Endometriosis is a chronic disease
In that sense, there is no cure for endometriosis, but the symptoms can
be reduced with the right treatment. Communication is the key to finding a treatment that fits you.
Surgical treatment involves the elimination of endometriosis lesions, division of adhesions and interruption of nerve pathways. Laparoscopic (key hole) surgery is preferred to laparotomy (open surgery) as it improves visibility of lesions and is associated with better patient outcomes such as less pain, smaller incisions, faster recovery and less risk of infection. Elimination of endometriosis may be achieved by excision, other techniques in use are called ablative techniques (diathermy/coagulation/evaporation). Adhesions are divided to help restore pelvic anatomy, and interruption of pelvic nerve pathways is carried out with the intention of improving pain control.
The evidence showing differences between excision and ablation is lacking, due to poorly performed studies, no randomised control trials, no difference been made between stages of endometriosis and not considering surgeon skill and experience in the reviews carried out. It is hoped that with current research that stronger evidence will be found. In speaking to surgeons who carry out hundreds of endometriosis surgeries annually, their method of choice is excision. There are many ways to excise, but the end results are the same – the physical removal of the endometriosis lesion and surrounding tissue. This is important for a number of reasons – endometriosis lesions can be wide as well as deep – but most importantly the tissue can be sent to the laboratory for histopathology. This examination at microscopic level will show that the lesions removed were endometriosis (or not) and if there are clear margins around the lesion. When ablation is used, the tissue is vaporised and destroyed. There is no tissue to send to the laboratory. Ablation can also lead to localised inflammation and endometriosis being left in place under the charred surface of the peritoneum.
The ESHRE guideline group concluded that “Ablation and excision of peritoneal disease are thought to be equally effective for treatment of endometriosis-associated pain. However, this information comes from one small study and a larger one with suboptimal design; hence their conclusions should be treated with caution. Excision of lesions could be preferred with regard to the possibility of retrieving samples for histology. Furthermore, ablative techniques are unlikely to be suitable for advanced forms of endometriosis with deep endometriosis component.”
When endometriosis is identified at laparoscopy, clinicians are recommended to surgically treat endometriosis, as this is effective for reducing endometriosis-associated pain i.e. ‘see and treat’
Clinicians can consider performing surgical removal of deep endometriosis, as it reduces endometriosis-associated pain and improves quality of life
Recommends that clinicians refer women with suspected or diagnosed deep endometriosis to a centre of expertise that offers all available treatments in a multidisciplinary context.
Surgical Interruption of Nerve Pathways
Severing the nerves to the pelvic and uterine area was considered a possible treatment for endometriosis related pain.
LUNA – Laparoscopic Uterosacral Nerve Ablation and PSN – PreSacral Nerve Ablation are the two most commonly used techniques. Both techniques are offered as part of a surgical treatment plan for endometriosis.
It can be concluded that LUNA is not beneficial as an additional procedure to conservative surgery for endometriosis, as it offers no additional benefit over surgery alone (Proctor, et al., 2005).
PSN is beneficial for the treatment of endometriosis-associated midline pain as an adjunct to conservative laparoscopic surgery, but it should be stressed that PSN requires a high degree of skill and is associated with increased risk of adverse effects such as bleeding, constipation, urinary urgency and painless first stage of labour.
Surgical treatment of ovarian endometrioma (Chocolate Cysts)
Ovarian endometrioma are difficult to treat, a paper produced by a European working group looked at the different types of surgery for endometrioma. They concluded that drug therapies may be used to treat endometriosis, but when endometriomas are found and need treatment, surgery is often required. There are risks associated with surgery as it can damage the follicles in the ovaries and reduce fertility. The working group looked at the main types of surgery which are used to treat endometriomas in women who may want to have children in the future.
They considered cystectomy, where the cyst is cut out, ablation, where the cyst lining is removed by using a laser beam or plasma energy, and electrosurgery, where an electric current is used. They also looked at the effectiveness of combining different types of surgery.
Removal of endometrioma is a balance between effective removal and preservation of ovarian reserve (fertility) and this should be carefully discussed with the surgeon. Removal of endometrioma can cause damage to the ovarian reserve (fertility). It is important to discuss this with your surgeon and consider the risks and outcomes. Your surgeon may offer a blood test to estimate AMH (Anti Mullerian Hormone) and a scan (Antral Follicle Count) to help determine fertility potential prior to surgery and again at a minimum of 6 months post surgery.
Treating endometrioma is a case by case decision, be sure to ask for individual guidance from your surgeon and fertility specialist (if necessary). It is important to choose a skilled and experienced surgeon.
Hysterectomy (removal of the uterus with or without the cervix and fallopian tubes)
If a woman has no future desire to have children (or has completed her family) and the uterus is considered a source of pain, removal of the uterus (hysterectomy) can be considered. Conditions that can lead to pain include adenomyosis and fibroids. Adenomyosis is a condition that causes similar pain to endometriosis. It can only be definitively diagnosed by removing the uterus and sending it to the laboratory. Heavy periods (menorrhagia) is another reason that women choose a hysterectomy. It is important to note that removing the uterus will not impact on endometriosis. Endometriosis does not come from the uterus. All endometriosis should be removed at the time of hysterectomy. If the disease is left behind it may continue to cause symptoms. Endometriosis will not “dry up” or disappear when the uterus is removed.
Removal of the ovaries is radical surgery, it results in so-called surgical menopause with the side effects of menopause and long term health effects. It has to be mentioned that hysterectomy alone will not solve the problem since most of the time endometriosis is left behind and hence the pain symptoms remain present.
Removing the ovaries (when the tissue is healthy) has a long term impact on the health and quality of life for the woman. It is not a decision to take lightly. Removing the ovaries will not cause the endometriosis lesions to “dry up” or disappear. The removal of hormones (produced by ovaries) can help reduce symptoms, but it is important to note that endometriosis lesions can create their own oestrogen. This combined with residual oestrogen and the risk of ovarian remnant syndrome can lead to persistence of severe symptoms.
It is essential to discuss both a hysterectomy and oopherectomy (ovarian removal) with your surgeon. It should be made very clear that the removal of your organs alone will not treat endometriosis.
The ESHRE guideline recommends that clinicians only consider hysterectomy with removal of the ovaries and all visible endometriotic lesions, in women who have completed their family and failed to respond to more conservative treatments. Women should be informed that hysterectomy and removal of the ovaries will not necessarily cure the symptoms or the disease.
Medical Treatment Pre / Post Surgery
Medical (Hormonal) Treatments
There is some controversy on this subject as hormonal treatment is so widespread.
The ESHRE guideline group does not recommend hormonal treatment before surgery to improve the results of the surgery. Of course, many women in pain get hormonal treatment during a waiting period before surgery. After surgery, starting with an oral contraceptive pill or using a levonorgestrel-intrauterine device (Mirena) may prevent recurrence of pain.
Clinicians should not prescribe preoperative hormonal treatment to improve the outcome of surgery for pain in women with endometriosis
After cystectomy for ovarian endometrioma in women not immediately seeking conception, clinicians are recommended to prescribe hormonal contraceptives for the secondary prevention of endometrioma (chocolate cysts)
In women operated on for endometriosis, clinicians are recommended to prescribe postoperative use of a levonorgestrel-releasing intrauterine system (Mirena) or a combined hormonal contraceptive for at least 18–24 months, as one of the options for the secondary prevention of endometriosis-associated dysmenorrhea (period pain), but not for non-menstrual pelvic pain or dyspareunia (painful sex).
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