Endometriosis: A discussion about diagnosis and treatment webinar

Sara Whitburn: Hello and welcome to tonight’s Jean Hailes for Women’s Health webinar on endometriosis. My name is Sara Whitburn and I’m a GP and Clinical education manager at Sexual Health Victoria. I’m joined tonight by my colleagues, Dr. Pav Nanayakkara, a gynaecologist and advanced laparoscopic surgeon at Jean Hailes for Women’s Health, and Janetta Webb, pelvic floor physiotherapist. Welcome.

Pav Nanayakkara: Thank you.

Janetta Webb: Thank you, Sara.

Sara Whitburn: I’d like to start tonight by acknowledging the country that we are now presenting to you and learning on. Jean Hailes for Women’s Health acknowledges the Traditional Owners of Country throughout Australia and recognises their continuing connection to land, water, and culture. We pay respect to Elders past, present, and emerging. We’re going to start tonight with two case studies.

Jessica Chase: My name is Jessica Chase. I am 24 years old. I started my periods when I was 13. To begin with, they were irregular. But when they would come, they were heavy for six, seven days and I would flood through pads and onto my uniform. It was embarrassing. I got a bit better at managing them and they settled to six days once a month when I was about 16, 17. However, in the last few years they’re also quite painful. I get bloating, headaches, acne and crampy pain two days before my period and then really bad cramps for the first two days of my cycle.

I can manage with taking anti-inflammatories and a heat pack, but I did miss a lot of university for my period. Now that I’m working in my office, it is hard to take days off work. I would like my periods to be more manageable. My mum and sister also had heavy and painful periods. Mum said that maybe I should get checked out as she had trouble getting pregnant with me and my sister. I’m not ready to have kids yet, but I would like to someday. I am worried that my heavy, painful periods mean there is something wrong and I don’t want to do anything that might impact my fertility long term.

I don’t take any medication and don’t have any other medical problems. I don’t smoke, and drink alcohol only on the weekend. I love dancing and netball. I don’t have a regular partner at the moment, but I have had a sexual health check-up and they’ve all been normal.

Heather Butler: My name is Heather Butler. I’m 45 years old. I’ve had debilitating period pain since the age of 14 and was subsequently diagnosed with endometriosis and adenomyosis. I had laparoscopies every year between the ages of 14 and 27 to manage my symptoms and then another two more in my 30s. My pain always felt better after surgery, even if they just found scar tissue and endometriosis wasn’t removed, but my symptoms would always come back some months later. I’m a single mother to an 18-year-old son, Ben. I left his father due to domestic violence when he was young. It was a really difficult separation. I’ve always had period pain but has been progressively getting worse since Ben’s birth. I find myself in a fetal position almost every day with really bad lower back pain and pelvic pain which radiates right down my legs.

Ben’s birth has also left me with some other problems. I feel like I need to go to the toilet frequently for both my bladder and my bowel and sometimes it’s really painful to empty. I’ve had ongoing weight problem since his birth as well and I’m now over 160 kilos. I don’t have any other medical conditions, but I find myself on a cocktail of pain medications and drugs to help me sleep. I’m now finding the pain overwhelming, but I have to cope with it for Ben’s sake. I’m so sick of taking hormone pill after hormone pill. They seem to make my weight gain worse and they really don’t help me much in the way of relief. I’m less focused at work, I’m less motivated. I can’t concentrate. And sometimes I have really negative thoughts. Ben’s now having behavioural issues and I can’t help but feel it’s my fault. The pain and the challenges that it’s given me make parenting a really huge struggle. My GP recently ordered a scan which showed adenomyosis, and both my ovaries are now stuck. I really don’t know what to do. I’m totally over it.

Sara Whitburn: So, thanks to Jess and Heather, they’re both fictional cases, but I think that all of us on the panel can agree that they really are cases that represent people that we’ve seen, and we’ve helped in the past who’ve come to see us around endometriosis. So, I’m going to hand over now to my colleague Pav who’s going to give us an overview of endometriosis. And Jess and Heather will come back again throughout our talks as we try and talk about endometriosis and put it back into that clinical picture. So, Pav, thanks, over to you.

Pav Nanayakkara: Thanks, Sara. So, endometriosis is a disease where tissue that’s similar to the lining of the uterus grows in other parts of the body. It most often affects the reproductive organs but can also be found in other areas such as around the bowel and the bladder. It’s a chronic progressive condition that can lead to scarring, pain, fertility, and can be associated with cancers and cardiovascular disease.

Endometriosis is estimated to affect one in seven women according to the latest report by the AIHW this year. It’s been estimated to cost about $31,000 per year to each person with the diagnosis, and about 84% of that is related to loss of productivity. It’s the third leading cause of non-fatal disease burden among females due to reproductive and maternal conditions.

So, symptoms of endometriosis can vary between individuals. Some people experience no symptoms while others can experience severe pain, heavy bleeding, bleeding between their periods, bloating, fatigue, anxiety and depression. Pain is a common symptom and typically includes abdominal lower back or pelvic pain, painful periods, pain during and after intercourse or during ovulation, and pain during urination or defecation. So how do we know it’s endometriosis? It’s often a combination of their symptoms, signs and examination and the investigations that we order.

In terms of symptoms, again, they can vary between individuals, but typically the symptoms are cyclical and centralised around their period. So, pain during periods which is often quite debilitating, period cramping, heavy bleeding and pain with urination and defecation.

In terms of the symptoms, on examination, we often do an abdominal and a bimanual examination. We find that the uterus is often bulky in keeping with adenomyosis and may be fixed or immobile if there are adhesions present. We might also feel endometriosis nodules, particularly in cases of deep endometriosis and adnexal masses if the patient has endometriomas. And we often perform a recto-vaginal examination concurrently.
In terms of investigations, we know that a laparoscopy is the gold standard for diagnosing endometriosis and offers us the option to treat at the same time. However, nowadays we have high quality ultrasound scans that give us a lot of information about the presence of endometriosis and there are some soft markers that can give us clues as to where exactly it might be. MRI is also an emerging technology at the moment. The evidence for this is still limited and is very dependent on centres that are confident in identifying and diagnosing it.

So, I’ll hand back to you, Sara, to talk about a working diagnosis of endometriosis.

Sara Whitburn: Thank you very much. And thank you for that, Pav. As Pav said, we know that the gold standard for diagnosing and investigating endometriosis is a laparoscopy. But coming from a primary care idea of looking after endometriosis, often what we need to think about is a plan for a working diagnosis. We need to think about how we might think about it when we first see somebody like Jessica or Heather present because it can take time before we’re able to refer and get investigations. So, I’m going to present a plan for working up a diagnosis and considering a diagnosis of endometriosis in primary care.
So, what is a working diagnosis? So here we have a definition from the society to improve diagnosis in medicine, and they say that sometimes the most likely choice is designated to be the working diagnosis, meaning that it’s likely, but at this point we might not have been able to confirm the diagnosis. And I think that that’s very true with endometriosis because we’re seeing people coming and talking to us about those cyclical signs and symptoms and we need to flag that this is a possible diagnosis so that we can offer timely management and treatment.

So why do I think that’s important for endometriosis? Well, a working diagnosis is important so that we don’t add to the diagnostic delay that can occur, which can lead to negative impact on quality of life. And we heard in both of the case studies concerns around fertility, concerns around pain, the impact it was having on someone whereas they cared for their family members. If we don’t use a working diagnosis, we may not recognise that the likely diagnosis for pain or other cyclical symptoms as described by Pav, and I’m going to go through as well, we might not think about that diagnosis. And so, a working diagnosis helps keep that in our mind. Treatments can be both a helpful way to diagnose endometriosis by having treatment as investigation, but also, we don’t want to add to delay of treatment. It can help us refer appropriately for further investigations. And if we are thinking of a working diagnosis, then we’re able to empower and educate the people that we’re working with for their own self-care, but also for them to be able to self-advocate for further management.
So why is there a diagnostic delay in endometriosis? As we’ve already heard, there’s a real diversity of presenting symptoms. Many of the symptoms overlap with benign conditions. And we might have a low index of suspicion because of these varied symptoms overlapping with other conditions. One of the other reasons for diagnostic delay is that often frequent attendance with disparate symptoms or cyclical symptoms or symptoms that change between months can make the diagnosis harder to make, make it less likely to be our working diagnosis, and we might actually misdiagnose the symptoms as something functional maybe such as irritable bowel or that there is an overlying psychosomatic cause. I do think that this is important when considering somebody holistically. I’m not saying that psychosomatic or functional causes aren’t involved, but we don’t want to be too narrow. We want to have that broader working diagnosis of endometriosis so we don’t focus in and miss the group of symptoms.

I think we still struggle in primary care with some cultural attitudes that normalise that painful menses is a normal part, especially maybe in early reproductive life or as we get closer to the menopause. We need to think a little bit around could painful menses be actually endometriosis or adenomyosis and have that on our list of differential diagnoses. There may be for some people a lack of clinician awareness of updated guidelines. And we may be, in primary care, concerned about referring on because of the invasive nature of laparoscopy and knowing that all surgery does have risks as well as benefits. So how do we recognise endometriosis? How do we make that working diagnosis? Well, we need to consider the constellation of symptoms and the how and type of presentation. We need to ask questions that directly define and talk about associated symptoms. And self-reporting of symptoms can be very helpful, and I’ll give some resources that can be used for people to use diaries or to check their symptoms against lists of possible signs and symptoms of endometriosis.
So, what are those questions that can help? Well, I think you should ask specifically about when periods started or menarche, if anyone’s had a history of menstrual difficulties including if they’ve had to have time off school, work. Have they felt nauseous? Have they had to lie down? Have they had headaches? What has happened around their menses? Details of pregnancies and any changes of menses both before and after, and any difficulties with conception or fertility. Asking about them specifically. Asking further questions about the type and nature of dysmenorrhea. Asking those pain questions. Asking about painful sex and asking to chart pelvic pain through the cycle, seeing if there is that cyclical nature to what’s happening, and asking about any cyclical bowel and bladder symptoms.

Consider asking people who do present with the signs and symptoms of irritable bowel syndromes about their menstrual history. People can have irritable bowel and endometriosis at the same time, but sometimes the endometriosis symptoms present more like that functional bowel pain. So having the thought to just broaden those questions so that you’re considering all the possible differential diagnoses.
We know that there is a family history of endometriosis and that can be linked to people presenting with endometriosis. So, asking about family history of menstrual difficulties or any diagnoses, and really taking time to talk about the impact on the quality of life and any concerns that they might have about this pain and what it means for them and what might be their ideas and expectations around painful periods or pelvic pain.
So here are some of the helpful reporting resources that I’ve talked about which can help with clinical history and interview. So endzone.com.au is a great webpage, the QENDO app that people can download. They can track their pain, they can develop a pain management, and it’s a great tool to bring to their consults and actually look at together. The Royal College of Obstetrics and Gynaecology has a raising awareness tool for endometriosis that can help consider signs and symptoms. There’s the Jean Hailes Endometriosis Health Professional tool, as well as the Pelvic Pain Foundation and their website, which gives lots of great self-education resources, but also health professional resources.

My take home message is that any symptom which reliably worsens with the menstrual cycle should prompt the consideration of a working diagnosis of endometriosis. Pav’s already mentioned examination and what’s included in the examination, what we might find. Again, I’m going to mention physical examination as part of something that we can do in primary care to think about the working diagnosis of endometriosis, but I wanted to just touch on that often people have been living with pain, often what would be defined as chronic pain, which is any pain longer than three months, which it itself can cause concerns or fears around having examinations. Some people might come from a trauma background. And we know that sensitive examinations such as pelvic or vaginal examinations needs to be handled in a trauma-informed way.

You can see here on the screen that the Blue Knot Foundation has some great fact sheets about how to approach these sorts of examinations or histories with a trauma-informed lens. We’ve already talked about palpating the abdomen, looking for areas of tenderness or guarding, and a vaginal exam as already mentioned, looking for that tenderness and any change in the shape and size of the uterus or other adnexal areas.
Investigations gave a great outline on the importance of high-quality ultrasound, and so it is recommended if we are thinking of a working diagnosis of endometriosis, thinking about referring for a COGUS ultrasound obviously in areas where that can be hard to access or where cost is an issue speaking with the person in front of you, talking about how that could be beneficial for their care. But perhaps it’s also talking about to the imaging providers near you about what they can and can’t do for investigating endometriosis. It’s important at this point to not just think about endometriosis but excluding other causes of lower abdominal pain. So still considering, does somebody need a sexually transmitted infection screen? If someone has pelvic pain as in reproductive ages and is at risk of pregnancy, excluding ectopic pregnancy or pregnancy itself. And thinking about other causes like pelvic inflammatory disease or ovarian torsion. It might be important for our working diagnosis to do blood tests, especially if there’s heavy menstrual bleeding, so a full blood count, iron studies, thyroid function tests, von Willebrand and platelet function studies, trying to see what might be the cause of that heavy bleeding.

Once we’ve done investigations, sometimes it can be useful to use initial treatment as part of a working diagnosis. I’m going to hand over to Pav to talk about treatment and management in greater detail, but I wanted to touch on it now as part of a working diagnosis, using treatment to see if we get improvement. Or if we don’t get improvement, if that’s going to help us make the decision to refer on.

So, endometriosis guidelines do talk about that considering a three-month trial of a non-steroidal anti-inflammatory with paracetamol may be part of an initial workup for people with pain or suspected or confirmed endometriosis. We can also offer menstrual suppression with hormonal options such as the oral combined contraceptive pill or the 52 milligrams levonorgestrel IUD, the Mirena, as a shared decision-making option and always making sure that there’s no medical contraindications to those hormonal products and if these initial treatments are not effective or the person in front of you would prefer to be referred on. But if these initial treatments aren’t effective, then we can refer on to the gynaecologist for further investigation and management after we’ve given this short trial.

So, I’ve put that together and used the Jean Hailes’ toolkit for endometriosis and added on some of these investigations and treatment as investigation or trial for working diagnosis. And you can see that I’ve adapted it here on the screen. So when it comes to thinking of a working diagnosis, taking our history, our examination, [inaudible 00:19:46] self-recorded diaries or symptoms, remembering to do a pregnancy test, an STI screen, and a cervical screening co-test if there’s abnormal bleeding, offering the non-steroidal anti-inflammatories or the menstrual suppression, organising a transvaginal ultrasound. And then if those things have either not worked or there’s severe pain or it’s the person’s choice, referring on for further investigations.

So, I wanted to put all that ideas around working diagnosis, I wanted to apply that for Jessica’s case who’s come with symptoms and is really looking to understand what might be her working diagnosis. So, if we think back to the case study and consider Jessica’s symptoms, she had dysmenorrhea, heavy menstrual bleeding, cyclical boating, headaches, acne and crampy pain and had cyclical menstrual pain. She had a family history, and it was impacting on her quality of life, having to take time off university and now work. She does have some concerns. She wants to improve her period control, she’d like to have less pain, but she does have concerns about fertility as well. So, what would be needed for Jess if we’re going to apply our working diagnosis plan? A physical examination, diagnostic testing as already discussed, and perhaps offering that initial treatment as I said. But if that doesn’t work, then I would be referring. So, I think from our working diagnosis, it’s very likely that Jessica has endometriosis. So, I’m now going to hand over to Pav who’s going to talk about management.

Pav Nanayakkara: Thanks, Sara. So, in terms of management, we know that there is no cure for endometriosis and so treatments is really centered around managing those symptoms and improving the quality of life. So, I often talk to my patients about a triangular approach, which involves a holistic approach to the management. In terms of our conservative management options, we know that endometriosis can be associated with other pain syndromes such as irritable bowel syndrome and interstitial cystitis. And so therefore looking at it from a holistic point of view really helps to manage those conditions as well.

We’ve got medical management options and we’ve got surgical management options, and often it’s a combination of all three that gives outcomes that are better for the patient in the long term. So, looking at conservative management options, we look at the biopsychosocial model. And we know that dietary modification can help with endometriosis symptoms, and that may be changing diets to anti-inflammatory diets, looking at low FODMAP or gluten-free or dairy-free. And it doesn’t necessarily have to be through the whole of the menstrual cycle. Some people do find improvement in the lead up to their periods of just modifying certain things that they eat. And we often start with a pain diary or a food diary to monitor what sort of triggers may worsen people’s symptoms.

We know that exercise is really valuable. It increases endorphins which reduces inflammation overall, and the recommendation is 30 to 40 minutes, three to four times a week of some moderate exercise. Sleep is also hugely important. Ideally, we recommend about seven hours of good sleep a night. And stress management is another factor that can worsen symptoms. So, we always talk about whether it’s five minutes of me time every day or scheduling in a massage once a month just to reset some of those stress levels. Vitamin D is important. So, getting sunlight, particularly early morning sun is best. And lastly, we can think about complementary therapies. So, things like acupuncture and naturopathy may improve symptoms from a conservative point of view.

In terms of medical management, there’s sort of two broad categories. We have the non-hormonal management strategies, which are really just the band-aids. They manage the symptoms but do nothing to stop progression of disease. And so, usually we start with things like paracetamol and non-steroidal inflammatories. We can also think about neuromodulators like amitriptyline or duloxetine for cases of more chronic pain.
In terms of hormonal management, we often start with something like the oral contraceptive pill. We also have some progesterone-only options including things like the longer-acting IUDs, which give you five years of menstrual support. And for refractory cases, we then look at something called GNRH analogues, which are hormones to effectively sort of switch off the ovaries and we use them temporarily to try and mitigate some of the symptoms of endometriosis.

So lastly, we have our surgical management options, and that is ideally a laparoscopy to go in and investigate for endometriosis. And we can offer excisional treatment or ablative treatment depending on where the endometriosis is and the expertise of the surgeon. Last line, we have a hysterectomy which can work to manage dysmenorrhea or period pain, but not so much the pain that occurs between periods.
In terms of optimal management, we know that a multidisciplinary team is really central to getting the best outcomes in the long-term, and that can involve a women’s health GP, a gynaecologist, a pelvic floor physiotherapist, pain specialists, and some other complementary therapists such as naturopaths and acupuncturists.

So, linking the management back to our cases. When we think about Jessica, we know that she’s got painful periods, she’s had bloating, headaches and crampy pain. We know that she wants to manage her periods. That’s the goal of our treatment here. She’s got a family history where her mother and sister also had similar symptoms. And in particular, her mother had fertility concerns. So, in terms of the best management for her from a conservative approach, we look at getting a psychologist involved, getting support groups. We look at optimising her diet, exercise, her stress and sleep, and we try and optimise her pelvic floor and often that’s engaging her with a pelvic floor physio early.

From a medical point of view, we start with the non-hormonal strategies to manage her symptoms while they’re occurring and then look at some form of hormonal suppression. So, offering her the contraceptive pill or an IUD. And from a surgical point of view, we can offer her a laparoscopy. And that may be to confirm a diagnosis of endometriosis or if she’s having issues with falling pregnant, we can try and investigate that pathway.
Looking at Heather, the management approach is similar, but there are some differences. So, we know that already that Heather has endometriosis and adenomyosis. She’s had multiple laparoscopies in the past, which is not ideal. So nowadays we are trying to minimise the total number of operations that a woman has in her lifetime. And ideally, we want a single operation if we can where we treat all of the endometriosis that’s present and then put someone on hormonal suppression to minimise the number of times we have to go back in.

We also know that there’s some social issues at play here which may worsen her symptoms. And the other issue is the concern about the bladder. So, she may have some coexisting interstitial cystitis that’s contributing to her symptoms. She’s already on multiple pain medications, so we want to try and optimise that by getting a pain specialist involved. And she’s not particularly keen on continuing with hormones, so she’s looking for more definitive management at this stage in her life.

From a conservative point of view, we get psychological support. We can look at her diet, exercise, stress and sleep again. We get her engaged with pelvic floor physio. She was talking about the pain that was radiating down into her legs and into her back, and we can engage her with some of our complementary therapists.

From a medical point of view, I guess at this stage where she’s not particularly keen on hormonal management, we might want to consider neuromodulation. And from a surgical point of view where she’s looking for definitive treatment, we could offer her a laparoscopic hysterectomy to manage the period pain. Keeping in mind that it may not take away all of her pain completely, particularly if there’s pelvic floor muscle involvement or she’s got other coexisting issues like interstitial cystitis.

I would encourage everyone to read the Endometriosis Clinical Practice Guidelines that have been published by the RANZCOG and are available on the RANZCOG website to just go through all of the management options in further detail. And I will now pass back to Janetta.

Janetta Webb:Thanks, Pav.

So, following on from what Pav and Sara have already discussed, I’d like to now talk about the specifics of endometriosis-associated pain and particularly talk about pain science. But before I do so, I would like to very briefly acknowledge my dear friend and colleague, Amy Stevenson, who was to present tonight, but unfortunately due to personal issues is unable to be with us. But she did present most of the slides for this talk, so thanks Amy.

So, if we first think about the International Association of the Study of Pain, their diagnosis and look at specifically these underlined words, so pain is an unpleasant sensory and emotional experience associated with or resembling that associated with actual or potential tissue damage.

And in a little bit more detail, pain is a personal experience. It’s influenced not only by biological factors but also, as Pav and Sara have talked about, psychological and social factors. But pain and nociception are different phenomena. So, pain is purely an output of the brain. Nociception is what happens in the tissues. Individuals learn the concept of pain throughout their lives, and a person’s report of an experience of pain must be respected. Pain serves an adaptive role but can have adverse effects on function, but also social and psychological well-being.

So, if we look at our pain system and endometriosis pain in particular, there are three types of pain that we can talk about. Firstly, what’s commonly known as acute or nociceptive pain. There’s also neuropathic pain, which is when there is some disease of the nervous system, or nociplastic pain, which is when pain changes from being an initial acute reaction to tissue damage or tissue change to a more persistent condition. And of course, these are all, as well as overlapping, all affected by psychosocial factors and also by context. And we know that patients, their pain can vary over a period of time.

So persistent pelvic pain and endo. Persistent pelvic pain, again as defined by the IASP, is pain in the area of the pelvis present on most days for more than six months. It’s the most common clinical manifestation of endometriosis and also the most common reason for referral to women’s health services.

But as both Pav and Sara have already mentioned, there are a number of comorbidities that you’ll see in the top diagram that can occur with endo. And if we look at the top three, interstitial cystitis, bladder pain syndrome, irritable bowel syndrome, and vulvodynia, they all originate in the pelvis. And as well as that fibromyalgia and migraine headaches also do commonly occur. And so, I’d encourage you if someone presents to you with pelvic pain, that you also dive a little deeper into any other persistent pain, ongoing pain conditions that they may be reporting. Because if there is more than one persistent pain condition occurring, it’s often a sign that there is an increased sensitisation of the central nervous system.

So, let’s talk about how pain changes to become persistent. The brain interprets information from a stimulus in the tissues and combines it with, as mentioned before, past beliefs, past experiences, the patient’s current situation as well as physiological behavioural, cognitive and social factors. So, there are so many things in the body that the brain considers when it decides what sort of a message it’s going to give you in terms of the danger associated with the stimulus in the tissues.

Over a period of time with ongoing stimulation in the tissues such as with endometriosis, that develops an increased excitation and a reduced inhibition of neural pathways. And then these contribute to cortical adaptations and sensitization of the central nervous system. Then we see ongoing inflammatory and immune changes which enhance pain amplification, enhance its duration. So, as we saw with Heather, our patient, that not only was she experiencing pain during her periods, but then it increased to every day and also an increasing area of pain. So maybe starting in a smaller area in the pelvis but progressively referring to the back, the hips, the abdomen and the abdominal wall and down the legs.

So what results is an overprotective pain system, which remains in some patients even in the absence of pathology. And I think it’s really important to talk about how pain becomes persistent to our patients as almost the first line of addressing their ongoing pain so that they have an understanding also of neuroplasticity. So, if the brain and the central nervous system can learn pain, it can also unlearn pain. And this helps patients to see that they can then help to make changes and to achieve some control in the management of their pain. I think it’s really important for us all to discuss this with our patients. And if you’re interested in a more detailed explanation of this, Amy has a webinar in Jean Haile’s webinar library on persistent pelvic pain. So, I’d encourage you to look at that. And we also have a number of resources in the resource list that you’re going to receive at the end of the webinar that can help you to learn more about the development of persistent pain. And it’s so important as I mentioned before to discuss this with patients.

So, if we look at Heather, she now has pain present on most days. As we mentioned before, her pain is spreading. And she also describes severe pain and hyperalgesia, but also allodynia, which is when there is a stimulus that would not usually cause pain that then the patient reports as now causing pain. Heather also has some comorbidities in particularly bladder and bowel pain and some urinary and faecal frequency. Her pain is no doubt worsened by the stress that she’s experiencing. Her son’s behavioural issues, a history of family violence, and no doubt threatening experiences and a difficult separation as well as a change in her cognition. So, finding that things are much more challenging at work and that she’s now having quite negative thoughts. And with persistent pain, particularly looking at Heather’s bowel and bladder symptoms, there’s often convergence on the spinal cord of viscero-visceral or viscerosomatic inputs so that these presentations can unfortunately then occur together and wind each other up and we can then get a lot of crosstalk between pelvic organs and somatic such as muscles.

So, looking at pain science can help us to tease out some of the puzzles of endometriosis such as the discrepancy between the degree of disease and the severity of symptoms. So many of us have seen patients who have severe endometriosis but complain of little pain or no pain, and also patients who’ve had a laparoscopy or have a very small amount of endometriosis but report severe pain. And this can also be a reason why there can be a failure to respond as expected to lesion-focused treatment such as laparoscopy and removal of endometriosis because when pain has been there for longer than three to six months, then the brain and the central nervous system can change.

So, it’s very important as has already been mentioned, that we use a biopsychosocial approach to the management of endometriosis-associated pain. So that intervention addresses issues in the tissues as we offered say, as well as a sensitised nervous system and all of the other psychosocial aspects. And so, I think as we look through these, to discuss all of these with our patients can be very helpful because we’re always wanting to help to give them control in the management of their pain as much as possible. And so, they can see when we bit by bit discuss all of these issues with them that there are many things that are within their control to gradually change or to think about. And of course, again, involving all members of the multidisciplinary team is so important.

So, if we talk about physiotherapy, so often when we speak about physio, everyone thinks it has to be hands-on. So, we do spend a lot of our time with hands-on treatment if appropriate. But the pain science education really also is a large bulk of what we’re going to be doing in our sessions. Let’s have a look at research on the use of conservative therapies in the management of endometriosis-associated pain. There’s a lot of great research going on at the moment. Up until fairly recently, there has been a limited amount of evidence for the use of conservative therapies and multidisciplinary care, but fortunately there’s lots of great research going on both in Australia and around the world that is having some very promising results.

But one thing that we do know is that pain education changes pain levels more than any other treatment modality that we can offer as physios. Understanding pain gives patients a sense of control and helps to empower them, that there is something that they can do to change. And if we offer this hope to patients, then they’re going to feel much more positive rather than feeling that they’re purely placing all of their issues are in our hands. Increasing self-efficacy is so important, and again, so empowering for patients, and helping to reduce fear, particularly fear avoiding behaviours such as movement.

I really like this graphic from Amelia Mardon that patients also like to look at. Seeing that a sensitised nervous system leads to overprotective pain. Pain doesn’t mean that my pelvis is damaged. And of course, we know that initially endometriosis lesions will initially contribute to acute pain, but as we’ve talked about then, there can be ongoing changes after three to six months as pain becomes more nociplastic. How I think, feel and see my pain can make it worse, and also, I can change my pain albeit slowly with help because we know that as mentioned before, if the brain can learn pain, it can also unlearn pain.

So firstly, physios are going to down regulate the nervous system. Diaphragmatic breathing, we know, is very calming to the nervous system. Most patients that we see who have persistent pelvic pain will be very shallow upper chest breathers and there’ll be very little movement in the abdominal or pelvic area. So diaphragmatic breathing is often the first thing that we start with. And the physios in the audience will also agree that it’s often a way to help to get some movement in the pelvic floor because as we inhale, the pelvic floor muscles move downwards slightly.

Also, body scanning, to check for areas in the body that may be tense in response to pain and help to reduce that muscle work and that muscle tension. And some evidence-based mindfulness and meditation apps, which will also be in your resources can be helpful. Management of anxiety and hypervigilance, which we can all start together but of course may be best managed by referral to a psychologist. And the encouragement of general exercise and restorative sleep.

I think when we’re talking about exercise, I always ask patients, “What would you do? If you were able to do a little more exercise, what are the things that you would choose to do?” Rather than instigating something that maybe isn’t their sort of thing.

Some signs and symptoms that may suggest that there’s specific pelvic floor muscle dysfunction. So, the diagram is showing palpation of obturator internus and also levator ani. So here are some of the signs or symptoms that may suggest there’s pelvic floor muscle involvement and also the signs of an in-drawn perineum, hip adductor muscle spasm, and vaginismus. And I’d really encourage anyone who’s considering doing a vaginal examination as Pav and Sara mentioned, to ensure that they’re not ramping up the patient’s pain or increasing the fear that it is very sensitive, gentle, and of course trauma-informed. There are also specific symptoms that patients often report when pain originates from obturator internus muscle as written here.

But it’s not only about the pelvic floor muscles, there are so many other muscles in the pelvic and abdominal area. So, there could be abdominal muscle myalgia, a positive Carnett sign, which is a deep palpation and contraction of the abdominal muscles. If that elicits the patient’s pain, then that may suggest that there is abdominal wall involvement. And it’s important for us to assess and treat other muscles around the pelvis, particularly hip and lower back.

As well as downregulation of the central nervous system, it’s not only about pain science. There may be more specific physiotherapy treatment used. But the most important thing to talk about here is that it mustn’t be painful. So down training exercises, so learning, teaching the pelvic floor muscles to patient, how to relax her pelvic floor muscles and also possibly the use of myofascial therapy with massage trainers or dilators and pelvic wands. But again, this is not routine and is used according to examination findings of overactive pelvic floor. We may also use biofeedback either with an internal vaginal or rectal sensor or externally with trans-abdominal or trans-perineal ultrasound.

Everyone gets a home program of exercises as well. But specifically talking about general exercises. And if patients initially have been quite reluctant to move, we are wanting to start them just on a very easy program. So, for some patients, it may only be five or 10 minutes walking at a time a couple of times a day and slow walking and staying at home where it feels safe. And as I mentioned before, something that they enjoy doing. There may be stretches. We may suggest yoga. And usually, we wouldn’t suggest Pilates from the start, but many patients do enjoy Pilates. So, I think that should be assessed as to whether the exercises that a patient is performing in Pilates are likely to be aggravating her issues because we don’t want an over contraction of all of the core muscles. We’re really into down training.

Often at times when patients do start to feel a little bit better, then of course they really want to get exercising and may approach it with what we commonly call a boom or bust cycle. So going hard at it and then finding that unfortunately that has ramped up their pain. So just talking about pacing and taking it gradually because you really want people to feel good when they’re starting exercising or increasing exercising rather than having any exacerbations.

And also, a toolkit for speed humps. So, the use of heat, sometimes cold. The use of massage. Tense therapy is something that is increasingly popular among people with endometriosis, but always to be very careful because sometimes that can actually increase the sensitization and increase the sensitivity of the nervous system. So those of you who’ve prescribed TENS for patients may find that they say, “Actually, it seemed to make my pain worse.”

And finally, optimising bladder and bowel health. So again, as we mentioned with Heather, there could be issues that need addressing there along with the management of pain, and also educating and giving tools to address any physical responses to sexual dysfunction. So, Jessica, one of our patients, mentioned that she has been sexually active in the past. She doesn’t currently have a partner, but sometimes patients won’t offer that sex has been painful because they may think that this health professional is going to think, “Well, of course sex is painful because you have endo, or you have pelvic pain.” But it doesn’t necessarily of course have to be the case.

So, with Jessica, I would certainly like to gently and sensitively bring that up with her, was there any discomfort? And I think this is a great diagram to show patients the cycle of how engaging in activities that perhaps a patient is fearful of and would really rather avoid, but for many reasons engages in painful sex then of course leads to a reduction in arousal and desire, wanting to avoid intimacy due to the past experience of pain causing more anxiety and anticipation of pain. And then of course the body in a protective mechanism engages or tightens the pelvic floor muscles to protect the patient and prevent them from having receptive intercourse.
So encouraging patients to enjoy pain-free intimacy and to enjoy arousal rather than activities that cause pain as they go through their treatment. So, my key message is pain is not a reliable indicator of tissue damage. Persistent pain can become the disease. It’s always an output of the brain. A biopsychosocial approach to management is gold standard care, and that pain education changes pain levels more than any other treatment modality. Thank you.

Sara Whitburn: Thank you very much, Janetta. And we’ve now come to the Q&A part of tonight. This webinar will be available in the webinar library at a future date. There’ll be an email come out when it’s available including the resources we’ve talked about and the slides. And if we don’t get to all the questions tonight, then we will also be able to provide some answers in a written format at a later date. So, we’re just waiting for the questions to come up now.

Okay. And if you can put your questions through the live Q&A, also star the ones that you most like us to ask so that they come to the top. But we’ve got our first question here. Pav, you might be able to answer this one. How severe is the effect of endometriosis on fertility and how would you suggest we approach this if asked by a patient?

Pav Nanayakkara: So, I think the effect on fertility is variable. And I suppose my suggestion would be that we don’t know. And having a diagnosis of endometriosis doesn’t necessarily mean that your fertility will be affected at all. So, the timing of a pregnancy should really be when it is the right time for you. And then if you are having difficulties falling pregnant, which usually would consider after 12 months of trying, then we might suggest that you go and see an endometriosis specialist a little bit earlier than the full 12 months to get some advice.

Sara Whitburn: Thank you very much. There’s a question about COGUS. And I’m not surprised because I did touch on it briefly, that COGUS is not readily available in rural areas. Pav, you might need to enlighten me. I use COGUS all the time. Define COGUS for all of us tonight.

Pav Nanayakkara: Yeah, so that’s a scan performed by a COGUS, which is a Certified Obstetrician Gynaecologist Ultrasonologist, which is essentially an obstetrician gynaecologist who’s then done additional training in ultrasound. The benefit of a scan performed by one of them is that they’re over 90% accurate in predicting the presence of particularly deep endometriosis. Whereas scans that are done in the community are about 50/50 as to whether what they see is actually what we find. At the end of the day, I suppose in regional areas, my recommendation would be to either take what you see on the ultrasound with a grain of salt and try and get them into a metropolitan centre for a scan or potentially refer them to a women’s health clinic. There are lots of telehealth clinics where we might be able to facilitate an ultrasound that’s closer to them.

Sara Whitburn: Yeah, so thank you. So, one of the questions we have tonight is, can you get endometriosis outside of the abdomen or pelvis?

Pav Nanayakkara: Yes, you can. We know of cases where patients have presented with cyclical chest pain, for example, and have gone on to have endometriosis removed from their lungs. You can also get endometriosis on the skin. So, sites of previous laparoscopic surgery, the port sites can develop endometriosis and endometriosis of the caesarean section scars as well. You can get endometriosis within the vagina. So yes.

Sara Whitburn: Yes. Yes, you can. So we’ve had a question about any evidence around management options for people who identify as trans men with endometriosis on gender-affirming hormone therapy. I think it depends a little bit on what they’re using for gender-affirming hormone therapy. Often if somebody is using testosterone for masculising affirmation, testosterone can help with some of the suppression of some of the lining, but we can also offer the same sort of conservative management, physiotherapy management, and you are able to use progesterones with testosterone. So it’s about talking to people about what they want, what they need, a bit like what we’ve already presented. But a lot of those options you can still use.

I don’t think the guidelines specifically talk about this area, but I think thinking about management, I think the one thing would be perhaps talking about oestrogen and using oestrogen. Often people who are doing gender-affirming care don’t want to use oestrogen, but you certainly can use progesterones, anti-inflammatories, all the conservative psychological physiotherapy management. Janetta or Pav, would you like to add to that at all?

Pav Nanayakkara: No, I think you’ve covered it.

Janetta Webb: You’ve covered it, yeah.

Sara Whitburn: I think I’ve covered it. Very patient-centered, very thinking about what might be a good option. Current guidelines on endometriomas, Pav?Pav Nanayakkara: Specifically…

Sara Whitburn: I wonder if it’s any other, I guess thinking about laparoscopies, if there is more of an [inaudible 00:57:10] presentation. Anything you’d like to add around how you might manage an endometrioma?

Pav Nanayakkara: I suppose it’s somewhat related to the patient and their symptoms. In terms of endometriomas, we do know that there is a small risk of malignant transformation. So if a patient chooses not to have surgical management, which typically is only really offered for those cysts that are larger in size and that’s sort of centre-dependent, then we would be offering surveillance ultrasounds to monitor for that risk.

Sara Whitburn: Thank you. One of the questions here is, how long would you trial a Mirena or a 52 milligram levonorgestrel IUD before laparoscopy for someone who has endo and adeno?

I’m going to jump in here with the primary care version of it. So I mean I think one of the things that I talked about was that menstrual suppression as both treatment, but also using it as a working diagnosis. So I would say that you would put in the Mirena, you do need to let people know that it can take up to six months before you start to get the change in bleeding. So it can take time to help with the symptoms, but I think I would be checking in and seeing how people are doing with the Mirena at about the three-month mark just to see how they’re going, seeing if they’re able to manage to six to eight months. But then if things I think weren’t improving once somebody had a chance to see if the bleeding was improving, then I might suggest referral.

But I always say if somebody wants to be referred to talk about management and they are struggling with quality of life or pain and we’ve tried some of the physio options, the psychology options, the anti-inflammatory options, it’s really about a shared decision-making, informed decision making. And so I might refer earlier, but I do talk about that it can take for anyone who’s using the 52 milligram levonorgestrel IED for menstrual suppression, it can take up to six months before you start to get an improvement. Pav, would you suggest anything else?

Pav Nanayakkara: No, exactly the same. Yep.

Sara Whitburn: Thank you. Another question that we have here is, “Would someone like Heather who’s had multiple laparoscopies, is there a limit to how many you would offer?” Pav?

Pav Nanayakkara: For me personally, I suggest no more than three if that’s possible. And usually, I would say the first one may be to make the diagnosis if it hasn’t been made previously and medical management is failing. The second one might be in the context of fertility concerns. And potentially the last one is more definitive surgery in the form of a hysterectomy. Now, that’s very general and obviously every patient is different. But we do know that with repeated surgery, the effectiveness of the surgery can start to wane. You can start to get increased risks with surgery including scar tissue. And often the risk of recurrence after surgery is estimated at 1% at a year and something like 15% at the eight-year mark. So we know that the repeated operations is not necessarily the best route going forward.

Sara Whitburn: Thank you. I’ve had a question here about, are we aware of any states or hospitals or health departments that have pathways for endometriosis patients who have endometriosis presenting to emergency departments to support acute care? Pav, have you come across any emergency departments or acute care guidelines or processes that might support people with endometriosis?

Pav Nanayakkara: Look, I can only speak to The Royal Women’s Hospital, which is where I work publicly. And I know that patients that come through the emergency department who have symptoms of endometriosis, or a known diagnosis or possible diagnosis will get referred to their endometriosis clinic through the Women’s Hospital. I’m not sure of any sort of health specific directives.

Sara Whitburn: Next question is, “If a woman with endometriosis decides to access termination of pregnancy, whether it would be recommended a surgical or a medical termination for a better option for someone endometriosis, or is it more about offering patient choice, is there any sort of concerns around a surgical or a medical for someone who’s got endometriosis?”

Pav Nanayakkara:
I think that decision is based entirely on the pregnancy itself, the stage of the pregnancy and that endometriosis wouldn’t have an impact on the choices that was offered.

Sara Whitburn: Thank you, Pav. Great. So we’ve… Oh, we’ve got one. We were just looking for some more questions. This one. “Is there any evidence for any specific dietary recommendations?” We don’t have a dietitian with us today. So though we all work in a multidisciplinary team, we’re probably not got the real at the coalface information, but I wondered if anyone’s had an experience through their working with dietitians and multidisciplinary teams.

Janetta Webb: Yes, look, I think that certainly often patients will say, “Oh, my pain is a lot worse if I eat certain things.” Or if they also have bladder pain, interstitial cystitis, irritable bowel syndrome, they may already be aware of things that actually worsen their pain, things that they want to avoid. So I guess encouraging that. As a physio, I would never suggest to anyone, “You should try this diet or that diet,” but I would often refer on to a dietitian. But it’s really good if you can try to find someone in your area who’s a dietitian who has some knowledge or expertise in the management of endo and persistent pain conditions and other comorbidities.

Sara Whitburn: Thank you. If someone’s diagnosed with endometriosis and has already tried the 52 milligrams levonorgestrel IUD and symptoms are still recurring, we’ve had a question, what additional treatment would you suggest adding in? I must admit, I will often discuss if it’s safe for the person and they have no contraindications, I might suggest adding in an oral contraceptive, combined contraceptive pill. Pav, is there anything else you might add in to keep the Mirena but add in extra?Pav Nanayakkara: Yeah, so we often start with offering a piggyback contraceptive pill. That’s mainly because we know that the Mirena on its own does not prevent ovulation, and sometimes particularly ovulation-related pain and adding in a pill can help. But it may also be that there’s something else going on such as pelvic floor dysfunction, so often getting the pelvic floor physios involved and considering some of those that multidisciplinary team management can offer relief.

Sara Whitburn: Thanks, Pav. So this is a question for you, Janetta. I know it can be very individualised, but as an average, how often or how long does it take for someone who’s got the chronic pain of endometriosis to start to respond to physio treatment?

Janetta Webb: Well, I’d really like to say immediately because of all the things that I mentioned, the toolkit that you’re sending a patient home with, some of the things from your first consultation and the understanding of endometriosis but also persistent pain. But generally, patients would probably be having physiotherapy over a period of three to six months. That’s probably the average. But I’d like to start seeing some change in my patients even certainly in the first month.

Sara Whitburn: Thank you. Pav, question, do you have a preferred progesterone if we were going to use the progesterone-only methods besides perhaps the 52 milligrams levonorgestrel IUD?

Pav Nanayakkara: So there is a newer progesterone pill, the Slinda pill, which we know that can work to prevent ovulation. But it’s unfortunately not available on the PBS, so it can end up costing patients as much as $80 a month. We know that some of the other progesterones that are on the PBS are a lot cheaper, but don’t have that benefit of preventing ovulation as well.

Sara Whitburn: One of the things that’s come in, we’ve talked about using the gonadotrophins and those kind of options. When would you use that?

Pav Nanayakkara: It’s often second line, so where medical therapy is not working, or patients have had surgery and/or multiple previous surgeries with minimal relief. The benefit of the GnRH analogues is that basically we are switching off the ovaries or putting someone through medical menopause. And so if they still have pain despite that, then that suggests to us that there may be non-gynaecological factors contributing. But we do know that we can only really use it for short periods at a time because it does have an impact on bone mineral density. So it’s not often a first line that we would go to.

Sara Whitburn: Thank you. We’ve got a question. “From a physio perspective, how soon would you see someone post laparoscopy?”

Janetta Webb: So usually I would suggest to a patient to book in a couple of weeks after laparoscopy. But sometimes a patient will make an appointment a couple of weeks later and then feel, “I don’t feel that I’m quite ready to come in yet and postpone that.” But that would probably be the average. And in terms of any specific stretches, I think probably post-operatively keeping moving. Just gradually increasing the amount of movement, walking each day. If they’ve already been doing stretches, continuing on with those. But again, nothing that’s causing anything painful. I don’t actually practice visceral mobilisation myself. That’s certainly something that I know some physios do and other health professionals such as osteopaths, so that certainly can have its place. And I have had patients who’ve had significant improvements with visceral mobilisation. But I think certainly initially most patients are wanting over the first couple of weeks to really allow things to settle, but we just want to encourage them to keep moving. And I’d even encourage them just to keep going with some gentle pelvic floor movements. But as I say, nothing painful.

Sara Whitburn: I mean, we’ve talked about dietitians, we’ve got physiotherapists here. Thank you, Janetta. We’re starting to get questions around some of the other options that can be used. And we’ve had a question whether cognitive behavioural therapy is something that can be used in endo and pain management.

I can say definitely from a GP point of view, CBT or cognitive behavioural therapy, can be used in primary care consults. Five-minute cognitive behavioural therapy, talking about some of the pain science like you said, Janetta. So I would say absolutely cognitive behavioural therapy can be very useful for all sorts of pain conditions.

I’m not sure if anyone on the panel wanted to say a little bit more. I know that a psychologist who does CBT can often work with people with all sorts of pain or reproductive conditions. Have you either of you had some clients use CBT or have some thoughts around that? We would’ve needed a bigger panel with. It’d be lovely to have our dietitian colleagues and our psychology colleagues. Anything you’d like to add to that?

Janetta Webb: I think it could be really helpful if you’re referring a patient to a psychologist that they see someone who has expertise in pain management. And different psychologists have different areas of expertise in which they like to practice. So a lot will use CBT, but there are a lot of other techniques that they will use, and I guess will decide at the time what’s appropriate for their patient.

Sara Whitburn: Where can we find physios who are interested in endometriosis?

Janetta Webb: Yes. So physios interested in the management of endometriosis work in public hospital clinics, particularly tertiary women’s health hospitals. They may also work in community health centres. And quite often we are also associated with continent services, so regional and rural and also city continents services may have a physio who also has expertise in the management of endo and pain. But two of the best ways to find those people are either via the Australian Physiotherapy Association Find a Physio website or the Continence Foundation of Australia Physiotherapy special interest group. So that’s CFA Physios. I’m not sure if it’s .com.au or .org.au, but if you pop that in, that we’ll also show you the areas of expertise that each of those physios have.

Sara Whitburn: We mentioned quite a different medications between the two of us. There’s been a query around Visanne. I do remember that’s Dienogest. Obviously that’s come up in guidelines. I was wondering if you wanted to comment on that because we didn’t touch on that specifically tonight.

Pav Nanayakkara:
Yes, there is a role for it. I suppose, again, it’s not the first line often and it obviously doesn’t have oestrogen. So it’s great for people who oestrogen is contraindicated. And it’s one of the medications that we do mention as part of our medical management when we’re going through the options with patients.

Sara Whitburn: Thanks so much. I really like that it’s looking like a bit of community, as someone has mentioned and as I mentioned in, I think it was my talk, I mentioned the Pelvic Pain Foundation. There will be resources when this is available on the webinar library, including some of the links to the groups that we’ve talked about, which are so helpful. But I just want to shout out to someone who’s watching tonight who has said that Pelvic Pain Foundation also has a list of health professionals on their website, including physios.

Janetta Webb: Yeah. Thanks Sophie.

Sara Whitburn: Yes, thank you so much. And while we’re talking about Pelvic Pain Foundation, one of the questions was around education because I think especially in the case of Jessica, we did talk about presenting and having symptoms, and that symptoms can start early. And I mentioned around that it’s about that education around what is normal for menses or what is to be expected when pelvic pain is abnormal. And there was a question around education. Pelvic Pain Foundation certainly looks into school’s education. And I know quite a few of the sexual and reproductive health education services are starting to talk more and more about pelvic pain. But I think it comes back to those websites and resources that we talked about, really trying to give those to people, the EndoZone and the QENDO. So that can be used for anyone, I think, who’s starting to have periods. And so it can be discussed with younger people as well. Either of you got any resources you’d like to shout out for primary or secondary school and talking about painful periods?

Janetta Webb: I think probably the Pelvic Pain Foundation is the main one that I know, yeah.

Pav Nanayakkara: Yeah. They do PPEP talks now.

Sara Whitburn: They do, yeah.

Pav Nanayakkara: Which are really good. So a group of educators going out to the schools to explain pain to patients. Ah, to patients, to school children. So I think raising that awareness at an early age is really valuable.

Sara Whitburn: Yep, yep. So I think we’ll take a few more questions and then we might wrap up for tonight because the questions are just bringing in more questions, which is fantastic. But we’ve also got questions about the combined oral contraceptive pill and talking about is a history of migraine with aura, orea, oh, must be getting to the end of the night, with an aura associated with COVID a contraindication for the combined oral contraceptive pill.

Migraine with aura, whether it’s associated with COVID or any other migraine with aura is a complete contraindication to the combined oral contraceptive pill. And so that might be when you start to think about other options like the progesterones, the anti-inflammatories, and referring on to talk about secondary. So yeah, I’m going to put my contraception hat on there and say no, oral combined contraceptive pills with migraines with auras. But I think we might take this last question, which is, can all gynaecologists do laparoscopies to diagnose endometriosis, Pav?

Pav Nanayakkara: So, I think most gynaecologists that go through the RANZCOG training program will be able to do a laparoscopy to diagnose endo. In terms of whether they can treat all the endo that can be found, that’s variable. So, there are six levels of laparoscopic surgery and it’s often just the level 5 and 6 laparoscopic surgeons that can treat the complex or the severe cases of endometriosis. So that’s involving bowel and bladder and maybe close to other important structures like the ureter. So, I suppose in terms of minimising the number of operations overall, if there is a higher clinical suspicion of that moderate to severe endometriosis, then the recommendation would probably to go with an advanced laparoscopic surgeon with experience in endometriosis. But the mild to moderate cases can be managed by a general gynaecologist.

Sara Whitburn: Thank you so much. Thank you so much to both of you for joining me tonight to talk about endometriosis. As always, I always find when I’m presenting, I don’t only talk about the things that I’m passionate about, but I learned so much from my co-presenters. So, thank you so much for being here tonight. We’re going to wrap up tonight. Do either of you have one take home, one burning message you’d like to say to people around endometriosis? Janetta?

Janetta Webb: I think to think about both tissues, but also become familiar with pain science and educate your patients about pain science as well as treating the tissues.

Sara Whitburn: And Pav?

Pav Nanayakkara: My biggest advice would be don’t suffer in silence. Advocate for yourself. Get a second opinion. Speak to specialists in the area. And as a GP, if you’re not happy with the advice that you’ve been given, then again, seek help from a women’s health specialist. There’s so much that can be done.

Sara Whitburn: Thank you very much, Pav. I will always seek out advice from my women’s health specialist. Thank you.
And so I’d just like to wrap up and say from primary care, I think I titled my talk, I worked on it the whole time, which is, do think of endometriosis as a working diagnosis if there’s any cyclical symptoms that are painful in that pelvis, as you said, Janetta. But if it does seem to be a cyclical symptom that comes with the menses, I’d really, really consider endometriosis and think about support and management.
I want to thank both of you tonight. I want to thank Jean Hailes for Women’s Health for having us. Thank you very much for watching and for all your questions. And we look forward to seeing you at a webinar in the future. Thank you.


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