I have endometriosis, and the pain is starting to drive me crazy. I get about one pain-free week each month. I would still like to become pregnant. I have one son who is seven. I am 35 and fear I may not have much time left. What can I do? I am sick of having pain throughout the whole month!

Heidi

Too often I hear that people with pain related to endometriosis do not feel that their physicians take them or their pain seriously. In fact, studies have found that there is on average a nine-year delay from start of symptoms to diagnosis. Unfortunately, things do not always get easier once the diagnosis is made.

While some women will benefit from a trial of birth control pills, this is rarely successful. If the pain is severe, or you do not respond within two to three months, more aggressive therapy must be considered. In fact, for women with recurrent endometriosis, I prefer a three-month trial of a GnRH-analogue such as Zoladex, Lupron or Synarel, with the immediate use of "add-back" therapy with estrogen and progesterone. Simultaneously starting low-dose add-back therapy along with the GnRH analogue lessens the risks and side effects of this therapy. If satisfactory reduction of pain is achieved, women can remain on this therapy indefinitely or until they wish to try to get pregnant.

If medical therapy is not effective after a brief trial, then surgery is indicated. Unfortunately, while every gynecologist is trained to deal with endometriosis, there is marked variation in physicians' skills at managing this condition. Here are some questions you might ask to see if your physician is an endometriosis expert:

• Do you recommend a bowel prep before each surgery where endometriosis is expected? (Failing to perform a preoperative bowel prep may lead to a second surgery to completely treat disease that could have been treated at the first surgery. If your doctor does not recommend a bowel prep when evaluating pelvic pain, in my opinion, you are not seeing an endometriosis expert.)
  

• Will I need a second surgery if the endometriosis involves the bowel or the bladder, or are you prepared to deal with it at the first surgery? (The physician should be aware of symptoms that indicate bowel or bladder involvement, such as diarrhea with menses, urinary frequency, or frequent bladder infections with negative urine cultures. Preparation should be carried out to effectively remove all disease at the original surgery.)
  
• Do you excise involved tissue involving the uterosacral ligaments and the top of the vagina, or do you use a laser to vaporize the lesions? (Often disease is left behind if vaporization is used. These lesions can extend deeply into the space between the vagina and rectum and are often missed when laser is employed by a less-experienced physician.)
  
• An endometriosis expert is also someone who will listen to you and work with you to develop a plan that best meets your needs. Endometriosis is definitely not a one-size-fits-all condition. Unless your doctor is willing to listen and hear your questions and provide adequate answers, your care will be compromised.