warning. For others, it is a persistent presence. We’ve heard the pain described as knifelike, a feeling of heaviness, a hot poker, sharp and radiating. Like lying down on a bed of thistles. Can’t find a comfortable position for sleeping or sitting. Can’t lift my body out of bed. Can no longer imagine what it would be like to live without pain.

      The variety of the definitions and descriptions, the potential ubiquity of the pain, and the lack of consistency between the intensity of the pain and the stage of the disease process or the “amount” of endo found are among the reasons this disease is so puzzling. For healthcare practitioners confronting women afflicted with endo, the puzzle turns this disease into a chameleon, one that changes its identity depending on which particular symptoms are presented and, given the highly fragmented nature of our super-specialized medical system, on which specialty is doing the looking. The same complaint can appear very different to a urologist, a gynecologist, an orthopedist, or a physical therapist, each of whom is likely to prescribe his or her own specialty’s standard treatment. We call it “misdiagnosis roulette”—well-intentioned but confusing and ultimately both ineffectual and injurious. Talk to a urology specialist about bladder pain and she or he might plausibly diagnose interstitial cystitis/painful bladder