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Category Archives: Treatment

3 years ago Treatment

Should laser vaporization and electrocoagulation of endometriosis be banned

By Dr. David Redwine

Carbon left behind by laser vaporization is more problematic than just the question of being mistaken for recurrent disease. Carbon can stimulate a foreign body giant cell reaction which can be its own cause of pain and lymphadenopathy. Further attempts at treatment by laser can aggravate the problem. This seems like a pointless question. Why should two forms of treatment which are used around the world be banned? The answers are straightforward and compelling:

1. Neither has been validated as being effective in eradication or reduction of endometriosis. Validation of efficacy in eradication or reduction of endometriosis requires a systematic examination of disease extent in patients both before as well as after surgical treatment. In other words, at least two surgeries are required to validate the efficacy of a method of surgery (or medical therapy for that matter). At the first surgery, disease extent is measured, then the surgical modality is applied. At the second surgery, disease extent is measured and compared with disease extent noted at the first surgery. Both laser vaporization and electrocoagulation have been in use for over a quarter of a century, yet we still do not know how effectively either eradicates endometriosis. It is outrageous for those who promote these treatments to ignore the question of efficacy. The studies which have been published have measured only the response of symptoms, not the response of the disease.

2. Both violate common surgical sense. Endometriosis can be a very invasive disease. In some cases, fibrotic disease can be located up to 3 cm beneath the visible surface, with impressive nodular spherical volumes to match. Endometriosis can invade the bowel, bladder, and ureter, and can be associated with fibrosis which can envelope tubular structures in the pelvis including arteries, veins, and ureters. During surgical treatment, it is necessary to separate healthy tissue from the diseased tissue. It is inconceivable that a surgeon can expect to completely and safely treat such a disease by shining a light at it or spraying electrons at its surface. This violates simple common sense.

3. Both convert all manifestations of endometriosis into superficial disease in the eye of the surgeon. This is a corollary of #2. The surgeon who uses laser vaporization or electrocoagulation to treat the disease may be aware of its invasive potential but doesn’t want to be accused of incompletely treating deep disease. Therefore, many will fool themselves into imagining that the disease they are treating is fairly superficial and is being destroyed by shining a light at it or by spraying electrons at it.

4. Electrocoagulation has never been described in the literature so no one can reproduce it. For a surgeon to use electrocoagulation in a reproducible manner, he would have to know several things, including: The type of electrosurgical generator used; Power settings; Type of active electrode; Manner of use of the electrode; Visual endpoint marking completion of treatment. No article on electrocoagulation contains all of these details. A surgeon must either cobble together a list of specifications or, more commonly, just use electrocoagulation in a hopeful manner. Although laser vaporization has been described in more technical detail, the technique of complete treatment of all deep disease has still not been published.


  1. Both rely too heavily on opinions of the surgeon.

    a. What is being treated?
    Neither shining a light at nor spraying electrons at endometriosis produces a pathology report. The surgeon has no idea what is being treated. In some instances, cancer, or carbon or scarring from previous treatments rather than endometriosis is being treated.

    b. How complete was the treatment?
    Surgeons using these techniques have no objective means of ensuring that all endometriosis of any depth of invasion has been eradicated. While occasionally a surgeon might accurately judge that extremely superficial disease has been adequately treated with photons or electrons, the question becomes more problematic with more invasive disease in parenchymal structures such as the uterosacral ligaments or muscularis of the bowel or bladder.

    6. Both contribute support to an incorrect theory of origin, namely reflux menstruation. Reflux menstruation is not the origin of endometriosis. If it were, it would not be called a theory. Reflux menstruation cannot be the origin of endometriosis for several reasons:
    a. Endometriosis is not identical to endometrium.
    It has been taught incorrectly for many generations that endometriosis is identical to endometrium because of reflux menstruation leading to pathologic autografts. Modern studies have illustrated the dozens of profound differences between endometriosis and endometrium [1].

    b. Endometriosis is curable by conservative surgery.
    It has been taught incorrectly for many generations that endometriosis is a chronic, enigmatic, incurable disease. It is said to be “incurable” because of reflux menstruation: even if a surgeon really does destroy all disease, it will just come back because the pelvis will be re-seeded with refluxed endometrium during the next menstrual flow. Yet, it has been known for over half a century that endometriosis can be cured by conservative excision without the need for medical therapy [2]. The minimum cure rate following one conservative surgery is 41%. Following two conservative surgeries, it is 67% (Redwine, unpublished data.) If endometriosis is present after aggressive excision, it will be present in much smaller amounts [3].

    c. Robust photomicrographic evidence of initial attachment and secondary proliferation and invasion of the peritoneum by endometrium does not exist.
    It is estimated that 10% of women have endometriosis which will be symptomatic during their reproductive years. In the industrialized world, it seems likely that there are probably at least 25,000,000 women with endometriosis at any one time. These women will have monthly menses for at least 10 to 20 years. If we take 17 years as a conservative estimate of a woman’s menstrual lifespan, then such a woman will have about 200 menstrual cycles between the age of 13 and 30.

    If a typical flow lasts four days and on each day of flow 10 endometrial cells are refluxed into the pelvic cavity, then each woman will have 8,000 endometrial cells refluxed into her pelvis in her menstrual lifetime. If this is true, then during the menstrual lifetime of our cohort of 25,000,000 women with endometriosis, there will be 8 x 103 x 2.5 x 107 or 2 x 1011 instances of endometrial cells being refluxed into the pelvis in those women. If the rate of attachment of refluxed cells during any one menses is only 1%, then 2 x 109 instances of attachment will have occurred during the menstrual career of these women, or 0.2 x 109 instances of attachment annually. The actual numbers would be higher if previous generations of women are considered or if some women have more than 17 years of menstrual flows or if some women have flows lasting longer than 4 days or if some women have heavier flows. These calculations may seem to be on the low conservative side to some. In any event, if conservative estimates are that several hundred billion possible instances of attachment of refluxed endometrium will occur in this cohort over their menstrual careers, and if over one hundred million instances of attachment occur annually, isn’t it strange that no photomicrographs exist to confirm this supposedly ubiquitous and common phenomenon? The lack of photomicrographic proof of the initial two steps (attachment and proliferation/invasion) of the theory of reflux menstruation is the strongest evidence that this is not the origin of endometriosis.

    The theory of reflux menstruation as the origin of endometriosis and ineffective surgical treatments such as laser vaporization and electrocoagulation share a symbiotic relationship. Neither can exist without the other. So long as the theory of reflux menstruation exists to explain all treatment failures, surgeons don’t have to consider whether their treatments are effective since they can blame all failures on the theory of origin. So long as ineffective surgical treatments exist, the persistent disease which is left behind can be called “recurrent” disease because of this theory and surgery will be considered ineffective or futile. As a result, many surgeons will prescribe medical therapy, which we know does not eradicate the disease.

    7. Both aggravate the rising cost of health care around the world. It is axiomatic that ineffective treatments applied repeatedly are more expensive than effective treatments applied once or twice, especially when one of the treatments requires an expensive machine.

    8. Both reduce a surgeon’s skills. Shining a light at endometriosis or spraying electrons at it are easier than taking the time to remove the disease from the pelvis by careful dissection. As a result, surgical skills will erode since less skill is required for thermal ablative techniques. Removal of the disease, on the other hand, requires meticulous pelvic dissection, knowledge of anatomy, courage, and mental as well as physical stamina.

    9. Laser can cause pain by leaving behind carbon which can cause a painful foreign body giant cell reaction. Carbon left behind by laser vaporization is more problematic than just the question of being mistaken for recurrent disease. Carbon can stimulate a foreign body giant cell reaction which can be its own cause of pain and lymphadenopathy. Further attempts at treatment by laser can aggravate the problem.

    10. “Everybody does it”. Don’t forget what your parents told you: “Just because everybody does it doesn’t make it right.” With a disease which seems so mysterious such as endometriosis over the last 80 years, if everybody thinks alike and treats alike, then it is likely that everyone is wrong. Otherwise if everybody was right, it would be obvious by now. Progress is not made without change.

    11. Both contribute to the belittlement and medical oppression of women. How can we as a profession justify treatments with so many flaws provided to so many women for so many times over so many years? We cannot hide behind the notion that “endometriosis is a mysterious, enigmatic, chronic, highly recurrent disease which is difficult to treat.” We cannot continue to ignore the ill effects of these treatments on women. We must face the fact that these treatments are a large part of the problem in so many ways. Until they are abandoned, our patients will not be freed from our prejudices and from our mistakes.

    Most who read the twelve conditions above will immediately understand all of them, will abandon laser vaporization or electrocoagulation of endometriosis at once, and adopt excision which is the recognized treatment of choice for endometriosis. Welcome to a better way for your patients.


    References

    Redwine, D. B. (2002). Was Sampson wrong? Fertility and Sterility, 78, 686-693.
    Meigs, J. V. (1953). Endometriosis; etiologic role of marriage age and parity: conservative treatment. Obstetrics and Gynecology, 2, 46-53.
    Redwine, D. B. (1991). Conservative laparoscopic excision of endometriosis by sharp dissection: life table analysis of reoperation and persistent or recurrent disease. Fertility and Sterility, 56, 628-634.
3 years ago Treatment

Bowel Endometriosis Surgical Treatment

There are different approaches to the surgical management of bowel endometriosis, such as shaving, excision, and resection. Different studies reveal the advantages and disadvantages of the different techniques. Most experts express using a team approach (such as involving a colorectal surgeon), using imaging to help guide planning before surgery (with a preference for MRI), and decisions based on each individual. Those with more advanced skills in working with bowel endometriosis cite low complication rates.

Studies:

  • Bendifallah, S., Puchar, A., Vesale, E., Moawad, G., Daraï, E., & Roman, H. (2020). Surgical outcomes after colorectal surgery for endometriosis: Systematic Review and Meta-Analysis. Journal of Minimally Invasive Gynecology. Retrieved from https://pubmed.ncbi.nlm.nih.gov/32841755/

“Colorectal surgery for endometriosis exposes patients to a risk of severe complications such as rectovaginal fistula, anastomotic leakage, anastomotic stenosis, and voiding dysfunction. Rectal shaving appears to be less associated with postoperative complications than disc excision and segmental colorectal resection. However, this technique is not suitable in all patients with large bowel infiltration. Compared to segmental colorectal resection, disc excision has several advantages, including shorter operating time, shorter hospital stay, and lower risk of postoperative bowel stenosis.”

“For these reasons, surgeons should consider rectal shaving as a first-line surgical treatment of rectovaginal DE, regardless of nodule size or association with other digestive localizations. When the result of rectal shaving is unsatisfactory (rare cases), disc excision may be performed either exclusively by laparoscopy or by using transanal staplers. Segmental resection may ultimately be reserved for advanced lesions responsible for major stenosis or for several cases of multiple nodules infiltrating the rectosigmoid junction or sigmoid colon.”

  • Afors, K., Centini, G., Fernandes, R., Murtada, R., Zupi, E., Akladios, C., & Wattiez, A. (2016). Segmental and discoid resection are preferential to bowel shaving for medium-term symptomatic relief in patients with bowel endometriosis. Journal of Minimally Invasive Gynecology, 23(7), 1123-1129. Retrieved from https://www.sciencedirect.com/science/article/pii/S1553465016310032

“All 3 treatment modalities are effective in terms of immediate symptom relief with acceptable complication rates. However, significantly higher rates of symptom recurrence and reintervention were noted in the shaving group, whereas segmental resection is more likely to be indicated in cases of large nodules.”

  • Kent, A., Shakir, F., Rockall, T., Haines, P., Pearson, C., Rae-Mitchell, W., & Jan, H. (2016). Laparoscopic surgery for severe rectovaginal endometriosis compromising the bowel: a prospective cohort study. Journal of minimally invasive gynecology, 23(4), 526-534. Retrieved from https://www.sciencedirect.com/science/article/pii/S1553465015017100

“Our aim was to determine the quality of life after radical excision of rectovaginal endometriosis compromising the bowel….Severe rectovaginal endometriosis compromising the bowel can be treated surgically with experienced combined gynecologic and colorectal input with a low serious complication rate. Surgery by an experienced multidisciplinary team results in significant improvement in pain, sexual function, and quality of life up to 1 year postoperatively. Pelvic clearance improves outcome and patients should be counseled accordingly. There is no difference in outcome between the types of bowel surgery undertaken as long as all visible/palpable endometriosis is removed.”

  • Riiskjaer, M., Greisen, S., Glavind‐Kristensen, M., Kesmodel, U. S., Forman, A., & Seyer‐Hansen, M. (2016). Pelvic organ function before and after laparoscopic bowel resection for rectosigmoid endometriosis: a prospective, observational study. BJOG: An International Journal of Obstetrics & Gynaecology, 123(8), 1360-1367. Retrieved from https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/1471-0528.13975

“A significant and clinically relevant improvement in urinary and sexual function 1 year after laparoscopic bowel resection for endometriosis was found. Except for anastomotic leakage, this could be observed independent of any patient‐ or treatment‐related factor. Apprehension about impairment of urinary and sexual function should not be a contraindication for bowel resection in endometriosis patients.”

  • Wolthuis, A. M., Meuleman, C., Tomassetti, C., D’Hooghe, T., van Overstraeten, A. D. B., & D’Hoore, A. (2014). Bowel endometriosis: colorectal surgeon’s perspective in a multidisciplinary surgical team. World Journal of Gastroenterology: WJG, 20(42), 15616. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4229526/

“A precise diagnosis about the presence, location, and extent of endometriosis is necessary to plan surgical treatment. Multidisciplinary laparoscopic treatment has become the standard of care. Depending on the size of the lesion and site of involvement, full-thickness disc excision or bowel resection needs to be performed by an experienced colorectal surgeon. Long-term outcomes, following bowel resection for severe endometriosis, regarding pain and recurrence rate are good with a pregnancy rate of 50%.”

“Some experts have argued that a more conservative surgery, in which the endometriotic nodule is shaved or removed, may reduce the risk for complications associated with the more radical bowel resection, according to Mads Riiskjær, MD, of the Department of Obstetrics and Gynecology at Aarhus University Hospital in Denmark, and colleagues.

‘The surgical strategy in this group of patients has been subject to debate in endometriosis circles for many years,” Riiskjær said in a video abstract. “Indeed, rectal resection is a procedure that carries a substantial risk of short- and long-term complications, and it has been argued that it is too radical an approach for a benign condition.’

“Given this controversy, evaluated prospectively collected data on women who underwent laparoscopic bowel resection for rectosigmoid endometriosis between February 2011 and November 2015. ‘Indication for surgery included severe pain and obstructive bowel symptoms unresponsive to medical treatment.’

“Most of the patients (97.1%) completed questionnaires for pelvic pain and quality-of-life both before and 1 year after surgery, which showed significant reductions in all pelvic pain parameters (P = .0001), especially dyschezia, and significant improvements in quality-of-life scores (P = .0001). Notably, significantly more patients did not require hormone therapy (19% vs. 44%) or pain medication (6% vs. 38%) after surgery. Patients who experienced a surgical complication reported no negative impact on their outcome. Riiskjær and colleagues also noted that they previously showed this procedure results in positive effects on urinary and sexual function.

“’ No two patients are identical and all factors including age, wish for pregnancy, and other personal and social factors should be taken into account in each case, but we strongly believe that our study supports a more aggressive surgical strategy in case of failed medical therapy, and apprehension about impairment of urinary and sexual function should not be a contraindication for bowel resection,’ Riiskjær said in the video abstract.

“Due to a lack of randomized studies comparing different surgical approaches, there remains no consensus on the best surgery for rectosigmoid endometriosis, and providers should therefore take a ‘patient-tailored approach,’ and choose ‘the least invasive radical option,’ according to a related editorial by Jean-Jacques Tuech, MD, PhD, and Horace Roman, MD, PhD, of Rouen, France.”

Videos:

3 years ago Treatment

What to Expect in the Weeks After Skilled Excision Surgery

3 years ago Treatment

Managing expectations pre-op and post op

Let’s talk about “Managing Expectations” 

by Susan Pierce-Richards, DNP, ARNP, ANP-BC, FNP-BC, June 2020 (updated) 

The average time from symptom onset to diagnosis is 7-12 years. You cannot un-do this in a few hours of surgery. This does not mean individuals with endometriosis and pelvic pain cannot get well. They absolutely can but it is not like appendicitis where you have acute pain, surgery, surgical recovery and back to normal in a few weeks. 

I hear from many individuals who become frustrated when 3, 6, 12 weeks or a few months post expert excision they are not completely symptom free. 

Excision surgery is a crucial step – and the value of this step cannot be overstated. But it is the beginning. Remember – even perfectly prepared ground with perfectly healthy bulbs do not yield all of its blooms the first year. 

Timeframe: Symptom onset to Pre-Op for Expert Excision 

Individuals with endometriosis most often have pain for many years prior to undergoing expert excision. 

– When we perceive pain, we often involuntarily contract muscles – with endometriosis it is often pelvic muscles. 

– Over time these pelvic muscles stay tense and/or spasm, become weak and imbalanced, and can irritate nearby nerves. 

– Individuals can develop pain from this muscle tension. They can develop bladder pain syndrome and hip/back/leg musculoskeletal pain. 

– You can have changes in how your nervous system processes pain. Think 1+1+1 does not equal 3… it equals 10. This is particularly true when the symptoms interrupt sleep and other activities that would be restorative. Most individuals with endometriosis and pelvic pain have more than 1 source of peripheral and/or visceral nociceptive (generally interpreted as painful or unpleasant) signals. 

Many individuals have anatomic distortion by the time they have excision surgery. 

– Adhesions from endometriosis, adhesions from prior surgeries, endometriomas, deep fibrotic endometriosis, prior organ removal. 

Many individuals have a reduced quality of life due to years of invalidation, poor sleep quality, infertility, relationship difficulties, and social isolation from the pain and bowel/bladder/gastrointestinal symptoms. 

– Can result in depression and/or anxiety symptoms 

– Maladaptive habits 

– Hopelessness 

– Relationships change – when we cannot contribute as much physically or emotionally in our chosen families, dynamics change in the relationships 

My pre-op story: 

– I was symptomatic from tweens. My periods were always horrible. I had pain with bowel movements 

and in high school I would take Kaopectate so I would not move my bowels during my period. Sex was painful from the first time until I was 45 years old (post excision surgery). – By my 20’s I had pain throughout the month, pain with bowel movements regardless of time of month, 

and pain with passing gas. I had a “small bladder” and urinated a lot with frequent night awakenings. – I had several years of infertility and was diagnosed with polycystic ovarian syndrome (PCOS). 

Providers did not elicit the symptoms of endometriosis and did not explore signs of endometriosis (complex cysts, cul-de-sac nodularity). I did get pregnant and have a biological daughter who is now 16. I also have a 14-year-old son through adoption. I would live through every excruciating moment of my life to have these 2 children in my life. – I eventually sought care for persistent vaginal bleeding because I stopped reporting pain in my 20’s. 

The repeated dismissal of symptoms silenced me. – At 44 I underwent a hysterectomy for bleeding daily x 3 years (slowed down by a Mirena IUD). Again, I 

did not report pain because providers in the past did not address it. – I was diagnosed during a hysterectomy and had a fixed pelvis with extensive dense adhesions, 

obliterated cul-de-sac, bilateral very large endometriomas, bowel endometriosis, and widespread peritoneal disease. My surgeon was unable to remove the endometriosis. – I then did a 6-month course of leuprolide (Lupron®) hoping for a reprieve from the pain. I did very poorly on leuprolide. I ultimately had upper gastrointestinal bleeding that expedited my need for a higher level of care. – Throughout this time I worked like a dog – and exercised. Though this sounds counter-intuitive, 

exercise was my drug. I could not tolerate narcotics, and for few years before the surgeries I could not tolerate NSAIDs either, so distraction was my only tool. I withdrew from friends, family, and my husband. We did not have sex for 3 years before my excision surgery 16 months later. I never missed work and have a successful career. I always managed a smile in public. But I was a shell… 

Timeframe: Getting ready for Expert Excision 

Nervousness. Hopefulness. Excitement. There is a lot of pressure placed on both the surgical team and ourselves – this is the golden ticket, right? The magic bullet… or is excision just preparing the garden properly to plant the bulbs…. 

My story: I was weirdly giddy. I dared to hope. I had given up a chance for any semblance of a normal life. Hope both scared and excited me. I was also in total denial about how big of a procedure I was having. I was fortunate – I had fantastic surgeons and nurses who prepared me for what was going to happen, what I might expect post-op, and what the next steps would be. 

Timeframe: Post-op 

This is not the end… This is the beginning! 

– Post-op healing takes time 

– Menses (if you still have a uterus) and ovulation can be more painful the first few cycles after excision surgery 

– The pelvic muscles can worsen initially during the healing phase 

– Pre-op pain may have been masking or mixed with bladder, pelvic floor, uterine, nerve pain 

Undoing the years of damage 

This will not happen overnight for most individuals and may take months to years of gradual improvement. Be grateful for the incremental improvements in quality of life. Each gain in quality of life is a huge victory. And understand you may have setbacks and get your healthcare team to help you through it. 

– Surgical recovery: The body needs to heal from surgery. Surgical recovery is your job. You need to breathe, move, eat, sleep, and rebuild strength. Take the time to do this. Accept help. Let dust accumulate. 

– Pelvic Floor: The pelvic floor needs rehab – pelvic floor physical therapy. Pelvic muscle imbalance and tension can cause pain, bowel and bladder frequency, constipation, a sense of incomplete emptying, and can worsen interstitial cystitis/bladder pain syndrome (IC/BPS) symptoms. 

– IC/BPS: Endometriosis can mask or be mistaken for bladder pain. IC/BPS can cause persistent bladder symptoms. Guidelines for diagnosis and treatment of IC/BPS changed significantly in 2011 and are evolving. It is manageable but requires commitment. Diet can play a significant role for some people with IC/BPS as can the management of pelvic floor muscle spasm and tension (see above). Individuals can learn to self-catheterize and instill medications into their bladder for self-management. 

– Adenomyosis: This is a tough one. Some surgeons will perform a presacral neurectomy. This can reduce the uterine pain for many individuals (not all). Some individuals do go on hormonal suppression (such as continuous birth control pills) if they wish to retain their uterus or until they choose to have a hysterectomy. 

– Diet: You cannot expect to put garbage in and feel great. Many individuals with endometriosis, even after excision, have food sensitivities that make them feel unwell. Choosing whole organic (when possible) foods that are free from additives, and avoiding gluten, added sugars, and inflammatory fats are good starting places. 

– Exercise: It is important to set goals to restore physical strength, flexibility, and endurance. This can start early post-operatively with slow gentle walking which is critical to preventing post-operative complications. Work with your providers and physical therapists to help set realistic goals. 

– Relationships and mental wellness: This can take time as well. Consider counseling, yoga, and other restorative work. 

– Pain that persists with no obvious reason: Some people can have pain signals continue to fire despite having the source of tissue trauma, inflammation, or injury removed and healed. For some, their pain processing can take time to settle down. Pain management with medications that address pain processing can help for some patients with ongoing pain. Some surgeons may begin treatment to quiet the pain processing pre-op. Some pain processing problems can be reversed so it is important that all of the peripheral pain sources are addressed. Some patients are sent exclusively for pain management for pain processing treatment and management of the peripheral pain sources are abandoned. This is not very effective. 

Remember the 1+1+1 equals 10? Reversing chronic pain often requires additional work on the peripheral and central processing using physical therapy, medications, yoga and other modalities. 

My story: I had extensive excision with 2 surgeons. Endometriosis required removal of nearly my entire pelvic peritoneum, endometriomas on my remaining ovary, fallopian tubes, appendix that was stuck down on my psoas muscle, freeing bowel from the pelvic wall and included a low anterior bowel resection (about 1⁄2 my rectum and some sigmoid colon), careful excision of fibrotic endometriosis from my ureters, blood vessels, and other pelvic structures. My first words waking up were “I’m not nauseated” as I had profound and relentless 24/7 nausea for the 16 months prior to this surgery – from the moment I woke up from my hysterectomy. It was very painful early in my recovery but I am pretty tough – a marathon runner. I was really surprised at just how painful that first week was. 

It was clear about 2 weeks post-op that the endometriosis pain was gone. Wow. Amazing. But I was still urinating over 30 times per day and 8 times at night. I had to admit that maybe I did have this IC thing. This was more devastating for me than endometriosis because despite having symptoms for over 30 years, I never considered myself with any “chronic” health conditions. At my follow up, I had a bladder instillation. I cried – not because it hurt – because for 2 hours I had no pain at all. I had not experienced a moment with zero pain in my memory. I had real hope for the very first time. 

So I sailed off into my perfect life… Not so fast. My life gets better every day but it has taken commitment by me and my provider team to make this happen. It has been over 9 years since my excision. 

What my recovery process looked like after I healed from surgery: 

  • Get the IC under control: I was very symptomatic with IC and Pelvic Floor Dysfunction. To get control: – I did meticulous food journaling for 9 months after making sweeping changes in order to identify triggers. – I catheterized myself daily and instilled meds for the first month. Then every other day, then twice per week, then weekly… Now I do them monthly. – After very strict diet for 5 years, I can eat more liberally now – but foods that would make me sick for 3 weeks now might make me uncomfortable for a few hours or a day. – I still have flares, but I now know how to manage them.
  • The pelvic floor – my nemesis: My pelvic floor has been very stubborn and over time we have learned it was triggered by multiple issues. – Pelvic Botox® x 2 – I did this a year apart and also had pelvic floor PT. – Pelvic surgeon identified a left labrum tear. This improved over time, with PT as well. – Pelvic surgeon (again) and pelvic PT suspected spinal nerve root irritation. Long story but my primary care provider and 2 orthopedists missed the diagnosis (understandable when a working marathon runner comes in with posterior thigh pain and they attributed the pain to hamstring and piriformis which made sense to me). A physical medicine physician noted one-sided weakness in my foot/great toe and confirmed nerve root compression at L5. I underwent lumbar microdiscectomy to relieve the pressure. A bonus effect has been a noticeable reduction in bowel and bladder frequency!
  • Low anterior resection syndrome: I had the expected bowel frequency post-op, but mine has persisted for the past 9 years. – Diet has been very important as has pelvic floor rehab. – Although I have to organize my life around the symptoms, I have learned to manage. And the hours of daily incapacitating pain are gone. So the trade-off has been worth it.
  • Restoring relationships and balance: For years I ran to control the pain, in spite of the pain, TO spite the pain. Now I run for the joy and camaraderie. – For years I avoided social situations. Now I enjoy spending time with friends, going to concerts (when we are not in a pandemic), having dinner parties, and participating in my faith community. For years I avoided sex, it has to be well timed and is not as frequent as we would like (see pelvic floor – it’s a tricky balance) but it is so nice to have that part of my relationship back. –For years I kept insanely busy to avoid any quiet time – running from the pain. Now I enjoy yoga, both its power and its stillness. 
  • Getting back to goals and aspirations: In 2018 after 3.5 long years I completed my doctorate in nursing. There is no way I could have done this before excision and all the work since. 
  • 2020 update – Surgery for adhesions: I developed symptomatic adhesions that progressively worsened. – Adhesions (scar tissue) is a normal process of healing and often cause no symptoms at all. But they can if they restrict movement of, restrict, or deform organs. – For me, adhesions caused acute distention of my abdomen, bouts of severe pain and bowel urgency, and occasional incontinence of bowels. – I underwent surgery in 2020 to free the bowel from the pelvic side wall and abdominal wall. The good news – there was only one tiny spot of endosalpingiosis and no endometriosis found during this surgery! 

My story is not intended to frighten or overwhelm anyone – rather to provide hope and encouragement:

  1. With commitment and dedication – healing and improved quality of life is ongoing. I am 9 years out and continue to improve! And I celebrate each and every gain. 
  2. All pelvic pain is not endometriosis. 
  3. Pelvic floor muscles are a highly under-appreciated and common source of pain and bladder/bowel dysfunction. These neuromuscular behaviors can be rehabilitated but it takes time.
  4. IC/BPS is very common. It is very manageable but requires an investment of time and energy to identify triggers and commitment to your management plan. 
  5. Pelvic floor physical therapy – a critical partner in your rehabilitation. Physical therapy plays a role in managing endometriosis, pelvic floor dysfunction, interstitial cystitis, pudendal neuralgia, adhesions, hip and back issues and more. 
  6. Sometimes you have to address a new or stubborn issue. Advocate for the “next steps” in your care. 

(c) Copyright Susan Pierce-Richards, DNP, ARNP, ANP-BC, FNP-BC, June 2020 

3 years ago Treatment

Endometriosis Appearance and Location: Impact on Surgical Success

Endometriosis lesions can have many different appearances and varying locations. It used to be taught that the lesions had a “black, powder burn” appearance; however, we know now that they can vary widely in appearance and can be clear, yellow, tan, red, or black. They can also be indicated by collections of small blood vessels. It is important to know where to look for endometriosis because it can involve multiple areas in the pelvic region and in places outside of the pelvis as well. 

Appearances:

      Links:

      Studies:

  • Lier, M. C., Vlek, S. L., Ankersmit, M., van de Ven, P. M., Dekker, J. J., Bleeker, M. C., … & Tuynman, J. B. (2020). Comparison of enhanced laparoscopic imaging techniques in endometriosis surgery: a diagnostic accuracy study. Surgical Endoscopy, 34(1), 96-104. Retrieved from https://link.springer.com/article/10.1007/s00464-019-06736-8

“Enhanced laparoscopic imaging with 3D white light, combined with NBI, improves the detection rate of peritoneal endometriosis when compared to conventional 2D white-light imaging. The use of these imaging techniques enables a more complete laparoscopic resection of endometriosis…. the identification of endometriotic tissue during laparoscopy is not always clear which may partly contribute to the high rates of recurrence reported after surgical treatment (40–50% at 5 years) [3]. The polymorphic appearance of endometriotic lesions is supposed to be the origin of this impaired visual diagnosis during laparoscopy, especially non-pigmented endometriotic lesions which are hard to distinguish from healthy peritoneal tissue [4,5,6]…. Therefore, complete resection of endometriosis is difficult and re-operation, due to symptomatic recurrence, occurs in more than 50% of the patients [8]. The high costs of re-operation and the associated morbidity emphasize the importance of a more complete resection during primary surgery.”

  • Jose, C., Fausto, A., & Antonio, L. (2018). Laparoscopic Enhanced Imaging Modalities for the Identification of Endometriosis Implants a Review of the Current Status. MOJ Womens Health, 7(1), 00160. Retrieved from this link

“Laparoscopic identification of superficial endometriosis implants represents a challenge for the gynecologic surgeon. Endometriosis lesions may present in a wide spectrum of appearance according to a “lifecycle” of the implants. The lesions can be flat or vesicular. They can have any combination of color typically red, back/brown and white. Active “red” lesions, large endometriomas, deep infiltrating nodules, and typical “powder-burn” lesions are easier to identify than “white” old fibrotic lesions. The endometriotic implants are hypervascular. The diagnostic accuracy at laparoscopy is also affected by the experience of the surgeon and the laparoscopic equipment [16].”

“Visually normal peritoneum does not harbor a high prevalence of invisible microscopic endometriosis.”

Locations:

      Links:

      Studies:

“In the pelvis, endometriosis commonly involves the peritoneum (anterior and posterior cul-de-sacs, pelvic side walls and ovarian fossa), uterosacral ligaments, ovaries, fallopian tubes, and uterus. Other structures less commonly involved include the rectovaginal septum, rectum, sigmoid colon, appendix, ureters, and bladder. Additional extra-pelvic endometriosis is uncommon but can involve the diaphragm, cecum, small and large bowel, abdominal wall, and other abdominal organs.4 Other areas to assess include the inguinal canals, sciatic and sacral nerves, peri-hepatic region and pleura (Figure 1). There are three forms of intraperitoneal pelvic endometriosis. These include superficial peritoneal lesions (ie, noninvasive implants), endometriomas (ie, cystic endometriosis), and deep (or solid and/or cystic) infiltrating endometriosis (DIE).”

“The different forms of endometriotic lesions are superficial peritoneal implants, endometriomas and deep infiltrative endometriosis involving rectovaginal septum. Peritoneal implants are most commonly seen in the uterosacral ligaments, pouch of douglas, ovarian fossae and pelvic side walls. Less frequently, bladder and bowel are involved and rarely upper abdomen as well. Gastrointestinal involvement is seen is 3%-37% cases, with severe endometriosis affecting uterosacral ligaments, rectovaginal septum, rectosigmoid colon and appendix [7,8]. Genitourinary endometriosis is seen in 1%-2% cases with ureter involvement in 0.1%-0.2% cases, with majority affecting distal ureter. Typically, the left ureter is involved and endometriosis leads to extrinsic compression of the ureter leading to irreversible damage to renal function. This, thus warrants timely diagnosis and management.”

  • Charatsi, D., Koukoura, O., Ntavela, I. G., Chintziou, F., Gkorila, G., Tsagkoulis, M., … & Daponte, A. (2018). Gastrointestinal and urinary tract endometriosis: a review on the commonest locations of extrapelvic endometriosis. Advances in medicine, 2018. Retrieved from https://www.hindawi.com/journals/amed/2018/3461209/ 

“The gastrointestinal tract is the most common location of extrapelvic endometriosis with the urinary system being the second one. However, since sigmoid colon, rectum, and bladder are pelvic organs, extragenital pelvic endometriosis may be a more suitable definition for endometriotic implants related to these organs than extrapelvic endometriosis. The sigmoid colon is the most commonly involved, followed by the rectum, ileum, appendix, and caecum. Most lesions are confined in the serosal layer; however, deeper lesion can alter bowel function and cause symptoms. Bladder and ureteral involvement are the most common sites concerning the urinary system. Unfortunately, ureteral endometriosis is often asymptomatic leading to silent obstructive uropathy and renal failure. Surgical excision of the endometriotic tissue is the ideal treatment for all types of extrapelvic endometriosis. Adjunctive treatment might be useful in selected cases.”

3 years ago Treatment

Why See A Specialist?

The skill of the surgeon can affect the ability to accurately identify endometriosis in order to diagnose as well as remove all diseases (Jose, Fausto, & Antonio, 2018; Fischer et al., 2013). Also, endometriosis is not confined to the pelvis and can involve areas such as ureters, bowel, or diaphragm that require a higher level of care.

Why See a Specialist for Surgery?

“A multidisciplinary team approach (eg, gynecologic endoscopist, colorectal surgeon, urologist) can reduce risk and facilitate effective treatment. Likewise, advanced surgical skills and anatomical knowledge are required for deep resection and should be performed primarily in tertiary referral centers. Careful preoperative planning, informed consent, and meticulous adherence to the “best practice” technique is requisite to reduce morbidity and ensure effective management of potential complications. Although excisional biopsy and resection offer a higher success rate in treating the disease, surgical excision also requires a higher level of surgical skill. As a result, many patients receive incomplete treatment, which in turn may lead to persistent symptoms and recurrent disease. It should be noted that many women who have undergone repeated surgeries and had a hysterectomy still suffer. The need to improve surgical approaches and/or engage in timely referrals is unquestionable. Surgery to debulk and excise endometriosis may be “more difficult than for cancer”. Complete removal of implants may be difficult due to variations in appearance and visibility. True surgical resection and treatment pose formidable challenges, even in the hands of experienced clinicians. In particular, the deep disease is often difficult to treat due to the proximity of and common infiltration in and around the bowel, ureters, and uterine artery. Potential adenomyosis should also be included in the preoperative workup, as it can influence postoperative improvement patterns of pain and symptoms associated with endometriosis. Lesions may present as “powder burn” implants, foci of inactive disease containing glands embedded in hemosiderin deposits and stroma; non-pigmented lesions appearing as clear vesicles; and as pink, white, red, brown, yellow, and blue implants. Microscopic disease may be identified in otherwise normal-appearing peritoneum by light and electron microscopy. “Blood painting” or the use of staining agents such as indigo carmine or methylene blue may also improve detection. Cellular activity is believed to be greater in superficial or deep implants versus intermediate lesions. Upon visual diagnosis, laparoscopy is usually extended to an operative procedure, beginning with adhesiolysis between the bowels and pelvic organs in order to expose the pelvic cavity. Ovaries may then be dissected from the cul-de-sac or pelvic sidewall, tubes freed from adhesions, and implants resected or otherwise destroyed. Bowel and genitourinary lesions should be removed. If appropriate, presacral neurectomy or laparoscopic uterosacral nerve ablation may also be performed to treat central pelvic pain. Removal of endometriomas on the ovaries may also be performed. Peritoneal implants should be destroyed using the most effective, least traumatic manner to minimize and reduce the risk of postoperative adhesion formation.

“Complete excision of endometriosis, including vaginal resection, offers a significant improvement in sexual functioning, quality of life, and pelvic pain, including in those symptomatic patients with deeply infiltrating nodules of the posterior fornix of the vagina. As well, the technique offers good results in terms of reduced bladder morbidity and bowel symptoms. However, in that this kind of surgery requires advanced skills and anatomical knowledge, again, it should be performed only in selected reference centers. Randomized controlled trials also demonstrate that excision is associated with a higher pregnancy rate and lower rate of recurrence, though it may cause injury to the ovarian reserve. Improvements to this aspect may be represented by a combined excisional-vaporization technique or by replacing coagulation with surgical ovarian sutures. In general, laparoscopic excision significantly improves general health and psycho-emotional status at 6 months from surgery without differences between patients submitted to intestinal segmental resection or intestinal nodule shaving. Pain, sexual function, and quality of life were demonstrated to improve significantly in at least one study, and these symptoms were associated with a good fertility rate and a low complication and recurrence rate after a CO2 laser laparoscopic radical excision of endometriosis with colorectal wall invasion combined with laparoscopic segmental bowel resection and reanastomosis.”

References

Jose, C., Fausto, A., & Antonio, L. (2018). Laparoscopic Enhanced Imaging Modalities for the Identification of Endometriosis Implants a Review of the Current Status. MOJ Womens Health, 7(1), 00160. DOI: 10.15406/mojwh.2018.07.00160

3 years ago Treatment

Why Excision is Recommended

What Is Excision?

Excision is the surgical removal of tissue by cutting out. It differs from ablation/laserization/burning/vaporizing, which are techniques that use a heat source to destroy tissue. Excision allows for a biopsy to be sent to a pathologist for confirmation, and it better ensures that all of the endometriosis lesion is removed. With ablation, it may or may not reach deep enough to destroy all the endometriosis lesions, and it does not allow for pathology confirmation. While ablation may work for superficial endometriosis, it leaves the unknown of whether all of the lesion was truly destroyed. 

There are many tools a surgeon might choose to perform excision, but the tool is only as good as the surgeon who utilizes it. Your surgeon must be able to recognize the many appearances of endometriosis, know all the places to look for endometriosis, and have the ability to remove it from many areas. Some areas are more delicate areas to remove endometriosis (such as ureters, bowel, or diaphragm) and may require a multi-disciplinary team. This is why it is recommended to see someone whose practice consists of regular endometriosis excision.  

Why Excision Is Preferable to Ablation?

“Because there is no objective way of knowing how deeply an endometrial lesion might invade by simply looking at it, the laser surgeon may vaporize the surface of a lesion and still leave active disease below. This is particularly true for deeply invasive nodules of the uterosacral ligaments. In addition, the laser surgeon is frequently reluctant to vaporize disease located over the bowel, bladder, ureters, or major vessels for fear of damaging these organs. Again, active disease can remain in the pelvis and continue to cause pain.

“Because laser vaporization completely destroys tissue suspected of being endometriosis, there is no way to confirm through a pathology report that the vaporized tissue was in fact endometriosis, not some other type of abnormal tissue. This can lead to problems in the scientific study of the disease since the “evidence” presented in a medical journal becomes a matter of opinion rather than a matter of fact. No long-term studies have been published giving data on pain and recurrent disease after laser vaporization. Studies published to date reflect pregnancy outcome, which is misleading when one is treating pain.”  

“The European Society for Human Reproductive Endocrinology guidelines encourage excision, stating that pain due to endometriosis can be reduced by surgical removal of the entire lesion in severe and in deep, infiltrating endometriosis. The guidelines also state that the best approach is to diagnose and remove endometriosis surgically. Despite these recommendations, most surgeons do not excise endometriosis during diagnostic procedures. A recent survey of British gynecologic consultants and surgeons found that only 30% performed surgical removal. In the survey, 95% favored ablative techniques, and 25% used both ablation and excision.7 This reluctance to adopt excision of endometriosis has been judged appropriate by some, due to the lack of good long-term data regarding its effects and the increased potential for surgical complications.

“A review of the literature yields 2 randomized controlled trials (RCTs) and 5 cohort studies addressing the effectiveness of laparoscopic excision for the treatment of endometriosis.8-14 A 2003 study involving 39 subjects with histologically confirmed endometriosis randomized patients to either immediate excisional surgery or diagnostic surgery only.8 All patients underwent second-look laparoscopy, with 80% of women in the excision group reporting improvements in pain symptoms versus 32% in the control group. Women with more advanced disease experienced a greater response to laparoscopic excision. Furthermore, responses on quality-of-life instruments showed significant improvements in both mental and physical scores.8 In the second RCT, 24 women with mild endometriosis (stage 1 or 2) were randomized to either laparoscopic excision or ablation of endometriotic lesions.9 There was no significant difference between groups with respect to pain relief and pelvic tenderness, but there was a significant improvement in the signs of endometriosis (eg, back pain, fatigue, tenderness, adnexal pain) in the excision group. As in the first RCT, the severity of symptoms was the strongest indicator of the success of treatment.8,9 The latter study identified no additional morbidity associated with excision, but both trials were limited by small size and short follow-up.8,9

“There were 5 cohort studies involving laparoscopic excision of endometriosis, 4 of which directly assessed the effects of excisional surgery on pelvic pain (Table).11,12,14-16 A 1996 investigation reported on a 2-year follow-up of women undergoing excision versus laser vaporization. At 12 months, 96% of excision patients and 69% of vaporization patients were pain-free, falling to 69% and 23%, respectively, at 24 months.10 Findings from a study of 135 patients with a mean follow-up of 3.2 years revealed reductions in pain scores related to dysmenorrhea, nonmenstrual pelvic pain, dyspareunia, and dyschezia.11 As expressed by survival curves, the likelihood of avoiding further surgery over the subsequent 5 years was 64%, with the strongest predictive factor for reoperation being a revised American Fertility Score of 70 or higher. Interestingly, endometriosis was not identified at the time of subsequent surgery in 32% of subjects.11 A study that followed 62 women for an average of 13 months reported a 71% satisfaction rate with excision, but 40% of subjects still required regular medication and 11% underwent further surgery.12 Finally, among 107 women treated by laparoscopic excision and followed for a mean of 7.65 years, the 2-, 5-, and 7-year surgery-free rates were 79.2%, 51%, and 41.4%, respectively.14 All of these studies were limited by the lack of a control group, but they consistently showed a 2-year surgery-free rate of more than 70%. Three studies presented data regarding quality of life before and after excision.11,12,17 A 4-month follow-up of 57 consecutive patients undergoing laparoscopic excision of endometriosis reported significant improvement in the physical components of quality-of-life scores, but showed no improvement in the mental components.17 The aforementioned study of 135 patients noted improvement in a quality-of-life scale that persisted through 5 years of follow-up, but these improvements did not reach the quality of life of healthy subjects. 17 Finally, the study that involved 62 patients noted only limited increases in quality-of-life scores, with improvement in social life reported by 32%, in relationships by 24%, and in anxiety levels by 39%.12

“Deep dyspareunia is a common complaint among women with endometriosis, affecting 60% to 79% of patients undergoing surgery.13 An observational prospective cohort study addressed the effects of laparoscopic excision on deep dyspareunia and overall sexual function. The study enrolled 68 women, of whom 87% had stage 3 or 4 disease. At 6 and 12 months’ follow-up, patients demonstrated both significant reductions in the intensity of deep dyspareunia and improvements in the quality of sexual function.13 Two of these studies reported significant improvements in pleasure and comfort.11,13 One RCT comparing laparoscopic endometriosis ablation with diagnostic laparoscopy reported a 62.5% improvement in symptoms at 6 months versus 22% in the control group.15 At a mean followup of 73 months, there was a symptom recurrence rate of 74%, but a 55% rate of satisfactory symptom relief. Whereas the cohort study of 107 patients noted a 2-year reoperation rate of 21.2%, this RCT yielded a median time to symptom recurrence of 19.7 months and a 2-year reoperation of 37%.14,16 Overall, these data have several limitations.

“All of the studies were conducted by expert laparoscopic surgeons, whose results are unlikely to be reproduced by the generalist surgeon. Also, the absence of a control group in the cohort studies limits the significance of their findings. Finally, variations in designs, endpoints, and surgical techniques make it difficult to generalize. There is no definitive study as of yet, and a large, well-designed RCT of laparoscopic excision versus ablation of endometriosis remains to be performed. Based on the studies performed to date, it is the author’s opinion that laparoscopic excision of endometriosis, when technically feasible, should be the standard of care. First, whereas visual diagnosis of endometriosis is correct in only 57% to 72% of cases, excisional surgery yields specimens for histologic confirmation—and identifies endometriosis in 25% of “atypical” pelvic lesions as well.18 The availability of such specimens would prevent unnecessary treatment and ensure more reproducible research findings. Excision should also reduce the incidence of persistent disease secondary to inadequate “tip of the iceberg” destruction, removing both invasive and microscopic endometriosis to provide the best possible symptom relief.

“Finally, the results of excision are comparable to or better than those of ablation. Endometriosis usually recurs, but excision both prolongs the time to reoperation and reduces the severity at second surgery. Excision provides the greatest benefit for patients with extensive disease without increasing complication rates or morbidity Surgical treatment of endometriosis can be difficult due to its tendency to target the uterosacral ligaments adjacent to the ureter and to cause fibrosis and adhesions. However, these complexities need not result in suboptimal debulking of lesions. These studies suggest that converting from ablative to excisional therapy will refine diagnosis, reduce disease burden and morbidity, lengthen the time to recurrence, and improve outcomes overall..”   

Additional Studies on Excision of Endometriosis:

“Laparoscopic endometriosis excision improves quality of life for at least 7 years, even when women have conservative, fertility-sparing surgery, according to a survey study from the University of Pittsburgh.” 

  • Pundir, J., Omanwa, K., Kovoor, E., Pundir, V., Lancaster, G., & Barton-Smith, P. (2017). Laparoscopic excision versus ablation for endometriosis-associated pain: an updated systematic review and meta-analysis. Journal of minimally invasive gynecology, 24(5), 747-756.  Retrieved from https://www.sciencedirect.com/science/article/pii/S1553465017302637  

“The limited available evidence shows that at 12 months postsurgery, symptoms of dysmenorrhea, dyschezia, and chronic pelvic pain secondary to endometriosis showed a significantly greater improvement with laparoscopic excision compared with ablation.”

“The goal of laparoscopic treatment of extensive endometriosis is to excise all visible and palpable endometriosis and to restore normal anatomic relationships. Benefits to the patient include substantial symptom relief and resolution of infertility in many cases, circumvention of major abdominal surgery with its related morbidity, and avoidance of the hypoestrogenic effects of ovarian suppression therapy, which prohibits fertility during its administration and never eradicates deep infiltrating endometriosis. The laparoscopic approach can be lengthy, and the persistent nature of the disease may dictate more than one application. Therefore, determining factors in achieving the desired outcome are the surgeon’s skill and tenacity and the patient’s persistence.”   

  • Yeung Jr, P., Sinervo, K., Winer, W., & Albee Jr, R. B. (2011). Complete laparoscopic excision of endometriosis in teenagers: is postoperative hormonal suppression necessary?. Fertility and sterility, 95(6), 1909-1912.  Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/21420081 

“Complete laparoscopic excision of endometriosis in teenagers–including areas of typical and atypical endometriosis–has the potential to eradicate disease. These results do not depend on postoperative hormonal suppression. These data have important implications in the overall care of teenagers, regarding pain management, but also potentially for fertility. Further large comparative trials are needed to verify these results.”   

“Conclusion: Patients had significantly improved pain symptoms and quality of life after excision surgery, whether or not DRPs were present. This study demonstrated that a DRP may be a manifestation of endometriosis (even with a clear surface of the pocket), so that DRPs should be excised to achieve optimal excision of endometriosis.”

“Results: There was a reduction in all pain scores over the five-year follow-up in both treatment groups. A significantly greater reduction in dyspareunia VAS scores was seen in the excision group at 5 years (univariate p= .031 and multivariate p=.007). More women went on to use medical treatments for endometriosis amongst the ablation group (p= .004) by 5 years. Conclusions: Surgical treatment of endometriosis provides symptom reduction for up to 5 years. There are some limited areas, such as deep dyspareunia, where excision is more effective than ablation.” 

  • Abbott, J. A., Hawe, J., Clayton, R. D., & Garry, R. (2003). The effects and effectiveness of laparoscopic excision of endometriosis: a prospective study with 2–5 year follow‐up. Human Reproduction, 18(9), 1922-1927. Retrieved from http://humrep.oxfordjournals.org/content/18/9/1922.long 

“CONCLUSIONS: Laparoscopic excision of endometriosis significantly reduces pain and improves quality of life for up to 5 years. The probability of requiring further surgery is 36%. Return of pain following laparoscopic excision is not always associated with clinical evidence of recurrence.”  

  • Santoro, L., D’Onofrio, F., Campo, S., Ferraro, P. M., Flex, A., Angelini, F., … & Landolfi, R. (2014). Regression of endothelial dysfunction in patients with endometriosis after surgical treatment: a 2-year follow-up study. Human Reproduction, 29(6), 1205-1210. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/24777848 

“Surgical treatment of endometriosis leads to endothelial function improvement, resulting in reduction of cardiovascular risk.”  

  • Albee Jr, R. B., Sinervo, K., & Fisher, D. T. (2008). Laparoscopic excision of lesions suggestive of endometriosis or otherwise atypical in appearance: the relationship between visual findings and final histologic diagnosis. Journal of Minimally Invasive Gynecology, 15(1), 32-37. Retrieved from http://www.ncbi.nlm.nih.gov/m/pubmed/18262141/ 

“Diagrams detailing appearance, anatomic site, and surgeon’s suspicion of endometriosis versus atypical lesions were compared with final histologic diagnosis. The greatest number of patient lesions were excised from cul-de-sac (n = 309). For this site, using visual criteria for diagnosis of endometriosis, positive predictive value was 93.9%, sensitivity was 69.3%, negative predictive value was 41.9%, and specificity was 83.1%. Prevalence was noted to be 79.0% and accuracy was 72.2%. In addition, atypical-appearing tissue not presumed to be endometriosis was confirmed to be endometriosis histologically in 24.3%. In examining tissue specimens from multiple anatomic sites, laparoscopic visual diagnosis of typical endometriosis generally had a high positive predictive value. However, both sensitivity and negative predictive value were lower than expected because of atypical lesions subsequently diagnosed as endometriosis. These data suggest that when the surgical objective is complete eradication of endometriosis, the surgeon must be prepared to excise all lesions suggestive of endometriosis and tissue atypical in appearance as in most anatomic sites approximately 25% of atypical specimens proved to be endometriosis.”  

“Endometriosis could still be regarded as a recurrent disease; nevertheless recurrence could not be ascribed to the retrograde menstruation, but to an incomplete surgical intervention, since it is demonstrated that endometriosis lesions could be also made up of microscopic foci (Redwine, 2003), and or to different timing of growth of the lesions in the same patient, probably due to individual susceptibility that is a typical phenomenon of the diseases inducted by endocrine disruptors (Mori et al., 2003). Therefore surgery, if complete in exhausted growth disease can be considered curative. Contrarily, exposition to endocrine disruptors such as synthetic estrogens or SERM chemical compounds, though reducing the symptoms, could increase the growth of endometriosis.”  

“A systematic review found that post-surgical hormonal treatment of endometriosis compared with surgery alone has no benefit for the outcomes of pain or pregnancy rates, but a significant improvement in disease recurrence in terms of decrease in rAFS score (mean = −2.30; 95% CI = −4.02 to −0.58) (Yap et al., 2004). Overall, however, it found that there is insufficient evidence to conclude that hormonal suppression in association with surgery for endometriosis is associated with a significant benefit with regard to any of the outcomes identified (Yap et al., 2004)….Moreover, even if post-operation medication proves to be effective in reducing recurrence risk, it is questionable that ‘all’ patients would require such medication in order to reduce the risk of recurrence. It has been reported that about 9% of women with endometriosis simply do not respond to progestin treatment (Vercellini et al., 1997), which may result from progesterone receptor isoform B (PR-B) down-regulation (Attia et al., 2000). If PR-B is silenced due to promoter methylation, as reported in endometriosis (Wu et al., 2006b), progestin treatment or OC use may be of little value since the action of progestins is mediated mostly through PR-B. Therefore, the use of post-operation medication indiscriminately may cause unnecessary side effects (and an increase in health care costs) in some patients who may intrinsically have a much lower risk than others and in others who may be simply resistant to the therapy. The identification of high-risk patients who may benefit the most from drug intervention would remain a challenge. Finally, whether a single medication represents the optimal interventional option is debatable. The recent finding that PR-B and nuclear factor-κB (NF-κB) immunoreactivity jointly constitute a biomarker for recurrence (Shen et al., 2008) suggests the possibility that perhaps a combination of drugs may be superior to a single drug in reducing the risk of recurrence, especially if PR-B is silenced due to promoter methylation.

“Several clinical studies suggest that the recurring endometriotic lesions arise from residual lesions or cells not completely removed during the primary surgery. Nisolle-Pochet et al. (1988) reported that in women who received microsurgical resection of ovarian endometriosis, a high prevalence of active endometriosis without signs of degeneration is found after hormonal therapy. Compared with women receiving no treatment, the mitotic index was similar in women treated for 6 months either with lynestrenol (a progestin), gestrinone (an androgenic, antiestrogenic and antiprogestogenic agent) or buserelin (a GnRH agonist) (Nisolle-Pochet et al., 1988). This suggests that hormonal treatment does not lead to a complete suppression of endometriotic foci and that recurring lesions appear to grow from the residual loci. Vignali et al. (2005) found that for those patients who underwent a second surgery, the recurrence of deep endometriosis is observed in the ‘same’ area of the pelvis involved in the first operation. Exacoustos et al. (2006) reported that of 62 patients with recurrent endometriomas, 50 (80.6%) had a recurrence on the treated ovary, 7 (11.3%) on the contralateral untreated ovary, and 5 (8.1%) on both the treated and untreated ovaries. Overall, the majority of recurrent cases (88.7%) have recurrence involving the treated ovary, suggesting that the recurring cysts seem to grow likely from the residual loci.

 “Above all, this report is directly at odds with the one reporting that recurrent symptoms still occur in about 10% of women even ‘after’ hysterectomy and bilateral scalping-oophorectomy are performed (Namnoum et al., 1995). In fact, some earlier reports also found recurrence after hysterectomy. Sheets and Fetzer (1956) and Andrews and Larsen (1974) reported a 1–3% reoperation rate after hysterectomy with some ovarian conservation. Hammond et al. (1976) reported an 85% reoperation rate 1–5 years after hysterectomy surgery with ovarian conservation. Some anecdotal reports also documented the development of endometriosis after hysterectomy (Goumenou et al., 2003).” 

  • Redwine, D. B. (1991). Conservative laparoscopic excision of endometriosis by sharp dissection: life table analysis of reoperation and persistent or recurrent disease. Fertility and Sterility, 56(4), 628-634. Retrieved from http://europepmc.org/abstract/MED/1833246 

“RESULTS: Interval rates of reoperation and recurrence/persistence of disease and extent or invasiveness of disease when found at reoperation did not increase with the passage of time after surgery. The maximum cumulative rate of recurrent or persistent disease was 19%, achieved in the 5th postoperative year. CONCLUSION: Laparoscopic excision of endometriosis results in a low rate of minimal persistent/recurrent disease. The natural history of endometriosis after surgery suggests a rather static nature of the disease.”  

  • Garry, R., Clayton, R., & Hawe, J. (2000). The effect of endometriosis and its radical laparoscopic excision on quality of life indicators. BJOG: An International Journal of Obstetrics & Gynaecology, 107(1), 44-54. Retrieved from https://pubmed.ncbi.nlm.nih.gov/10645861/ 

“Main outcome measures: Effect of laparoscopic excision on pain scores and quality of life, operative findings, type of surgery, length of surgery, and incidence of intra- and post-operative complications. Results: Patients with endometriosis were severely ill with significant pain and impairment of quality of life and sexual activity. Four months after radical laparoscopic excision for deep endometriosis there was significant improvement in all the parameters measured including their quality of life-based on EuroQOL evaluation: EQ-5D (0.595:0.729, P= 0.002) and EQ thermometer (68.9:77.7, P= 0.008); SF12 physical score (44.8:51.9, P= 0.015); sexual activity (habit P= 0.002, pleasure P= 0.002 and discomfort P≤ 0.001). Only the mental health score of SF12 failed to show any statistical improvement (47 1:48.4, P= 0.84). Symptomatically, there was a significant reduction in dysmenorrhoea (median 8.0:4.0, P≤ 0.001), pelvic pain (median 7.0:2.0, P≤ 0.001), dyspareunia (median 6.0:0.0, P≤ 0.001) and rectal pain scores (median 4.0:0.0, P≤ 0.001). Complications were noted but were deemed to be acceptable for the extent of the surgery. Conclusions: This is an early analysis of the first 57 cases studied, but structured evaluation suggests that meaningful improvements in clinical symptoms and quality of life can be obtained with this approach with acceptable levels of operative morbidity. Further, follow-up of this series is required, but early evidence would suggest that the technique should be further evaluated as part of a randomized trial.” 

  • Garry, R. (2004). The effectiveness of laparoscopic excision of endometriosis. Current Opinion in Obstetrics and Gynecology, 16(4), 299-303. Retrieved from https://pubmed.ncbi.nlm.nih.gov/15232483/

    “Recent findings: Large, long-term, prospective studies and a placebo-controlled, randomized, controlled trial suggest that laparoscopic excision is an effective treatment approach for patients with all stages of endometriosis. The result of such laparoscopic excision may be improved if affected bowel, bladder and other involved structures are also excised. Adjuvant therapies such as the levonorgestrel intrauterine system and pre-sacral neurectomy may further improve outcomes. Ovarian endometriomas are invaginations of the uterine cortex, and surgical stripping of this cortex removes many primordial follicles. Despite this apparent disadvantage, stripping of the capsule is associated with better subsequent pregnancy rates and lower recurrence rates than the more conservative approach of thermal ablation to the superficial cortex. Summary: Laparoscopic excision is currently the ‘gold standard’ approach for the management of endometriosis, and results may be improved with careful use of appropriate techniques and suitable adjuvant therapies.” 
  • Koninckx, P. R., & Martin, D. (1994). Treatment of deeply infiltrating endometriosis. Current opinion in obstetrics and gynecology, 6(3), 231-241. Retrieved from https://europepmc.org/article/med/8038409 

“Surgical excision can be carried out by laparoscopy, laparotomy or vaginally using sharp dissection, electrosurgery or with the use of a CO2 laser. Excision is the treatment of choice because of a high pregnancy rate, a complete cure of pain in most women, and a low recurrence rate….The choice of treatment will therefore depend on the local expertise with minimal invasive surgery, certainly if a first excision has been incomplete and pain symptoms recur.” 

“Which one is better for pelvic pain and recurrence in ovarian endometrioma, excisional surgery versus ablative surgery? A recent Cochrane review evaluated the most effective technique for treating an ovarian endometrioma, either excision of the cyst capsule or drainage followed by electrocoagulation of the cyst wall, measuring the primary outcome as pain symptom improvement [15]. Two randomized studies of the laparoscopic management of ovarian endometrioma, greater than 3 cm were included. Laparoscopic excision of the cyst wall of the endometrioma was associated with a reduced recurrence rate of dysmenorrhea (OR, 0.15; 95% CI, 0.06 to 0.38), dyspareunia (OR, 0.08; 95% CI, 0.01 to 0.51) and nonmenstrual pelvic pain (OR, 0.10; 95% CI, 0.02 to 0.56). For the secondary outcome measures, laparoscopic excision of the cyst wall was associated with a reduced rate of recurrence of the endometrioma (OR, 0.41; 95% CI, 0.18 to 0.93) and with a reduced requirement for further surgery (OR, 0.21; 95% CI, 0.05 to 0.79) compared with ablative surgery.” 

  • Yeung Jr, P., Tu, F., Bajzak, K., Lamvu, G., Guzovsky, O., Agnelli, R., … & Sinervo, K. (2013). A pilot feasibility multicenter study of patients after excision of endometriosis. JSLS: Journal of the Society of Laparoendoscopic Surgeons, 17(1), 88. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3662751/pdf/jls88.pdf 

“A particular strength of this study is that it describes outcomes after excision for endometriosis from multiple referral centers; as such, it is the first study known to include data from multiple centers after excision. This shows that a multicenter trial is feasible, even among surgical referral sites. Most studies that have been published on excision for the surgical management of endometriosis have been from a single surgeon or center.5,8,9 Patients were suspected to have endometriosis based on the overall assessment of the surgeon from the clinical history and examination findings. One of the benefits of excision is the histologic confirmation of disease, and more than 7 of 10 patients who underwent surgery in this study for the suspicion of endometriosis had histologically proven disease. Even more noteworthy is that of the patients in whom histologically proven endometriosis was found, a high percentage (84.6%) had received either previous hormonal therapy or surgery by ablation as “treatment” for presumed endometriosis, indicating that these interventions are ineffective at suppressing or preventing disease. The data from this study further indicate that the addition of hormonal suppression after excision did not further reduce VAS scores for pain or benefit QOL scores when compared with patients without postoperative hormonal suppression.

“In the RCT of excision versus ablation for endometriosis by Healey et al.5 (2010), differences in pelvic pain were not statistically significant, but there were trends for a difference in bowel-related symptoms and dyspareunia. In addition, as mentioned earlier, the results of their study came from a single center and are likely only applicable to generalist gynecologists. In our prospective multicenter study on excision for endometriosis, there were significant reductions in pelvic pain, dysmenorrhea, dyspareunia, and bladder symptoms but not bowel symptoms. 

“In contrast to the study by Healey et al.,5 where fewer than one-third of patients who underwent surgery previously received either hormonal or surgical treatment, patients in our study received either hormonal or surgical treatment in the vast majority of cases (_80%). One might predict that patients having previous treatment might respond with less benefit from another surgical intervention, yet the rates of improvement in VAS scores were comparable in both studies. Also of note is the finding that patients did not have symptom improvement in QOL scores when no endometriosis was found histologically. A strength of this study is the inclusion of a single validated measure of QOL before and after excision surgery. A scale of 0 to 100 for the QOL score is easy to use and has been validated as an assessment tool.7 Most studies on the surgical management of endometriosis use pelvic pain as the primary outcome as measured by VAS scores.1,3,5 A potential problem with using pelvic pain as the primary outcome of a study on endometriosis is that some components of pain may improve after surgically treating endometriosis whereas others may not, at least to the same extent. A QOL assessment may be a better overall measure of the clinical benefit of surgery for treating endometriosis by translating multiple pain symptoms into a single measure of their effect on daily functioning. In fact, published reviews have recommended the inclusion of a QOL assessment in trials that look at pain as an outcome.10,11 Our study showed a statistically significant improvement in QOL scores after excision at multiple centers. It is our recommendation that a QOL measure be used as the primary symptom outcome measure for future comparative trials on excision versus ablation in the surgical management of endometriosis. This study has produced an estimate of the benefit of QOL after excision to be an increase of 20 points. There are no known studies that have evaluated QOL after ablation. Weaknesses of this study include the skewed actual numbers of recruitment, with more than 58 of 100 patients coming from a single center and 78 of 100 from 2 centers. Perhaps more important is the lack of quality assurance or some objective way to determine whether adequate or complete excision of all areas of abnormal peritoneum was achieved at each of the centers. In any subsequent randomized comparative trial comparing excision and ablation, objective or third-party quality assurance will need to be included for both techniques, especially if a particular referral center favors a particular approach over the other. As reported in a recent study on complete excision of endometriosis in teenagers, one of the most important benefits of excision may not be symptom relief but may be the eradication of the disease.12 Potential eradication of disease by excision might benefit future fertility, and this benefit might need to be evaluated also in a comparative trial of excision versus ablation in the treatment of endometriosis.

“One of the aims of this study was to obtain an estimate of the rate of patients presenting to referral centers for pelvic pain or endometriosis (in particular, centers that specialize in the excision of endometriosis) who would be willing to be randomized to either excision or ablation of endometriosis at the time of surgery. The vast majority of patients (84.0%) were willing to be randomized when asked this question. This bodes well for the feasibility of a randomized comparative trial even at referral centers that specialize in a particular surgical approach to the treatment of endometriosis.

“The results of this study indicate that patients were overwhelmingly willing to be randomized to either excision or ablation for endometriosis even at referral centers, that QOL may be a better overall measure as a primary outcome when one is looking at the benefit of surgery for endometriosis, and that a comparative RCT is feasible, as well as needed, among multiple centers that specialize in surgically treating endometriosis.”  

  • Johnson, N. P., Hummelshoj, L., World Endometriosis Society Montpellier Consortium, Abrao, M. S., Adamson, G. D., Allaire, C., … & Bush, D. (2013). Consensus on current management of endometriosis. Human reproduction, 28(6), 1552-1568. Retrieved from https://academic.oup.com/humrep/article/28/6/1552/603470 

“Laparoscopic surgical removal of endometriosis (through either excision or ablation of endometriosis or both) is an effective first-line approach for treating pain related to endometriosis (Jacobson et al., 2009). Although RCTs have failed to demonstrate the benefit of excision over ablation (Wright et al., 2005; Healey et al., 2010), there is unanimous consensus over the recommendation to excise lesions where possible, especially deep endometriotic lesions, which is felt by most surgeons to give a more thorough removal of disease (Koninckx et al., 2012). It is also acknowledged that, even after expert removal of endometriosis, there may be a recurrence rate of symptoms and endometriotic lesions that varies from 10 to 55% within 12 months (Vercellini et al., 2009), with recurrence affecting _10% of the remaining women each additional year (Guo, 2009). The risk of requirement for repeat surgery is higher in women younger than 30 years at the time of surgery (Shakiba et al., 2008). First operations tend to produce a better response than subsequent surgical procedures, with pain improvements at 6 months in the region of 83% for first excisional procedures versus 53% for second procedures (Abbott et al., 2004). Excessive numbers of repeat laparoscopic procedures should therefore be avoided. The role of a purely diagnostic laparoscopy has been questioned and, ideally, there should always be the option of continuing to surgical removal of endometriosis, within the limitations of the surgeon’s expertise….

“Laparoscopic surgical removal of endometriosis is recognized as being effective in improving fertility in stage I and II endometriosis (Jacobson et al., 2010)… Laparoscopic excision (cystectomy) whenever possible for endometriomas .4 cm in diameter improves fertility more than ablation (drainage and coagulation) (Hart et al., 2008).”  

  • Riley, K. A., Benton, A. S., Deimling, T. A., Kunselman, A. R., & Harkins, G. J. (2019). Surgical excision versus ablation for superficial endometriosis-associated pain: a randomized controlled trial. Journal of Minimally Invasive Gynecology, 26(1), 71-77.  Retrieved from https://www.sciencedirect.com/science/article/pii/S1553465018301808 

“Treatment with ablation improved dysmenorrhea at 6 and 12 months and improved dyspareunia at 6 months as compared with preoperative data. However, only dyspareunia demonstrated a significant difference between ablation and excision. Excision and ablation showed similar effectiveness for the treatment of pain associated with superficial endometriosis, with ablation showing more significant individual changes. Careful patient counseling regarding expectations of surgical intervention is vital in the management of endometriosis.”

Links:

General Outcomes:

Deep Infiltrating Endometriosis (DIE)

Bladder

Reproductive/Pregnancy Outcomes:

Bowel/Gastrointestinal (GI)

Diaphragm/Thoracic

Cul-de-sac

3 years ago Treatment

Why Surgery

While medications can be effective for symptom relief, they can have difficult to tolerate side effects, do not stop the progression of disease, and symptoms can return once stopped. Surgery can offer long term benefits and prevent further damage to tissue. Your treatment plan should be based your knowledge and your provider’s knowledge of endometriosis. It should be a shared decision based on your desires, goals, and abilities. 

“Laparoscopic surgery for endometriosis had a low rate of reoperation, and long-term improvement in pelvic pain, sexual function, quality of life and fertility outcomes, with a high satisfaction rate.”

Why See A Specialist?

“A multidisciplinary team approach (eg, gynecologic endoscopist, colorectal surgeon, urologist) can reduce risk and facilitate effective treatment. Likewise, advanced surgical skills and anatomical knowledge are required for deep resection and should be performed primarily in tertiary referral centers. Careful preoperative planning, informed consent, and meticulous adherence to “best practice” technique is requisite to reduce morbidity and ensure effective management of potential complications. Although excisional biopsy and resection offers a higher success rate in treating the disease, surgical excision also requires a higher level of surgical skill. As a result, many patients receive incomplete treatment, which in turn may lead to persistent symptoms and recurrent disease. It should be noted that many women who have undergone repeated surgeries and had a hysterectomy still suffer. The need to improve surgical approach and/or engage in timely referrals is unquestionable. Surgery to debulk and excise endometriosis may be “more difficult than for cancer”. Complete removal of implants may be difficult due to variation in appearance and visibility. True surgical resection and treatment poses formidable challenges, even the hands of experienced clinicians. In particular, deep disease is often difficult to treat due to close proximity of and common infiltration in and around bowel, ureters, and uterine artery. Potential adenomyosis should also be included in the preoperative workup, as it can influence postoperative improvement patterns of pain and symptoms associated with endometriosis. Lesions may present as “powder burn” implants, foci of inactive disease containing glands embedded in hemosiderin deposits and stroma; nonpigmented lesions appearing as clear vesicles; and as pink, white, red, brown, yellow, and blue implants. Microscopic disease may be identified in otherwise normal-appearing peritoneum by light and electron microscopy. “Blood painting” or use of staining agents such as indigo carmine or methylene blue may also improve detection. Cellular activity is believed to be greater in superficial or deep implants versus intermediate lesions. Upon visual diagnosis, laparoscopy is usually extended to an operative procedure, beginning with adhesiolysis between bowels and pelvic organs in order to expose the pelvic cavity. Ovaries may then be dissected from the cul-de-sac or pelvic sidewall, tubes freed from adhesions, and implants resected or otherwise destroyed. Bowel and genitourinary lesions should be removed. If appropriate, presacral neurectomy or laparoscopic uterosacral nerve ablation may also be performed to treat central pelvic pain. Removal of endometriomas on the ovaries may also be performed. Peritoneal implants should be destroyed using the most effective, least traumatic manner to minimize and reduce risk of postoperative adhesion formation.

“Complete excision of endometriosis, including vaginal resection, offers a significant improvement in sexual functioning, quality of life, and pelvic pain, including in those symptomatic patients with deeply infiltrating nodules of the posterior fornix of the vagina. As well, the technique offers good results in terms of reduced bladder morbidity and bowel symptoms. However, in that this kind of surgery requires advanced skills and anatomical knowledge, again, it should be performed only in selected reference centers. Randomized controlled trials also demonstrate that excision is associated with a higher pregnancy rate and lower rate of recurrence, though it may cause injury to the ovarian reserve. Improvements to this aspect may be represented by a combined excisional-vaporization technique or by replacing coagulation with surgical ovarian suture. In general, laparoscopic excision significantly improves general health and psycho-emotional status at 6 months from surgery without differences between patients submitted to intestinal segmental resection or intestinal nodule shaving. Pain, sexual function, and quality of life were demonstrated to improve significantly in at least one study, and these symptoms were associated with a good fertility rate and a low complication and recurrence rate after a CO2 laser laparoscopic radical excision of endometriosis with colorectal wall invasion combined with laparoscopic segmental bowel resection and reanastomosis.”

3 years ago Treatment

The Standard of Care is Not Sufficient!

By Dr. J. Arrington There has been a lot of “chatter” on Endometriosis social media pages lately about hormone therapy to prevent endometriosis from progressing as well as “chatter” regarding hysterectomy to “treat” endometriosis.

Given that most patients only know what they are told by their gynecologist, I’d like to break down the one publication that general gynecologists refer to to “educate themselves.” The ACOG Practice Bulletin #114 on Endometriosis, covers a wide variety of topics in a “politically correct” way. Most of the studies they use to make their observations focus only on management of endometriosis related pain (for hormone therapies), and reoperation rates and pain for surgical treatment.

A short reiteration on hormone therapy. Any medical therapy for Endometriosis is meant to help with pain. This is called “palliation.” The purpose of hormone therapies is the same as that for pain medications and anti-inflammatory medications. There are no data to suggest that medications prevent progression of endometriosis. As endometriosis surgeons, we often see patients who have had ok pain control on medication, yet present with advanced, stage 4, fertility stealing endometriosis. This clarification is often overlooked by gynecologists as they read though the ACOG Bulletin. They teach patients that GNRH agonist therapy after incomplete endometriosis surgery will “get rid of” or “kill off” any remaining disease. This is simply NOT TRUE!

Gynecologists also often quote hysterectomy with removal of the ovaries to be “definitive treatment for endometriosis. The general understanding of a “definitive” treatment is that it completely takes care of the problem so it does not keep troubling the patient. This attitude is severely misleading and untrue.

The ACOG Bulletin also has a section on this that is overlooked or misunderstood. They quote the reoperation rate of around 15% after hysterectomy and castration for endometriosis patients. Interestingly they also state that it is unclear in the studies if the endometriosis was removed at the time of hysterectomy. In studies where Endometriosis is completely removed at the time of hysterectomy, there is no benefit to castration or removal of both ovaries if they are unaffected by endo. (This part is correct).

Interestingly, the rate of reoperation after hysterectomy and castration of 15%, is close to the accepted percentage of patients with deeply infiltrating endometriosis or D.I.E. Hysterectomy and removal of ovaries DOES NOT TREAT Endometriosis unless there is endo growing on those organs. If hysterectomy is performed and the endometriosis left behind, this is considered incomplete surgery. In fact this practice does go against ACOG recommendations in the bulletin. The bulletin states that hysterectomy can be helpful at the time of surgical treatment for endometriosis. In other words, the removal of endometriosis should be the primary focus of the surgery and hysterectomy may be considered additionally for uterine related pain symptoms. The most common of these would be endometriosis of the uterus or cervix or adenomyosis. General gynecologists have taken the Bulletin statement to mean that hysterectomy alone is “definitive” treatment for endometriosis. This harms patients in a few ways. First they continue in pain that severely affects their lives. On top of this, they are often told that the pain cannot be from endometriosis as they have had a hysterectomy. This teaching continues the cycle of patients believing they are “crazy” or that there is no hope. Other therapies such as pelvic physical therapy or psychiatric care, or pain management referrals are then pushed on the patient so the gynecologist can “wash his/her hands” of the problem. Please don’t get me wrong, those other treatments do have a role in the appropriate patient, especially physical therapy. But, as long as there is Endometriosis that is provoking a pain response, I believe that the benefit from pelvic PT may have limited benefit. Too many patients are referred out due to a belief that the pain cannot be endometriosis related because of a hysterectomy.

Gynecologists are terribly “mis-educated” about endometriosis treatment. This largely relies on the inadequate surgical education we receive. General gynecologists simply do not leave residency with the skill to identify and remove Endometriosis in all its presentations and locations. When met with disease that they can’t treat, they run to the only “treatment” they have been trained to provide, hysterectomy and castration. Most of them have not reviewed any literature or received any education in Endometriosis management since leaving residency. Their knowledge is old and based on studies that used incomplete surgery as the benchmark for comparison. Few general gynecologist “want” to treat patients with endo, yet they also do not want to “lose their patient.” Whether it is outdated education, worry about losing patients, or pride, many gynecologists simply will not admit when endometriosis is beyond their capability of treating.

This disease is, by far, the most difficult surgical treatment we see in benign gynecology. This is often worse disease and more difficult surgery than gynecologic cancer. It takes tremendous time and experience to be able to recognize all forms of disease and not “freak out” when confronted with stage 4 endo with frozen pelvis, obliterated culdesac, and DIE. It truly is time that we must recognize that the “standard of care” for endometriosis is not sufficient. There is a proven better way to treat this disease. As patients better educate themselves and gynecologists learn about the disease and stop their selective bias reading of literature, we may begin to speed the progress. © Dr. J. Arrington

3 years ago Treatment

How is Endometriosis Treated?

Treatment for endometriosis includes management of symptoms, surgical diagnosis, surgical removal of disease, and identification and management of additional conditions that cause pelvic symptoms. 

The decision to have and the timing of surgery will vary. An individual may not want surgery or may have medical conditions that prevent them from having surgery (this is uncommon). An individual may wish to or need to delay surgery for a variety of personal, financial, or medical reasons.

Surgery is needed for a definitive diagnosis. A “working diagnosis” may be made and treatment options discussed based on that. However, many treatment options may not stop the progression of endometriosis, and some surgical options may not address endometriosis in certain places (such as around the bowel, ureters, or diaphragm). It is important, if an individual does not have endometriosis surgically addressed, that they are followed closely. Endometriosis in certain areas (such as close to ureters) can present further complications that may not present symptomatically; damage can be done without a change noticed in symptoms. Ideally, follow-up and treatment would be someone with expertise in endometriosis. 

Treatment to eradicate (completely remove) the disease:

  • Complete excision of abnormal tissue is the Gold Standard treatment and seeks to completely remove endometriosis (most often permanently) by surgically cutting out all of the disease at its roots.
  • This method seeks to restore normal anatomy and preserve organs when possible.
  • Recurrence rates are low when this procedure is done by surgeons skilled in identifying all forms of endometriosis and removal of endometriosis wherever it is found.
  • It is important to identity and treat other causes of pelvic pain to have the best reduction/elimination of pelvic pain

Medical treatment – treats symptoms, but does not remove disease and can have significant long-term side effects. Medical therapy is an important part of endometriosis care, particularly for those whom surgery is not currently an option or have other ongoing problems or related conditions.

  • Medication to treat pain such as non-steroidal anti-inflammatory drugs (see “Inflammation with Endometriosis“)
  • Hormonal birth control medications often given continuously to stop menstruation include: combined birth control pills, progestin only birth control pills, progesterone containing intrauterine device (Mirena® IUD), injectable progesterone (Depo-Provera®), implanted progesterone (Nexplanon®) 
  • Hormonal medications to induce menopausal state include: GnRH agonist/antagonists (Orilissa®, Lupron®, Synarel®, Zoladex®), androgens (Danazol®)

Surgical treatments that do not eradicate disease

  • Ablation surgery is common. This is a surgical technique that attempts to destroy (“burns”) the surface of endometriosis lesions. However, it can often leave disease behind under the ablated areas, and it also does not allow for tissue to be confirmed by a pathologist. 
  • Incomplete excision surgery 

Additional therapies can help manage symptoms, treat common conditions that contribute to pelvic pain, provide emotional support and reduce stress:

What skills does my doctor and their team need to diagnose and treat endometriosis? 

Endometriosis care requires holistic, multidisciplinary care. Who do you need on your team?

  • Primary care providers and generalist ob/gyn providers need to recognize symptoms and understand the skill set needed for specialty care so that they can make the appropriate referral. Your primary care provider or ob/gyn providers may also be able to provide you with some medications to manage your symptoms until you can see a specialist. Most generalist ob/gyn providers do not perform enough surgery on endometriosis patients to have the skill level of surgeons who specialize and treat primarily endometriosis. (see “Managing Your Relationship With Your Current Doctor“)
  • Surgeon – Identification of endometriosis and complete excision of disease require a surgeon to do a large volume of endometriosis surgery. Endometriosis lesions come in many shapes, colors, and sizes and can present in numerous places in the body. Endometriosis, particularly deep infiltrating endometriosis (DIE), requires a very high level of surgical skill. Endometriosis in some locations requires that an endometriosis surgeon partner with another specialized surgeon to remove lesions on the bowel, lung, sciatic nerve, or other locations. (see “Choosing Your Surgeon“)
  • Other specialists: Physical therapist, Nutritionist, Pain Management, Mental Health Therapist, and Others
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