Ep 009: Understanding Endometriosis with Dr. Shrikhande
March is endometriosis awareness month. Endometriosis is estimated to affect 1 in 9 women. It can cause physical issues such as pelvic pain and infertility, psychological pain, and functional limitations as well. The pathophysiology of this disease isn’t completely clear, but it’s important that women are diagnosed in an efficient manner and have access to skilled medical and rehab providers who can help them with proficient treatment. Truthfully, it takes a team of providers working together to treat the person comprehensively.
Today we will be talking with Dr. Shrikhande of Pelvic Rehabilitation Medicine. Pelvic Rehabilitation Medicine provides an advanced model of care for treating pelvic pain conditions centered around treating the person and not just the symptoms. Their network of providers include overseeing physicians, surgeons, nutritionists, mental health, and rehab providers.
Dr. Allyson Shrikhande, is a board certified Physical Medicine and Rehabilitation specialist and is the Chief Medical Officer of Pelvic Rehabilitation Medicine. She is also the Chair of the Medical Education Committee for the International Pelvic Pain Society.
SHOW NOTES & SUMMARY:
What is endometriosis and the pathophysiology behind this disease?
Endometriosis is endometrial like cells that are found outside the uterus; essentially these cells can get inflamed and irritated, and then they scar down. These cells can travel really anywhere outside the uterus, but classically they're deposited within the pelvic area or the pelvic cavity and can cause both how the pain and infertility.
I’ve heard of endometrial cells travelling even as far as the brain…is this really possible?
Yes, there is some data, but it's mostly on mice for the brain that I'm aware of. But yes, we had a case last week at Pelvic Rehabilitation Medicine where the endometriosis was in the thoracic cavity, so the patient presented with atelectasis which is a collapsed lung, so it can spread far from the pelvis; it really can go anywhere.
Can you talk to us about some of various tests that can help differentially diagnose endometriosis?
Currently, that is the major challenge with endometriosis; it really is a silent disease process in that, in the end, the medical community we don't have a proper diagnostic other than surgery right now. So currently, the gold standard for a proper diagnosis is as laparoscopic surgery, then some pathology; you have to take some cells and send to the path lab and then you have to confirm the endo that way.
Really, however, that being said, physicians who really do pelvic pain have gotten extremely proficient at really having a high suspicion for endometriosis. Really a lot of it's history and exam, listening, knowing what questions to ask and then putting your history together with the proper exam; that's our best diagnostic tool. We trans-vaginal ultrasounds are ordered which are often normal. We sometimes do get MRIs of the pelvis with with contrast to diagnose, but really what we're mainly looking for is something called an endometrioma, otherwise known as a chocolate cyst, because that can and often show up on MRIs for us. We are also looking for adenomyosis which can often coexist with endo; if we see adenomyosis, it gives us a higher suspicion that we are correct in there is endometriosis.
But overall it still at this point a clinical diagnosis, and then you refer for a proper surgical diagnosis, which is the gold standard. We are working with geneticists in New York City at the Feinstein Medical Institute to really come up with a proper diagnostic; it's called the Rose Trial (Research Outsmarts Endometriosis) where we really want to be able to analyze their biomarkers and the menstrual affluents of patients, and let patients know whether or not they have it. So we are looking at the differences between patients with known endo, patients with suspected endo being sent for surgery, and then normal controls. We are analyzing the menstrual affluents; looking at the biomarkers to see if there is a strong genetic predisposition here.
If a patient were going in for laparoscopic surgery to confirm a diagnosis of endometriosis, could that patient potentially wake up and have had some tissue excised or some other procedures done, or is that typically reserved for a subsequent surgery?
Typically, if the patient is going to go under anesthesia and go through the surgery, they would not only have a diagnostic, but the endometriosis that is seen would be excised; now that is clearly discussed prior to surgery (it is never a surprise, but it's usually recommended just because, if you're going through with it, you wouldn't want to leave it and most patients would agree to have it exercised, but it's discussion to have pre operatively with your surgeon/
Is excising the tissue by cutting or ablating (cauterization) a better approach?
At Pelvic Rehabilitation Medicine, we are big believers in a proper excision surgery versus an ablation. You need a little more training (fellowship training) to have this technique down. Excision does a better job than ablation at getting the endometrial cells out properly at a bit of a deeper level which will help decrease the recurrence rate.
How would you recommend someone go about researching a good surgeon for their surgery?
There's a fantastic website called Icarebetter.com which really has vetted surgeons; to be part of that website, surgeons really have to demonstrate their surgical skills with proper videos of multiple surgeries they’ve done. It's a highly vetted, highly clinically forward website, so I think that's the best option for patients in America.
How is it determined when a hysterectomy is indicated and is the patient notified of that in advance of the surgery?
Classically the surgical approach is to preserve the uterus, if possible, and normally if there is no significant adenomyosis or fibroids we are able to preserve the uterus (remember, endometriosis are deposits outside of the uterus). However, it is important to consider a non-operative approach first so that we can address the nerve and muscle dysfunction, which is causing a lot of the symptoms anyway. I think for this complex disease process, the dream is to have this team that offers an interdisciplinary approach and that’s what we do here at Pelvic Rehabilitation Medicine; working together as physiatry, pelvic PT, gynecological surgery, cognitive behavioral therapy, and nutrition is our core model.
Can you tell us about what physiatry does from an evaluation and treatment standpoint?
Two things that are a bit different than classic pain doctors or gynecologists is that we're not really trained in one organ system, we are really an extension of pelvic floor PT. Our whole roll is the holistic approach, and we are looking at the interplay between organ systems, the nerves, and the muscles. We are really focused on finding the root cause, the primary pain generators…and quite often there are multiple, but we kind of break it down and try to address each one as best as we can. We are trying to understand which organ systems are involved and then how much muscle and nerve dysfunction there is secondary to that. We also address any underlying anxiety that can continuously upregulate the nervous system.
Can you talk just a little bit about the relationship of the gut with endometriosis?
One red flag for endo is a history of autoimmune disease so we look for things like vitiligo, Hashimoto’s thyroiditis. We also look for signs of SIBO (small intestine bacterial overgrowth). There's that whole brain gut connection where you really want to calm down the central and peripheral nervous system. This is where we might use outpatient, external ultrasound- guided peripheral nerve blocks with trigger point injections concomitantly treating the peripheral sensitization, central sensitization and myofascial pain. We believe in treating all three concomittently for patients to get better; so a multimodal approach with pelvic floor PT and that is what we are publishing on.
Central sensation and peripheral sensation definitely affects the gut, so helping calm down that nervous system, both by treating any inflammation around the nerves. We’re pretty much treating any neurogenic inflammation along the different peripheral nerves that might involve the gut. The main ones are the pudendal and its branches, as well as the posterior femoral cutaneous; with the cross-sensitization those two nerves talk to each other; they are very close, they upregulate one another so we classically turn them both off. That’s kind of been one of our secret sauces and then in addition we will treat ilioinguinal and genital branch of genitofemoral if needed depending upon the patients exam and symptoms. That does help their gut; just by chilling out those nerves, it really can help their gut function.
SIBO is complicated though and that is one of our most challenging. Sometimes you do need to bring in that doxycycline to treat the SIBO in addition to diet changes; a low sugar, anti inflammatory diet classically, but every patient's a bit different. Sometimes you do need a nutritionist do a bit of an elimination diet and then see what bothers you because everybody's body chemistry a bit a bit different. SIBO can be one of our larger challenges, but I do think one positive aspect is turning off the excess firing of these peripheral afferents.
Can you talk about the physical therapy branch of your business and what they do for your patients to help calm down those peripheral nerves and achieve your patient’s goals?
We always tell patients “to get you better, you need your pelvic floor PT.” Physiatry and pelvic floor PT are working in conjunction trying to release any short spastic weak musculature, either in the levator ani, the pelvic floor sling, the external rotators of the hip, as well as increase blood flow to the peripheral nerves by addressing fascial restrictions. We are really just trying to release the fascial restrictions around the peripheral nerves, which will ultimately increase blood flow to the nerves and then they can really heal themselves. Nerve gliding happens with our pelvic floor physical therapists as well as visceral mobilization, internal vaginal and rectal myofascial release. We also look at the body as a whole; how is the thoracolumbar fascia connected to the pelvis? Opening up the hips is a miracle with our patients; once you see the hips open up everything just flows nicely and you are not restricting that pudendal nerve along it’s path anymore. So that is how it works for the downtraining.
When we feel the patient is ready for that neuromuscular reeducation and strengthening you get the deep core muscles firing; the multifidi, the levator ani, and the hip abductors, that's when things start to really fall into place. After downtraining is when we will start the neuromuscular reeducation which is usually about six to eight weeks.
How is cognitive behavioral therapy helpful?
CBT can include diaphragmatic breathing, meditation, muscle memory techniques where you are downtraining and relaxing the pelvic floor muscles, teaching patients the connection of the brain to the pelvis, coping with anxiety techniques, hypnosis for IBS, sex therapy sometimes and improving central sensitization.
Mentioned Links:
The ROSE Trial (Research OutSmarts Endometriosis study by Feinstein Institutes for Medical Research)
ICareBetter.com (find an endometriosis expert)
Retrain Your Brain (online course by Dr. Sckrivani)
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