Female Trouble
When Patty Meredith’S pain grew so bad that She had to move out of her second-story bedroom and into a guest room on the first floor of her home, she knew something had to change.

“it was so horrible,” says meredith, now 49. “i was incapacitated. i live in a two-story house, and going upstairs was awful. i am a very active person, and it was very depressing to be that sick.”

meredith has endometriosis, a condition in which the cells lining the uterus implant themselves and grow in other areas of the body, causing pain, irregular bleeding and possibly infertility. The course of the disease can vary greatly among women. Some experience few or no symptoms, while others may experience chronic pain or infertility. 

“Patients with endometriosis come to us either with a mass on an ovary (an endometrioma), or they come with pain,” says Claire Templeman, assistant professor of clinical obstetrics and gynecology at the Keck School of medicine of USC. “it can be pain with periods, pain with ovulation, pain with bowel movements, pain with sex, pain with urination, and it may be some or all of those. and you’ve got a third set of women who see a doctor because they can’t get pregnant, and their endometriosis diagnosis comes about as a result of an infertility workup.”

meredith, who lives in lincoln, Calif., which is near Sacramento, remembers first experiencing very painful menstrual cramps at age 20, but credits pregnancies with her two children in her mid-twenties with keeping the pain at bay. by the time she was in her thirties, meredith learned to schedule her work and home lives around her monthly cycle.

The pain was like really, horribly bad cramps – much beyond normal,” she says. “when it got really bad, if my period lasted for five days, i would have to stay in bed at least one of those days. i learned to schedule my life around my period. when i was planning major events, i would count out 28 days, just to make sure i wouldn’t be on my period.” 

The causes of the disease are not known, and many experts believe that while diagnosis often occurs between the ages of 25 and 35, the condition may have been present for many years prior. 

“There are lots of theories about why women get endometriosis, but there is no one theory that covers everybody who gets it,” says Templeman. “what we do know is that it tends to be a disease that is progressive over time, at least in some women. The reason we try and make the diagnosis early is so we can intervene early in the hope of easing symptoms and stemming progression of the disease.”

meredith managed her life around her condition every month for several years until she turned 40, when the pain increased significantly. but searching for better solutions led her in circles. She visited multiple doctors in several different specialties, but the advice she received didn’t work for her.

“at this point, i was vomiting when i’d get my period,” says meredith. “i’d lost 35 pounds, going from 140 pounds to 105. i was miserable. … one doctor told me she was convinced my only solution was a hysterectomy. ‘Take it all out – that’s your only course!’ ”

removal of the uterus used to be a standard treatment for women suffering from endometriosis, but as the disease has begun to be diagnosed in younger women, preferred treatments have changed. 

“The way we understand endometriosis now is that, for young patients, performing a hysterectomy is a bit like trying to remove weeds without removing the roots,” says Templeman. “you’ve taken out the weed, but it’s going to grow back because the roots are still there. There has been a shift in approach that radical surgery is removing the disease rather than removing the uterus and the ovaries, which essentially puts someone into menopause. There are sometimes other reasons for a woman to have a hysterectomy, such as large fibroids or cancer, but that procedure as a primary treatment for endometriosis is not what we do.”

Treatment for endometriosis begins with medications to control the pain, as well as hormonal treatments – such as birth control pills – although surgical options can be necessary for severe cases.

“if someone has a persistent mass on an ovary that we suspect may be an endometrioma, we’ll operate so we can confirm that it is not ovarian cancer,” says Templeman. “we’ll operate in patients who have severe pain, who may not have responded to medical treatment, if patients have involvement of organs such as the bladder or the bowel, or severe bleeding from these organs. and sometimes we’ll operate in patients who are trying to become pregnant because that can certainly help from a pain perspective and from the fertility perspective. what’s important is that treatment needs to be individualized.”

when looking for treatment options that could help her overcome the debilitating pain while not sacrificing her uterus, meredith found USC University hospital. despite the fact that she lived more than 400 miles away, meredith made an appointment with Templeman.

“when i saw her, she told me she had good news and bad news,” says meredith. “She said: ‘The bad news is that you have deep endometrial disease. The good news is this type benefits the most from surgery.’ She gave me the perfect balance of hope and reality.”

The gyneCology Service at USC University hospital takes a multidisciplinary approach to endometriosis treatment, working in conjunction with physicians and surgeons from the division of Colorectal Surgery and the department of Urology.

“The gynecology service provides patients with up-to-date medical treatment options that are individualized to specific patient needs,” says laila muderspach, chair of the department of obstetrics and gynecology at the Keck School. “This team of gynecologists is amazing and has specialized and advanced training in caring for women. The physicians are skilled and compassionate and committed to excellence.”

another strength of the program is its research component. being at a major academic medical center means that patients know their doctors are engaged in the process of discovering new treatments. “our patients are offered the opportunity to participate in tissue studies we are doing,” says Templeman. “we have an active interest in understanding the disease and pursuing new therapeutics of the disease.”

endometrial tissue had spread throughout meredith’s pelvis, invading her upper and lower bowel and bladder. her colon had become completely blocked, which had led to her drastic weight loss and vomiting . She required extensive surgery to remove the tissue. Templeman utilized pelvic laparoscopy – a minimally invasive surgery – to remove all of the endometrial tissue and adhesions.

according to Templeman, most surgeries last a couple of hours. “Patricia’s case was very extensive disease that involved the small and large bowel, and a lot of areas in her pelvis,” she says. “So her surgery was obviously very extensive, and even though it was done laparoscopically, she had to recover in the hospital for several days because she had segments of her bowel resected.”

after several procedures, including two colon resections and the removal of her appendix, meredith began to see a glimmer of hope that she would be able to live free of the pain that had plagued her for years.

now, six years later, meredith is active once again. She doesn’t have to schedule her activities around her monthly cycle. She even plans to complete a “resolution run” in Carmel, Calif., to celebrate.

“i am so amazed to think back to where i was, and to realize that i have recovered from the depths of despair,” she says. “it’s just night and day from where i was to where i am now.”

The long-term chronic pain associated with endometriosis can cause depression and other emotional and psychological problems in the women who suffer from it.

“Chronic pain and infertility can be a huge drain, not only on a patient, but also on her relationships with various members of her family and friends,” Templeman says. “it’s important for women to know that endometriosis is actually a very common disease. i think what people need to know is that they are not alone, and that it is a disease that we are learning more about. if they think that they have symptoms, they need to seek medical attention and see whether this could be what’s going on.”

Surgery such as meredith’s can be a welcome option for women whose endometriosis has not responded to medical therapies.

according to Templeman, providing relief that can change women’s lives has been very gratifying to her as a physician. “working with patients like Patty meredith, who’ve had bladder endometriosis or bowel disease, and who have had the disease resected and whose pain has really responded well to that, is really wonderful,” says Templeman. “or young women who’ve been told that a hysterectomy is their only option, and they’ve come to USC and had their pelvis operated on and their fertility preserved, and they’ve gone on to have pregnancies and their own families. when we hear stories like that, it makes it a very gratifying area to work in.” because the disease can return – even after a hysterectomy

Templeman states that women need to continue to be followed by their doctors. meredith took hormonal medications for four years after her surgery and continues to visit Templeman every six to 12 months, but she has had no recurrence of disease.

“There is always a possibility of my disease coming back,” meredith notes. “hysterectomy isn’t always an answer. even menopause doesn’t guarantee that it’s gone. with this disease, there are no guarantees.”

For more information, or to make an appointment with a physician at the gynecology service at USC University Hospital, please call (800) USCCARE or visit doctorsofusc.com/gynecology