As a gynecologist practicing for over 33 years and specializing in endometriosis, I can attest that Abigail's experience is sadly not uncommon. And as a male physician, I have encountered innumerable patients whose complaints of pelvic pain were dismissed by other physicians - including plenty of female docs, whose attitudes could be sum…
As a gynecologist practicing for over 33 years and specializing in endometriosis, I can attest that Abigail's experience is sadly not uncommon. And as a male physician, I have encountered innumerable patients whose complaints of pelvic pain were dismissed by other physicians - including plenty of female docs, whose attitudes could be summarized as "I have periods, I've given birth, your pain is not that bad."
It turns out endometriosis is a relatively straightforward condition to diagnose - if the doc takes a careful history. It is far and away the most common cause of chronic female pelvic pain. It cannot be detected on physical exam, by a Pap smear, ultrasound, CT scan, or MRI. There is no screening blood test. It can be strongly suspected by a history that includes dysmenorrhea (painful periods), dyspareunia (painful intercourse), and menstrual dyschezia (painful bowel movements, especially at the time of the menstrual period). It should be always suspected if the patient has the above triad of symptoms **despite** menstrual suppression with hormonal contraceptives such as the Pill, the Depo Provera shot, NuvaRing, contraceptive patch, or IUD (intrauterine device).
However, the diagnosis cannot be confirmed without direct visualization of the characteristic lesions by direct inspection using video camera attached to a telescopic instrument known as a LAPAROSCOPE, and more importantly, EXCISIONAL BIOPSY (removal of abnormal tissue) which is ideally performed laparoscopically. Some surgeons simply perform ABLATION using electrocautery or laser but this only destroys the superficial disease, and it is known that endometriosis can be a deeply infiltrating disease. We often liken this to missing the 2/3 of the iceberg that is beneath the surface of the water.
The sad state of affairs as to why few gynecologists have the awareness or expertise to promptly detect and remove endometriosis is because of several factors. One is the somewhat steep learning curve for doing this type of laparoscopic excision. It takes LOTS of practice to become skilled at excising endometriosis safely. Part of why there is a dearth of skilled GYN laparoscopic surgeons is that the total amount of training one gets in Ob/Gyn residency is woefully inadequate for independently performing this type of surgery. Once in practice, unless the new doc has an experienced surgical mentor, they will be hard pressed to acquire such skills. The other elephant in the room is reimbursement, coupled with the risk of that type of surgery. It turns out there is only one CPT billing code for removal of endometriosis, 58662, and it is poorly reimbursed. Couple that with the fact that for complete removal of endometriosis the surgeon often has to operate in very close proximity to vital structures, such as the ureter, the bladder, large blood vessels, the colon and rectum, and in an anatomically challenging space known as the retroperitoneum, with the risk of injury to those nearby structures, plus the time it takes to dissect in those locations, and many GYN docs quickly decide the whole thing just isn't worth the time and anxiety and risk. This is why many of the skilled GYN laparoscopic surgeons who have expertise in endometriosis are intentionally "out of network" with health insurance companies. They often charge exorbitant fees (I've seen between $10,000 and $20,000) and won't file insurance.
As a gynecologist practicing for over 33 years and specializing in endometriosis, I can attest that Abigail's experience is sadly not uncommon. And as a male physician, I have encountered innumerable patients whose complaints of pelvic pain were dismissed by other physicians - including plenty of female docs, whose attitudes could be summarized as "I have periods, I've given birth, your pain is not that bad."
It turns out endometriosis is a relatively straightforward condition to diagnose - if the doc takes a careful history. It is far and away the most common cause of chronic female pelvic pain. It cannot be detected on physical exam, by a Pap smear, ultrasound, CT scan, or MRI. There is no screening blood test. It can be strongly suspected by a history that includes dysmenorrhea (painful periods), dyspareunia (painful intercourse), and menstrual dyschezia (painful bowel movements, especially at the time of the menstrual period). It should be always suspected if the patient has the above triad of symptoms **despite** menstrual suppression with hormonal contraceptives such as the Pill, the Depo Provera shot, NuvaRing, contraceptive patch, or IUD (intrauterine device).
However, the diagnosis cannot be confirmed without direct visualization of the characteristic lesions by direct inspection using video camera attached to a telescopic instrument known as a LAPAROSCOPE, and more importantly, EXCISIONAL BIOPSY (removal of abnormal tissue) which is ideally performed laparoscopically. Some surgeons simply perform ABLATION using electrocautery or laser but this only destroys the superficial disease, and it is known that endometriosis can be a deeply infiltrating disease. We often liken this to missing the 2/3 of the iceberg that is beneath the surface of the water.
The sad state of affairs as to why few gynecologists have the awareness or expertise to promptly detect and remove endometriosis is because of several factors. One is the somewhat steep learning curve for doing this type of laparoscopic excision. It takes LOTS of practice to become skilled at excising endometriosis safely. Part of why there is a dearth of skilled GYN laparoscopic surgeons is that the total amount of training one gets in Ob/Gyn residency is woefully inadequate for independently performing this type of surgery. Once in practice, unless the new doc has an experienced surgical mentor, they will be hard pressed to acquire such skills. The other elephant in the room is reimbursement, coupled with the risk of that type of surgery. It turns out there is only one CPT billing code for removal of endometriosis, 58662, and it is poorly reimbursed. Couple that with the fact that for complete removal of endometriosis the surgeon often has to operate in very close proximity to vital structures, such as the ureter, the bladder, large blood vessels, the colon and rectum, and in an anatomically challenging space known as the retroperitoneum, with the risk of injury to those nearby structures, plus the time it takes to dissect in those locations, and many GYN docs quickly decide the whole thing just isn't worth the time and anxiety and risk. This is why many of the skilled GYN laparoscopic surgeons who have expertise in endometriosis are intentionally "out of network" with health insurance companies. They often charge exorbitant fees (I've seen between $10,000 and $20,000) and won't file insurance.