Dr. Lora Liu, Endometriosis Excision Specialist, New York City
Case Studies
ENDOMETRIOSIS CASE STUDY #1: 15-year-old high school student
SITUATION
“Alison” had extremely painful periods since age 13. She was having to miss or be tardy to school the week before her period and the week of her period due to her debilitating pain. She had trialed birth control pills for 6 months, however, did not note any improvement in symptoms. Her mother Karen, was desperate to help her, but was unsure how to. Karen was referred to an online endometriosis education group and educated herself on endometriosis and excision surgery.
TREATMENT
Symptoms of endometriosis frequently emerge during adolescence. Numerous individuals recount experiencing severe menstrual periods during their teenage years, often leading to missed school or events due to the intense pain. Hormonal suppression, typically through birth control pills or intrauterine devices (IUDs), is a common treatment approach. In many cases, this method proves highly successful, resulting in symptom alleviation or complete resolution. Nevertheless, there are occasions where little to no improvement is observed despite these interventions.
Karen and Alison agreed that the next step was surgical excision. Allison was then diagnosed with pathology-proven endometriosis, where 6 out of 18 specimens returned positive for endometriosis. Her school was able to provide online support for her so she did not fall behind in her classes and she was able to return to in-person classes 10 days after her surgery.
RESULT
Alison, now a junior in high school, recently enjoyed her junior prom! Although she experienced a recurrence of pain six months after surgery, through adjustments to her medication and starting physical therapy, she successfully managed the situation and continues to embrace her teenage years to the fullest.
ENDOMETRIOSIS CASE STUDY #2: 57-year-old postmenopausal homemaker
SITUATION
“JoAnn” had previously undergone excision surgery for endometriosis a decade ago. While she initially felt relief, she began experiencing heightened bloating, constipation, and severe rectal pressure and pain over time. Being postmenopausal, she couldn’t attribute her symptoms to her menstrual cycle. Following a colonoscopy, she received an IBS diagnosis and was prescribed medication for her constipation, yet she observed no improvement. Recalling information about endometriosis possibly causing bowel dysfunction, she questioned whether the condition could still manifest symptoms even after menopause.
TREATMENT
A prevalent misconception is that endometriosis will improve after menopause or a hysterectomy. Regrettably, this is untrue for numerous patients. Despite the absence of a menstrual cycle, endometriosis lesions persist and can continue to induce pain and other symptoms such as bowel dysfunction or discomfort due to years of scarring and inflammation.
JoAnn proceeded with endometriosis excision surgery where 10 out of 19 specimens came back positive for endometriosis. She also elected to have her ovaries and fallopian tubes removed to prevent the risk of developing ovarian cancer in the future.
RESULT
JoAnn had complete resolution of symptoms for a year post-surgery. She then started to note some mild recurrence of rectal pressure 1.5 years later, therefore she was referred to a pelvic floor physical therapist, as well as a physiatrist for conservative management. And, of note, she referred her two daughters to Dr. Liu for surgical excision of endometriosis and both daughters were found to have pathology-proven endometriosis as well.
ENDOMETRIOSIS CASE STUDY #3: 32-year-old Social Worker
SITUATION
“Rachel” had a history of endometriosis, diagnosed one year prior after having ablation surgery (burning of the endometriosis lesion). She did not note much improvement with her symptoms, but was focused on wanting to start a family with her wife. She underwent 7 intrauterine inseminations (IUIs), 3 egg retrievals, and 6 failed embryo transfers, with no success.
TREATMENT
Endometriosis often manifests as infertility, affecting up to 50% of patients. Rachel, for instance, received a diagnosis of endometriosis, however underwent ablation rather than excision of endometriosis. While ablation is a common “treatment,” it is a suboptimal approach as it may leave residual disease behind, leading to incomplete treatment. Additionally, it can induce heightened scarring, potentially exacerbating pain and other symptoms.
Rachel proceeded with endometriosis excision surgery where 12 out of 21 specimens came back positive for endometriosis.
RESULT
After recovering from surgery, Rachel resumed pelvic floor physical therapy with improvement in symptoms. She was also referred to a different infertility specialist by Dr. Liu, and underwent another frozen embryo transfer 4 months after surgery, which was successful!
ENDOMETRIOSIS CASE STUDY #4: 34-year-old Nurse Practitioner
SITUATION
“Jessica” had been on birth control pills for painful periods the majority of her adult life, but then discontinued when she and her husband decided to try to conceive. They tried to conceive for 6 months, however were not successful. Therefore, they went to an infertility specialist, where all lab tests, imaging, and other fertility tests came back normal and she was diagnosed with “unexplained infertility.” She underwent egg retrievals and were able to create and freeze embryos, but noted that her pelvic pain, as well as “IBS” and urinary symptoms were exacerbated during the IVF process.
TREATMENT
Even though Jessica had a myriad of other symptoms suspicious for endometriosis, she was diagnosed with “unexplained infertility.” Unexplained infertility occurs when no identifiable cause for infertility is found, despite normal test results. The current reported prevalence of endometriosis in individuals with unexplained infertility ranges from 30% to 63%, though recent studies propose a potentially higher prevalence rate1. This underscores that, often, the sole symptom of endometriosis may be the inability to conceive.
Jessica underwent endometriosis excision surgery with 15 out of 28 specimens were confirmed for endometriosis.
RESULT
Jessica was able to spontaneously conceive after one month post-surgery and had to cancel the appointment for her upcoming embryo transfer! She returned to work and is now an active advocate in her field of women’s health.
1Nezhat C, Khoyloo F, Tsuei A, Armani E, Page B, Rduch T, Nezhat C. The Prevalence of Endometriosis in Patients with Unexplained Infertility. J Clin Med. 2024 Jan 13;13(2):444. doi: 10.3390/jcm13020444. PMID: 38256580.
ENDOMETRIOSIS CASE STUDY #5: 29-year-old international patient
SITUATION
“Brittney” had known bilateral endometriomas, which were pressing on her bladder and both of her ureters (the tube that transports the urine from the kidneys down to the bladder). Her kidney function was starting to become compromised, as evidenced on imaging as well as blood work. She was an international patient, and the waitlist for an endometriosis specialist in her country was over a year.
TREATMENT
Endometriosis can affect other organs outside of the reproductive system, such as the kidneys, bowel, bladder, and the diaphragm (among other organs, nerves and muscles). Many times, patients are unaware that other organs are being damaged until it is almost too late because they are so used to being in so much pain (and ignored) for so many years.
Because Brittney’s situation was so urgent, we expedited her surgery and were able to operate on her 11 days after her initial consult.
RESULT
Brittney underwent extensive surgery for Stage IV endometriosis, including a segmental bowel resection. However, her entire surgery was able to be accomplished robotically. Her kidney function improved rapidly after surgery. She was monitored in the hospital for 2 nights and then returned back home 2 weeks later.