Multidisciplinary approach for endometriosis patients

Posted on 12 August 2022

Endometriosis is a complex disease, and symptoms vary between patients. At Mediclinic Kloof, patients are treated by a multidisciplinary team with a broad base of skills. 

Doctors aren’t sure why endometriosis affects some women, while in others the cells causing the disease are cleared away by the immune system.

What they do know is that the disease responds to the hormones related to menstruation. “Normally, we see the monthly shedding of the lining of the uterus, which lands in the pelvis via the fallopian tubes and in the vagina via the cervix,” explains Dr Abri de Bruin, a gynaecologist at Mediclinic Kloof with a special interest in deep endometriosis, endoscopy and fertility treatment. “However, in endometriosis sufferers, this lining (made up of endometrial cells) ends in the pelvis, but can also spread beyond and start growing into other parts of the body, including the bladder, nerves, ovaries, vagina and rectum. In some cases, the cells grow in between the muscle fibres of the uterine wall; a condition called adenomyosis.”

The varied spread of endometriosis, and the subsequent diverse symptoms, makes it difficult to diagnose. “There are few rules to this disease. Variability is massive,” Dr De Bruin comments. That said, it’s common for sufferers to experience severe period pain and painful intercourse, as well as heavier bleeding and an increase in the size of the uterus if the disease is in the wall of the uterus. Infertility is also common, as implantation is decreased in the inflamed environment created by the condition.

Variable disease and symptoms

Depending on the location of the endometriosis, the patient may experience other symptoms too. For example, endometriosis located in the bowel may lead to a narrowing of the colon, which leads to constipation, in turn contributing to the development of conditions like haemorrhoids. Patients who have endometriosis on the diaphragm may experience severe pain in their shoulder (typically on the right-hand side), especially during menstruation.

The variability of the disease makes endometriosis complex in terms of treatment – particularly if the case extends to more than a few spots, and if several organs have been affected. “With this in mind, our multidisciplinary team consists of many more people besides doctors and specialists. None is more important than the other,” Dr De Bruin says.

A gynaecologist heads up any treatment and it’s vital that they’re highly experienced – surgery is a lengthy and high-risk procedure, accompanied by many complications, which are in themselves high risk. This is even truer for patients who present with deep endometriosis. The gynaecologist is supported by a nursing sister, who is present during ultrasounds as well as theatre and is well placed to answer any questions the patient may have.

Cohesive team

In theatre, the team comprises a cohesive group who’ve operated together often enough to be familiar with each other’s mode of working. The team includes an anaesthetist who is familiar with the finer details of preparing an anaesthetic for a longer-than-usual laparoscopic procedure, with the added complication of possible dehydration due to bowel preparation before surgery.

Dr De Bruin is assisted by three GPs with a special interest in advanced endoscopy, and five specialists interested in learning advanced surgical skills to provide better care for their own patients. Importantly, this is a consistent and dedicated team, Dr De Bruin emphasises. This team includes a colorectal surgeon who can help a patient requiring colon, rectal or small bowel surgery, and treat conditions that may arise, such as fistulas.

A urologist also participates, as the disease often affects the bladder and ureter.

The referring specialist has a vital role, says Dr De Bruin, as their understanding of the need for a multi-pronged approach to treatment ensures they direct their patients to the correct practitioners.

In the ward, staff are equally important, because they understand how to manage patients who’ve had surgery for deep endometriosis affecting different organs. They’re also responsible for administering medication, such as painkillers and antibiotics, and giving appropriate post-operative care.

Following the procedure, a physiotherapist will assist the patient. Dr De Bruin explains it’s vital that patients become mobile as soon as possible. “Those who’ve had long surgery for deep endometriosis may find it hard to breathe deeply, especially if the diaphragm was affected, but these organs may become infected if they don’t inflate.”

A biokineticist will support patients who’ve experienced postural changes in their efforts to manage debilitating pain. Treatment from a pelvic-floor physio is also advisable in certain cases, as the condition is so painful that the muscles of the pelvic floor are often severely affected.

Finally, a dietician will be called on to advise patients whose colonic endometriosis has caused bad constipation, or who need a temporary stoma. These patients will also need help from a stoma nurse, who shows them how to clean and replace the bag, while patients who struggle to pass urine post-surgery may require the aid of a nurse who can help them insert a catheter by themselves.

The good news? Although the chance of recurrence differs from patient to patient and stage to stage, Dr De Bruin says that if lesions are cut out, there’s an 80% chance the disease will not recur after five years if it was in Stages 1 or 2. The picture changes if the lesions are merely burnt or lasered off: in this case, there’s a 75% likelihood the disease will persist within 12 months. “In other words, this is not a new case of the condition; rather, the disease that presented in the first case was not adequately treated and the symptoms will occur once more,” Dr De Bruin explains. This is why it’s crucial to treat the condition thoroughly, and to provide appropriate follow-up support.

There’s also hope for patients struggling with infertility as a result of deep endometriosis: Dr De Bruin says although in-vitro fertilisation (IVF) procedures might be necessary, a definite chance of pregnancy exists even without assisted reproduction treatment (ART).

“We’re seeing an increasing incidence of this disease, and – worryingly – among younger patients. Outcomes are better when the disease is treated early, which is why we need to raise awareness of this condition.”

If you’re suffering excessive pain during menstruation, speak to your GP, who may refer you to a specialist gynaecologist at your nearest Mediclinic.