"Ask Dr. Cook" is a series of questions and answers regarding endometriosis. The current subject and answer can be found on Current Ask Dr. Cook web page. The questions may represent a summary of questions I have been asked by several different patients. I hope you find this information helpful. If you have a question you would like answered, please Submit A Question.

Treatment of Rectal Endometriosis

Question:
I have recently had a hysterectomy and my Dr. said that I have endometriosis in my rectum. He also said internal endometriosis. He says the only way to get rid of it is to "starve" it out, with low doses of estrogen. Due to this "low dose", I feel horrible, nausea, weak, shaky, hot flashes, etc. Does this line of treatment sound correct?

Answer:

First of all lets make sure we are talking about the same thing. It sounds like you had both your uterus and ovaries removed when they did the hysterectomy. As a result your body was producing virtually no estrogen after the operation. I am not certain what your doctor meant by internal endometriosis. There are old terms used decades ago, not currently used in the medical literature - endometriosis interna and endometriosis externa. Endometriosis interna was used to refer to adenomyosis, that is endometriosis in the wall of the uterus. Endometriosis externa is simply called endometriosis today. The old term implied that the endometriosis was outside of the uterus in the pelvis. After removal of the ovaries a woman's estrogen production dramatically decreases and often experiences side effects of menopause, some of which you described - nausea, weak, shaky, hot flashes, etc. The current medical treatment for endometriosis, a class of medications known as GnRH agonists (Lupron, Synarel, etc), is withdrawal of endometriosis. These medications perform a temporary medical menopause turning off the estrogen production by the ovaries. This treatment is crude with side effects often out weighing the benefits. Contrary to popular belief these medications do not always work. If your doctor tells you that endometriosis can not be causing your pain because you are on a GnRH agonist, start looking for another doctor. He or she does not understand endometriosis. Recent studies have helped us understand why some patients continue to have pain on when in a hypoestrogenemic state (low estrogen either as a result of medical suppression of the ovary with GnRH, surgical menopause or natural menopause). Endometriosis can produce its own estrogen. Thus even if the ovaries are turned off or removed, the estrogen level in the blood decreases and the patient fells horrible, the endometriosis can still continue to grow and cause pain. At best a low estrogen state will temporarily eliminate the pain and symptoms of endometriosis, but they usually return with increasing estrogen levels.

The pictures from below are from a patient that was on "double dose" Syneral. She continued to have symptoms.

Laparoscopic view of symptomatic endo on GnRH agonist	Bladder endo on GnRH agonist	Broad ligament and uterosacral ligament endo on GnRH agonist

The first picture is the initial laparoscopic view of the uterus and the uterosacral ligaments. As you can see when viewed this far away from the tissue it looks pretty normal. This is a good example of why it is so important to view the tissue up close during laparoscopy. This is one reason patients with endometriosis are told that they do not have endometriosis. The second picture shows clear endometriosis. It is small but the pathology report did confirm endometriosis. The last picture is a close up of the uteroscaral ligament which can also been seen in the lower left of the first picture. This non-pigmented white endometriosis was extensive and confirmed on multiple specimens on the pathology report.

All of these principles apply to bowel endometriosis as well. It is not going to go away with low estrogen. If you physician is giving you estrogen replacement, especially without progesterone, it is probably feeding the endometriosis. If you are not having any symptoms, then you may not need to have it removed. If it is symptomatic then it show be removed surgically, just as any other endometriosis. If the lesion is superficial it can be either resected or vaporized with the CO2 laser. If it is a full thickness coin lesion, that the size of a coin, then this portion of the bowel wall can be removed and closed up with suture (usually all laparoscopically). If the endometriosis have replaced a segment of intestine then that complete section of intestine will have to be removed and the ends of the bowel put back together.

I would not subject one of my patients to the "treatment" that you are describing. Always follow your physicians advice, but you may want to get a second opinion from another local physician.

Return to Dr. Cook's Endometriosis and Pelvic Pain Information Center

Updatede October 29, 2005