Lighting up Endometriosis

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More than six million American women and girls struggle with endometriosis, a chronic condition that causes pain before and after their periods. (KFSN)

More than six million American women and girls struggle with endometriosis, a chronic condition that causes pain before and after their periods. It can also cause infertility. In some cases, endometriosis is difficult to diagnose, but a new imaging method may shed light on difficult to detect cases.

Twenty-eight year old Susie Veech has spent more than half her life in the kitchen. She's a food service consultant and a budding caterer.

Susie also spent more than half her life trying to figure out the source of the monthly, searing pain in her side. Veech told Ivanhoe, "Eleven, on a scale of one to 10, the pain."

Veech had endometriosis. The tissue normally lining the inside of her uterus was also growing on the outside and blocking other organs.

Gynecologist and co-director of the Endometriosis Center and the Minimally Invasive Surgical fellowship program at Mercy Medical Center in Baltimore, Kevin Audlin, MD, is studying a new imaging technique designed to help gynecologists detect endometriosis. Traditionally, doctors use a minimally-invasive tool called a laparoscope to look for tissue.

"Full spectrum light looks just as if we would see. If you're looking into a belly, you'll see organs, most everything is either a yellowish or a pink," Dr. Audlin explained.

In addition, Dr. Audlin is testing special lighting called narrow band imaging. When he presses a button on the laparoscope, the light changes, making endometriosis stand out.

Dr. Audlin said, "The red hue tends to be the endometriosis, the green we see tends to be the actual vasculature."

For Veech, finally a diagnosis followed by a procedure to keep the endometriosis at bay. She said, "When everyday pain goes away, you have tons of energy. You don't realize how much it's weighing you down."

In a study of 150 women undergoing the laparoscopic procedure for endometriosis, researchers found the addition of narrow band imaging improved detection by 20 percent. Dr. Audlin says the narrow band imaging offers another avenue for women who have had chronic pain but are not showing signs of endometriosis with traditional screening.

Lighting up Endometriosis -- Research Summary

BACKGROUND: Endometriosis is a condition where endometrial tissue, normally found within the uterus, is found outside of the uterus, most commonly on the pelvis. The pain, inflammation and scarring associated with the condition are the biggest issues with endometriosis. Many women mistake the pain for menstrual cramps, so it can take years to identify correctly. It is one of the most common lower abdomen conditions in the female body, affecting at least 6.3 million American women. The condition can be diagnosed through a pelvic exam, an ultrasound or through laparoscopy to rule out other painful lower abdomen conditions like Crohn's disease, irritable bowel syndrome (IBS) or ulcerative colitis. (Source: Kevin Audlin, MD, http://www.womenshealth.gov/publications/our-publications/fact-sheet/endometriosis.html, http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0072685, http://endo-online.org)

TREATMENTS: Endometriosis is incurable but there are several treatments for endometriosis that can reduce or eliminate the inflammation and pain associated with it:

Pain medication: Doctors will prescribe over-the-counter pain medication if the symptoms are mild. Usually, they recommend nonsteroidal anti-inflammatory drugs (NSAIDs) or they may use opioids, a medication that interacts directly with the nervous system, if the pain is severe.

Hormone treatment: Hormone treatment is also helpful and it has shown to reduce the growth of new cysts. Hormone therapy can include birth control pills or progestin or progesterone injections like Depo-Provera.

Hysterectomy: A hysterectomy is the removal of the uterus. Doctors consider this a last resort for endometriosis but the surgery is not effective on its own. If the ovaries remain in the body, they can cause the condition to return. According to American College of Obstetricians and Gynecologists, 15 percent of women who receive a total hysterectomy have a recurrence of endometriosis. (Sources: http://www.nichd.nih.gov/health/topics/endometri/conditioninfo/Pages/treatment.aspx, http://www.mayoclinic.org/diseases-conditions/endometriosis/basics/treatment/con-20013968)

NEW TECHNOLOGY: Researchers at Mercy Medical Center in Baltimore have performed a study that compared standard white light imaging and narrow band imaging (NBI) in detecting and diagnosing endometriosis. NBI is a high-resolution endoscopic technology that improves visibility of blood vessels in the body. Gynecologist and co-director of the Endometriosis Center at Mercy Medical Center, Kevin Audlin, MD, says that NBI allows them to identify abnormal blood supply commonly associated with endometriosis, making the condition "stand out". With white light imaging, only 78.9 percent of lesions were detected. NBI was able to positively identify 84.1 percent of lesions in study participants. (Source: Kevin Audlin, MD) MORE.

FOR MORE INFORMATION ON THIS REPORT, PLEASE CONTACT:

Dan Collins

Media Relations

Mercy Medical Center - Baltimore

dcollins@mdmercy.com

Lighting up Endometriosis -- Doctor's In-depth Interview

Kevin Audlin, M.D. Gynecologist at Mercy Medical Center in Baltimore talks about a new technology that is used to help doctors discover a painful disease in women.
Interview conducted by Ivanhoe Broadcast News in July 2015

What is endometriosis?

Dr. Audlin: Endometriosis is when the glands from inside the uterus that shed each month with the menstrual cycle, actually get back inside the pelvis and other organs of the body. The ovaries produce hormones that allow the glands to grow and at the end of each month they shed. If the tissue is outside of the uterus it does not have a place to go and it ends up causing a lot of pain, a lot of inflammation and a lot of complications. Often times its down in the pelvis so those ladies end up with quite a bit of pain and that's essentially what endometriosis is.

Is the main symptom the pain?

Dr. Audlin: Pain is common and is found from many different things. Just because you have pain doesn't mean you have endometriosis. It's a constellation of symptoms; pain is usually worse with cycles and can include lower back pain, painful bowel movements, diarrhea at times and painful intercourse. Depending on where the endometriosis is, that really does dictate which symptom you have.

What are some of the risks if you have endometriosis?

Dr. Audlin: Infertility is the big one. There are a lot of patients that come in concerned about endometriosis or being referred because they know they have it. Their biggest concern of course is infertility. Infertility is increased with endometriosis. On average, there's about a ten percent decrease in the ability to get pregnant at the normal age. What that means is if you're a 30 year old woman, there's a specific likelihood of pregnancy that's about ten percent smaller for people with the diagnosis of endometriosis. It can be significantly worse. Stage three and Stage four disease can be completely occluding the fallopian tubes making it impossible to get pregnant without fertility help.

How is it diagnosed? Is it difficult to discover whether or not a woman has symptoms?

Dr. Audlin: That answer is difficult because the honest answer is there's only one way to diagnosis it, it's through direct laparoscopy. You have to visualize it. I'm often astounded that ladies come to me for their third and fourth opinion with an obvious case of endometriosis and they've never been told that's what it is. I think it's a relative easy diagnosis for the most part. But unfortunately a lot of ladies are very, very frustrated by an inability to get an answer as to why they have such horrible pelvic pain, why they can't have intercourse through most of the month and why they always have bowel issues. Often times in a young woman it is endometriosis.

In terms of looking at it and diagnosing it, for you is it fairly easy to tell? Are you able to look at it during a surgical procedure and tell whether it's endometriosis?

Dr. Audlin: There are classic types of endometriosis, we call it red endometriosis which is essentially where the glands of the uterus go back in to the pelvis and it grows just like you would see moss growing on the side of a wall. It's a very red, irritated, swollen type of lesion and that's obvious. There are many other types of endometriosis and they are not as obvious. That is actually one of the many things that we're trying to improve upon is detection rates. There are people that are considered experts at this. If you do more than five endo cases a month you're considered an expert. The detection rate for experts is roughly 75 to 80 percent, meaning that if you would excise or remove five lesions, four of those five would be considered or expected to be positive for endometriosis because you have a better idea what to look for. Whereas, if you're going to a physician who isn't an expert, who doesn't do five or more per month, the identification rate is as low as 40 percent. You can see that who you go to for the care of your endometriosis really does impact how well you respond to treatment and if they're able to identify you accurately.

Why is it difficult in some cases?

Dr. Audlin: Because the classic lesions are easy to see and the non-classic lesions are very hard to see. They are clear, they are white, they are black and they can almost look like anything. What you need to find is someone who has done enough of this and has seen enough of this so that they realize non-classic lesions that can also cause a lot of pain and excise them as well. That's another thing, a lot of people don't actually excise the endometriosis they burn it. Burning it produces a powder burn look, you remove the endometriosis that's on the superficial portion of the pelvic area and the deep tissue or the roots are still there. And three to six months later after stimulation of the estrogen again it comes right back. I liken it to weeds, you cut the dandelions it looks like you got rid of it but another week or so and the dandelions come right back because the roots were still there.

Talk to me about NBI.

Dr. Audlin: Narrow band imaging is a light source. It's nothing more than a filter that is found on specific laparoscopes. All of the more recent Olympus endoscopes have this filter. What it allows me to do is identify vasculature. We know that endometriosis up-regulates vasculature. It produces all sorts of chemokines and factors that increase vascular blood supply to the area. It makes sense because you want to bring estrogen to the endometriosis. The more blood supply you have, the more endometriosis can grow. So in these non-traditional lesions, they still have the blood supply they just don't have that classic red lesion architecture. When we put on our filter, the filter shows the abhorrent blood supply; very classic for the endometriosis and we excise the areas that have that in addition to the areas that have the red lesion look as well. We're excising significantly more lesions and we're finding more through pathology that we are able to remove.

How much more accurate does the narrow band imaging allow you to be?

Dr. Audlin: In my initial pilot study we enlisted 21 patients and of those 21 patients, seven were not able to see any endometriosis with white light. Of those seven we were able to find four to have it with narrow band imaging. Those four ladies would have gone home without a diagnosis of endometriosis, without a treatment, and would have been told there's nothing wrong with them. But they were able to be identified, able to be given the appropriate diagnosis and were able to treat it. That was a powerful statement that actually started a multi-center trial. We had 167 patient enrolled in a trial that actually was just published and it shows that we're able to increase our detection rate of endometriosis by up to 21 percent with the Olympus laparoscopes using NBI. We are able to absolutely improve our ability to find and treat endometriosis and it's reproducible by other physicians as well.

Can you describe the difference of the lights?

Dr. Audlin: If you're looking, what we all see is a full spectrum white light. Whereas a narrow band image actually is a dual filter. It allows us to isolate 415 nanometers and 540 nanometers which are specific for hemoglobin. Hemoglobin is found in the blood supply, it's in your red blood cells and when it shows up, those particular light sources allow us to see the vasculature. One of them is red one of them is green so it gives us a little bit of depth and they're all very superficial. It allows me to roadmap the peritoneum which is where you find the endometriosis.

What will our viewers see, how can they tell the difference? What are the doctors seeing?

Dr. Audlin: Full spectrum light looks just as if we see normally. If you're looking in to a belly you'll see organs and almost everything is either a yellowish or a pink. Whereas when you flip on the light source, you'll see a little more grayish picture not as bright vibrant colors but you'll see an overlay of green and red. Those are the vasculature and that is the depth that it gives us so we can see. We don't want to go too deep in the pelvis because obviously big vessels are very deep so we want very superficial vasculature. Those are just the two wave forms that allow us to see superficial vasculature.

When you see that red and green what does that tell you?

Dr. Audlin: That's the blood supply. I think when you see it you'll see a net of green which is the vasculature and a little bit of a red hue. The red hue tends to be the endometriosis and the green tends to be the actual vasculature.

When I see the red that's the endometriosis that you would not have seen with the regular light source?

Dr. Audlin: Sometimes, it shows that as well. But it's in addition. It allows you to see more.

In your opinion, is this going to be the way of the future; is this something that should become more of a standard of care?

Dr. Audlin: It should. If you're going to be a person who wants to work with patients that have endometriosis there's no reason not to. There's no extra cost, it's not switching telescopes, there's very little minimal increase in time and over time it's going to help you identify lesions that you wouldn't have identified otherwise. I use the narrow band imaging less today than I did four and five years ago because I've taught my eye to see what I would see with the narrow band.

Is there anything that I didn't ask you that you think is important for the viewers to know?

Dr. Audlin: Our hopes are that narrow band imaging is going to allow surgeons that aren't experts become more of an expert. If the accepted standard for non-expert surgeons is 40 percent we want to improve their detection rate, we want to get them in that 60, 70 percent detection rate. It puts them in the expert category because the camera helps them identify lesions that they wouldn't see otherwise. That's important. The second thing is that I think that it's a very frustrating disease and hopefully you may have got that from Susie. I think she had gone to three or four other doctors before she even got to me and the first thing I said is you've got endo. Now granted endo is on my brain so I think everyone has endo but the sad thing is almost everyone does have endo. What I found is through these WBAL Women's Doctor segments is that this provides a lot of direct to consumer referrals. The patients are tired of having their doctor say just take birth control pills, just take these narcotics this will take care of it, when in reality it's got to be gotten rid of so you don't have to take narcotics. There's a ton of quality of life issues, there's a ton of work loss. These are often 20 to 35 year old women that are functional, that are missing work, that are getting hooked on narcotics, that are doing things they wouldn't do otherwise. They end up staying away from boyfriends and husbands because they are in horrible pain all because they don't have a diagnosis. Or if they have it, their doctor didn't do a good job of fixing it.

If you would like more information, please contact:

Kevin Audlin, MD

Mercy Medical Center, Baltimore

345 St Paul Pl, Baltimore, MD 21202

(410) 321-8452.
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