Mr Ashwini K Trehan MBBS, DRCOG, FRCOG, FRCS (Edin)

Consultant Minimal Access Gynaecologist

(with special interest in Endometriosis and Keyhole Surgery)

ENDOMETRIOSIS - INFORMATION AND FACTS

Summary, Advice and Questions You Can Ask Your Doctor/Gynaecologist

 Produced by Mr A K Trehan FRCOG, FRCS

·       Endometriosis is a chronic gynaecological condition producing pelvic pain and infertility.

o   Ask your doctor to refer you to an endometriosis specialist.

IN DEPTH
 

Endometriosis is a common condition affecting 10-15% of women of reproductive age (1,2).  The disease is encountered in some form in 25% of infertile women and 60% of those with endometriosis suffer from infertility (3).  Approximately 1.25 million women in the UK are affected with endometriosis.

In this condition patches of tissue similar to the lining of the womb appear on the lining of the pelvis, ovaries, bowel and occasionally other organs and respond to hormones from the ovaries in the similar way as lining of the womb resulting in menstrual bleeding at endometriotic sites.  The amount of loss of blood in these endometriotic implants depends on the size of the implant.  This bleeding result in bruising and by the time this bruising starts to heal there is further onslaught of bleeding during the following menstruation.  This repeated bleeding, bruising and healing results in scarring of the lining of the pelvis.  These scars result in organs like tubes, ovaries, uterus and bowel to stick to each other (adhesions) distorting anatomy and may also involve nerves.  Bleeding can also result in cyst formation (called chocolate cysts).

Symptoms

Endometriosis is a common cause of chronic pelvic pain, painful sex, painful periods, backache, bowel symptoms and infertility. The pain & infertility caused by endometriosis can place strain on a woman's relationship, family, career and even psychological well being.

What Causes Endometriosis

Following are the two most common theories. 

• Lining of the womb (endometrium) in the menstrual blood comes out through the vagina during menstruation but small amount passes through fallopian tube into the pelvic cavity and settle on the skin (peritoneum) lining the pelvis and grows forming endometriosis.

• The lining of the pelvis (peritoneum) develops from the same tissue as the lining of the womb (endometrium) and so has potential to change in to endometrium under certain influence like genetic, hormonal, immunological etc; and forms endometriosis.

Is Endometriosis a Progressive Disease?

Endometriosis is generally considered as a progressive disease but the data to substantiate this are scanty.  Repeat laparoscopy over 12 months,  endometriotic deposits resolved spontaneously in a quarter, deteriorated in nearly half and were unchanged in the remainder (4).

Diagnosis of Condition

Although the history may suggest the diagnosis at present the only way to confirm it is by Laparoscopy (5-7) under a short general anaesthetic.  A specialist looks in to the tummy with a special camera through one or two small cuts in the abdominal wall. It is usually done on a day stay basis.

Laparoscopy is the gold standard test for Endometriosis.

Click here for the corresponding presentation (may take a few minutes).

Management of Endometriosis

Endometriosis is an extremely complex medical condition and treatment is similarly complicated.  Treatment needs to be based on each patient’s individual circumstances and objectives.

A careful diagnosis by a specialist with a special interest in this condition is needed before a realistic prognosis can be achieved. 

The treatment options are medical and surgical.

Medical Treatment

The aim of medical treatment is to prevent cyclical bleeding in the endometriotic implants.  This is achieved by stopping menstruation for approximately 6 months.  Women do not menstruate during pregnancy, menopause or if they have a high level of male hormones in the body so one of the above situations is mimicked by giving drugs.  It is hoped that these drugs will dry up and inactivate (atrophy) the endometriosis. 

Except for combined contraceptive pills and Mirena (hormone coil) most of the drugs for example GnRH analogues, Danazole and Progestogens are used for a short period of 6 months to avoid side effects.

Whilst easy to prescribe, drug therapy has number of problem:

• All these hormones may produce unpleasant side effects reducing quality of life (8) resulting in discontinuation of treatment. 

• During treatment 70-90% of patients have a significant and substantial improvement of pain score (9) and a short term improvement of quality of life (8,10) but up to 75% may experience symptoms after discontinuation of treatment for 6 months (11).

• Medical treatment mainly suppresses, not eradicates (12) with annual recurrence rate of 5-20% and 5 yearly recurrence rate of 37% for minimal disease and 75% for severe disease.  (13-16).

Short-term medical treatment has a place in the management of pain produced by very early (stage 1) disease; advanced disease 2-3 months before operation to make the operation safe and after the operation (17-19) to treat remaining invisible endometriosis and larger endometriotic areas close to the bladder, ureter (tube carrying the urine), bowel and blood vessels not removed at surgery to avoid complications.  Long-term medical treatment in the form of combined contraceptive pills (6,20) and Mirena (hormone coil) can also be used to control symptoms of endometriosis. 

Medical treatment should not be used to treat infertility (21) as it delays fertility and there is no evidence that it increases fertility.

Surgical Therapy

The surgery offers long term and effective treatment for endometriosis without producing unpleasant side effects of medicines but there are risks of surgical complications as with any major procedure.  Several studies have shown that surgery helps return the anatomy of the pelvis to normal, significantly reduces pain (22) and improve chances of pregnancy (23-25).  The operation is usually undertaken by the laparoscopic (keyhole) method.  Laparoscopy permits better access, better magnification and more complete excision than laparotomy (large cut on the tummy).  In very extensive disease involving bowel a traditional open operation may be necessary.

Excision/Laser

The operation is usually undertaken by the laparoscopic (keyhole) method. Using the Laparoscope the endometriosis is either burned with laser or electric cautery or "peeled" off (excision). Although laser had been and still being used in the surgical management of the endometriosis, but the excisional (peeling off) treatment of endometriosis is the most effective, successful (26-33)and modern surgical treatment of endometriosis with five-year cure rate of  81% (22, 34-35). In excision (peeling) off method the skin covering the pelvis (peritoneum) containing endometriosis is peeled off from the organs of the pelvis.

In very advanced disease involving the bladder, bowel, ureter (tube carrying urine) or pelvic blood vessels it may not be possible to remove (laser or excise)every patch of the disease without risking damage to vital organs and thus some endometriotic patches on these vital organs maybe left behind to avoid complications

There are several drawback of laser ablation (burning) in comparison to excision (peeling off) of the endometriosis.

In laser surgery:

• Incomplete removal of lesion occurs - anatomy and pathology distorted by heat and thus lesion especially deep patches of endometriosis is less easily seen.   Laser burns the surface of endometriosis leaving deep patches(5mm or more lesion) behind which continue to grow resulting in an early return of symptoms.

• As the tissue is burned it does not allow removed tissue (endometriosis) to be analysed (histology) under the microscope. 

• There is an increased risk of thermal damage to internal organs.

• There is an increased risk of adhesion formation (sticking to organs) - as ablation leaves ischaemic raw area.

• Carbon particles left behind by the laser may cause a reaction in the tissue which can be its own cause of pain.

Click here to view corresponding presentation (may take several minutes).

Endometriosis & Place of Hysterectomy

• There is a misconception among women that hysterectomy is the answer for endometriosis. The disease is usually on the lining of the pelvis and not on the uterus and therefore removing the uterus does not eradicate the disease or cure all the symptoms (36-38).  In most cases of endometriosis, the uterus is entirely normal.

• Hysterectomy may be necessary in a few special circumstances such as the presence of a fibroid, enlarged uterus due to endometriosis in the womb (adenomyosis) and associate pelvic infections etc. 

• If hysterectomy is necessary it should be combined with excision (peeling off) endometriosis from the pelvis, as endometriosis will continue to grow under the influence of hormones from ovaries. 

• Apart for cases with very advanced disease with bowel involvement where conventional abdominal hysterectomy may be required a keyhole hysterectomy is advantageous as endometriosis can be effectively peeled off (excised) under the magnification of Laparoscope at the time of hysterectomy.

Click here to view corresponding presentation (may take several minutes).

Endometriosis & Place of Removing Ovaries

As the ovarian hormones feeds endometriosis it is expected that if the ovaries are removed at the time of hysterectomy all of the endometriosis may die off resulting in cure of all the symptoms:  

o   However, this does not always happen and symptoms may continue (36, 38-40) if the endometriosis itself not removed.

o   Hormone replacement treatment may stimulate endometriosis and the pain may return if endometriosis not removed

Thus it is likely to give a better cure rate if endometriosis is excised (peeled off) even if the ovaries are removed at the time of hysterectomy.

In women under the age of 50 years, an attempt should be  made to conserve at least one ovary if not both, because removal may result in menopause and all its long-term unpleasant after-effects.  However with preservation of ovaries there is a possibility of recurrence of endometriosis but it is still worth considering this approach rather than losing the ovaries in early age.  For more information on why the ovaries should be preserved, please click here.

Finally both medical/surgical  treatment has a place and it should be based on each patients individual circumstances and objectives.

All the information provided above reflects the modern view for the management of endometriosis.  The information is based on various medical publications.

Click here to view corresponding presentation, may take several minutes).

References

1.         Schmidt LC, Endometriosis: a reappraisal of pathogenesis and treatment.  Fertility Sterility 1985; 44:157

2.         Hasson HM, Incidence of endometriosis in diagnostic laparoscopy. J Reprod Med 1976; 16:135-8.

3.         Olive DL, Haney AF.  Endometriosis associated infertility: a critical review of therapeutic approaches, Obst Gynaecol Surv 1986; 41:538

4.         Cooke ID, Thomas EJ.  The medical treatment of  mild endometriosis. Acta Obstet Gyneacol Scand Suppl 1989; 150: 27-30.

5.         Brosen I.  Diagnosis of Endometriosis.  Seminar in Reproductive Endocrinology; 1997 15, 229-233.

6.         Moore J, Kennedy S, and Prentice A.  Modern combined oral contraceptives for pain associated with endometriosis.  Cochrane Database of Systematic Reviews.  8-8-1997.  Update software.

7.         Bergqvist A Current drug therapy recommendations for the treatment of endometriosis.  1999; Drugs 58, 39-50.

8.         Scottish clinical Research Audit Group.  Measuring health-related quality of life outcomes in women with endometriosis: results of the gynaecology audit project in Scotland.  Health Bull 1997: 55: 109-117.

9.         Damario MA Roack JA, Pain recurrence: a quality of life issue in endometriosis.  (Review) (99refs).  International Journal of Obstetrics & Gynaecology.  50 suppl 1: S27-42, 1995 Sep.

10.        Burry KA.  Nafarelin in the management of endometriosis: quality of life assessment.  Am J Obstet Gynaecol 1992: 166: 735-739.

11.        Miller JD.  Shaw RW.  Casper RF.  Rock JA.  Thomas EJ.  Dmowski WP.  Surrey E.  Malinak LR.  Moghissi K: Historical prospective cohort study of the recurrence of pain after discontinuation of treatment with Danazol or a Gonadotropin-releasing hormone agonist.  Fertility & Sterility.  70(2): 293-6, 1998 Aug.

12.        Brosen IA – Endometriosis current issue in diagnosis and medical management (Reviews 28 refs) Journal of Reproductive Medicine 43 (3 suppl): 281-6, 1998 March)

13.        Redwine DB.  Laparoscopic excision of endometriosis (LAPEX) by sharp dissection In: Martin DC, Redwine DB, Reich H, Kresch AJ, editors.  Laparoscopic Appearances of Endometriosis, Vol 1.  Memphis, Tennessee: Resurge Press, 1990: 9-19.

14.        Barbieri RL.  The use of danazol as a treatment of endometriosis.  In: Thomas E, Rock J, editors.  Modern approaches to Endometriosis.  London: Kluwert Academic Publishers, 1991: 239-256

15.        Walker KG, Shaw RW.  Gonadotropin-releasing hormone analogues for the treatment of endometriosis: long-term follow-up.  Fertil Steril 1993: 59: 511-515.

16.        Moore J, Kennedy S, Prentice A.  Modern combined oral contraceptives for the treatment of painful symptoms associated with endometriosis (Cochrane review).  In: The Cochrane library 1999, Issue 3.  Oxford: Update software.

17.        Hornstein MD, Hemmings R, Yuzpe AA, Heinrichs W.LeRoy.  Use of nafarelin versus placebo after reductive laparoscopic surgery for endometriosis.  Fertil Steril 1997; 68:860-4.

18.        Vercillini P, Crosignani PG, Fadini R, Radici E, Belloni C, Sismondi P.  A gonadotrophin-releasing hormone agonist compared with expectant management after conservative surgery for symptomatic endometriosis.  Br J Obstet Gynaecol 1999; 106:672-7.

19.        American College of Obstetricians and Gynaecologists.  Endometriosis.  Int J Gynaecol Obstet 1993;43:221-7.

20.        Farquhar C and Sutton C The evidence for the management of endometriosis.  Current Opinion in Obstetrics and Gynaecology 1998; 10, 321-262.

21.        Hughes E, Fedorkow DM, Collins J, Vandekerckhove P.  Ovulation suppression versus placebo in the treatment of endometriosis in: The Cochrane Library, issue 2: 1998: Oxford: Update software.

22.        Redwine DB.  Conservative laparoscopic excision of endometriosis by sharp dissection: life table analysis of reoperation and persistent or recurrent disease.  Fertil Steril 1991;56:628-34.

23.        Hughes EG, Fedorkow DM, Collins JA: A quantitative overview of controlled trials in endometriosis-associated fertility.  Fertil Steril 1993: 59(5): 963-970.

24.        Adamson DJ, Pasta DJ.  Surgical treatment of endometriosis-associated infertility: Meta-analysis compared with survival analysis.  AM J Obstet Gynaecol 171: 1488-1505, 1994.

25.        Marcoux S, Maheux R, Berube S laparoscopic surgery in infertile women with minimal or mild endometriosis.  Canadian Collaborative Group on Endometriosis.  N Engl J Med 1997 337, 217-2.

26.        Martin DC.  Laparoscopic and vaginal colpotomy for excision of infiltrating cul de sac endometriosis.  J Reprod Med 1988: 33: 806-808.

27.        Konincz PR, Meuleman C, Demeyere S, Lesaffre E, Cornillie FJ.  Suggestive evidences that pelvic endometriosis is a progressive disease, whereas deeply infiltrating endometriosis is associated with pain.  Fertil Steril 1991: 55: 759-765.

28.        Reich H, McGlynn F, Salvat J.  Laparoscopic treatment of cul de sac obliteration secondary to rectocervical deep fibrotic endometriosis.  J Reprod Med 1991: 36: 516-522.

29.        Nezhat C, Nezhat F, Pennington E.  Laparoscopic treatment of infiltrative rectosigmoid colon and rectovaginal septum endometriosis by the technique of video laparoscopy and the CO2 laser.  Br J Obstet Gynaecol 1992: 99: 664-667.

30.        Reich H.  Endometriosis.  In: Hulka JF, Reich H.  Textbook of Laparoscopy.  Philadelphia: WB Saunders, 1994: 211-217.

31.        Redwine BD.  Laparoscopic en bloc resection for the treatment of the obliterated cul de sac in endometriosis.  J Reprod Med 1995: 37: 695-698.

32.        Wood C, Maher P.  Peritoneal surgery in the treatment of endometriosis-excision or thermal ablation? Aust NZ J Obstet Gynaecol 1996: 36: 190-197.

33.        Garry R.  Laparoscopic excision of endometriosis: the treatment of choice? Br J Obstet Gynaecol 1997: 104: 513-515.

34.        Redwine D.  Non laser reduction of endometriosis.  In Sutton C and Diamond M (eds) Endoscopic Surgery for Gynaecologist.  Saunders, London.  1993; 220-228.

35.        Wheeler JM, Malinak LR.  Recurrent endometriosis.  Contrib Gynecol Obstet 1987;16:13-21.

36.        Redwine DB: Endometriosis persisting after castration: clinical characteristics and results of surgical management.  Obstet Gynaecol 83: 405-413, 1994.

37.        Namnoum AB, Hickman TN. Goodman SB, Gehlback DL, Rock JA.  Incidence of symptom recurrence after hysterectomy for endometriosis.  Fertil Steril 1995: 64: 898-902.

38.        Metzger DA, Lessey BA, Soper JT, McCarrty KSJ, Haney AF: Hormone resistant endometriosis following total abdominal hysterectomy and bilateral salpingo-oophorectomy: correlation with histology and steroid receptor content.  Obstet Gynaecol 78: 946-950, 1991.

39.        O’Connor DT: Endometriosis.  Melbourne, Churchill Livingstone, 1987.

40.        Clayton RD, Hawe JA, Love JCC, Wilkinson N, Garry R.  Recurrent pain after hysterectomy and bilateral salpingo-oophorectomy for endometriosis: evaluation of laparoscopic excision of residual endometriosis.  Br J Obstet Gynaecol 1999: 106: 740-744.