Surgical Treatment without hysterectomy!
Endometriosis is the presence of endometrial tissue (tissue identical to the endometrium, the uterine lining) outside the uterus. Usually the endometriotic implants are located in the pelvis but endometriosis may also involve other parts of the abdominal cavity, the abdominal wall and, rarely, other locations such as the chest. The endometrial implants respond to ovarian hormonal changes in a fashion similar to the uterine endometrium. This results in local bleeding, irritation, inflammation, scarring and adhesion formation. In the ovaries, endometriosis may lead to the formation of cysts containing old blood (so-called chocolate cysts or endometriomas). These hormone-related changes are the basis for the symptoms of endometriosis. Approximately 19% of hysterectomies in the U.S. are performed because of endometriosis.
Endometriosis may be symptomatic or asymptomatic. There is poor correlation between the extent of the disease and the degree of symptoms. Pain is the main symptom. It may be periodic, before or during the periods, or it may be constant. It may cause painful intercourse, pain in the middle of the pelvis or on either or both sides, or rectal pain. There may be irregular uterine bleeding. Infertility is frequently associated with endometriosis. The rate of progression of endometriosis is highly variable among patients; even in the same patient it may vary at different time periods.
Endometriosis may be suspected in women of reproductive age with pelvic pain, infertility, or irregular uterine bleeding. Pelvic exam may reveal a retroverted (tilted backwards) uterus, tender adnexae (ovaries and tubes), enlarged ovary due to cyst(s) or tender nodules in the cul de sac (the space between the uterus and rectum.)
Ultrasound usually cannot diagnose endometriosis because the small implants are not visible. In some cases, ultrasound identifies a typical chocolate cyst in the ovaries, suggesting endometriosis.
Laparoscopy (or laparotomy) with direct visualization and biopsy of the implants are the only definitive diagnostic measures. At surgery the extent and severity of the disease can be assessed allowing optimal treatment planning; at surgery the disease can also be treated by means of surgical removal, laser, cautery, etc.
The progression of endometriosis is estrogen dependent. Treatment with continuous progesterone can shrink endometriotic implants. Overall, the treatment that causes significant decrease in estrogen levels (pseudomenopausal state) is more effective than measures involving prolonged progesterone effect. Agents with prolonged progesterone effect such as provera may be given by mouth or by injections. Prolonged progesterone effect can also be achieved with birth control pills which contain estrogen and progesterone, taken continuously for six to eight months. Such treatment may relieve pain; some endometriotic implants may resolve and/or decrease in size.
Agents that suppress ovarian estrogen production include Danazol, a weak androgenic (male) hormone, and GnRH agonists such as Lupron. These agents are more effective than progestins in suppressing symptoms and reducing implants. However, their use is limited by side effects which resemble those of menopause. The low estrogen state leads to hot-flashes, bone demineralization, increase in "bad" cholesterol (LDL) and decrease in "good" cholesterol (HDL). The latter changes increase the risk of cardiovascular disease. Therefore, these agents are rarely prescribed for more than six months. Usually, the beneficial effects do not last very long after the cessation of treatment. At times a course of a GnRH agonist is prescribed in preparation for surgery or as adjuvant treatment after surgery.
Surgical treatment of endometriosis is indicated when medical treatment fails, when large endometriomas (ovarian chocolate cysts) are present, or in the treatment of infertility.
The role of surgery, via laparoscopy or laparotomy, is to resect or destroy endometriotic implants, remove an endometrioma, remove pelvic adhesions and repair obstructed fallopian tubes (tuboplasty.)
Removal of the uterus, alone or with the ovaries and fallopian tubes, should be considered only when it has been established that the ovaries or uterus are the source of the symptoms and that all other treatment modalities have failed. The last requirement is critical. "Failed treatment" is a relative term and depends to a large extent on the dedication, expertise, surgical skills and motivation of the treating physician to spare the involved organs. Meticulous surgery including microsurgical technique in resecting endometriotic implants, lysis of adhesions and pelvic reconstruction may achieve better and more lasting results than less sophisticated surgical techniques. Combining medical and surgical treatment may also be helpful.
Surgical excision of endometrial implants demands more expertise than ablation of these lesions because of higher risk of damage to the ureters, bowel and bladder. However, the literature indicates that surgical excision better reduces symptoms, such as pain and quality of life and also prolonged the time to recurrence of symptoms. It was also found that continuous treatment with birth control pills will decrease significantly cyst recurrence.
A special procedure to relieve pain caused by endometriosis is LUNA (laparoscopic uterosacral nerve ablation.) It involves the destruction of many nerve fibers that provide sensation to the cervix and lower uterine segment. The effectiveness of this procedure in relieving menstrual pain is variable (50-75%). Another procedure known as presacral neurectomy involves severing the nerve fibers which convey pain sensation from the uterus and pelvic floor and is more effective in relieving pain. If presacral neurectomy is performed meticulously it may give long term relief from pelvic pain even if the endometriosis progresses. In my experience hysterectomy with or without ovarian resection is necessary in only a very small percent of patients with endometriosis. It should be emphasized that hysterectomy is not a foolproof treatment for the symptoms of endometriosis. The rate of recurrent symptoms is high (up to 63%) after hysterectomy; after hysterectomy and bilateral oophorectomy recurrent symptoms appear in a significant percent (10%) of women.
© COPYRIGHT 1996-2012 ALL RIGHTS RESERVED MICHAEL E. TOAFF, MD, MSc
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