Patients with endometriosis will be treated primarily with surgical therapy but drugs can also be used particularly in patients who are about to undergo IVF. The cure rate over 3 years for surgical therapy is over 70% and the best figure for medical therapy with the new drug, gnrh analogue, is 40%. Drug therapy has a place, particularly in a patient undergoing IVF.
Laparoscopic surgical treatment is the primary treatment for endometriosis. The best treatment is to remove the endometriosis at the time of the laparoscopy. As mentioned earlier there may be a special place for drug therapy with gnrh analogues prior to IVF. With women with active endometriosis, gnrh analogues for 2-3 months prior to an IVF cycle increases the IVF pregnancy rates. It is important to note that the use of ovarian stimulation (as part of the IVF cycle) increases the oestrogen levels significantly. This may increase the regrowth of the endometriosis. In a number of patients endometriosis flares up after a failed IVF stimulation cycle. If a pregnancy occurs then this is not a problem as the pregnancy itself slows or stops the growth of endometriosis.
In women who have new symptoms after an IVF treatment cycle their treating physician should consider a further laparoscopy or drug therapy prior to any further IVF treatment. Women who have lost one or part of both ovaries or with significant endometriosis in both ovaries which has destroyed ovarian tissue need to be counselled that they also have a lower chance of success on IVF as compared to women who have not had ovarian damage.
Women who are not planning a pregnancy but have significant endometriosis may want to discuss egg freezing or cryo preservation of ovarian tissue. Referral to an IVF specialist should be made at that time.
Further discussions regarding treatment of the infertile woman with endometriosis should be discussed with your ECCA practitioner.
Surgery is still considered the “gold standard” in treatment of moderate to severe endometriosis. The most commonly performed surgery for endometriosis involves removing peritoneum (tissue covering) from pelvic structures such as bladder, pelvic sidewall and the Pouch of Douglas.
The peritoneal lining can be removed using different energy sources such as Laser, Electro Surgery and Ultrasound Energy. There does not appear to be any advantage of one source over another. A histological or microscopic diagnosis of endometriosis is important, as not all lesions that look like endometriosis prove to be positive for the disease (40-82% only). Lesions can be either red, black, white or clear in appearance and only red or clear blisters respond well to drug therapy.
Laparoscopy has many advantages over open surgery (laparotomy) in the treatment of this disease and these include small scars, less pain, early discharge from hospital and return to normal domestic/working duties. It is important to realize that laparoscopy is not suitable in all cases, particularly when the bowel is involved and bowel resection is necessary.
While the incidence of complications is low with peritoneal excision, injury can occur when vital structures are involved, such as ureter, bladder and rectum. The incidence of these injuries should be discussed in detail with your surgeon before operation.
When an endometrioma forms within the ovary (endometriotic cyst), drug therapy is ineffective. Although some improvement in the site may occur with drug therapy, regrowth occurs at the cessation of this therapy. Two methods of surgical therapy are available and both are relatively successful. Firstly, the cyst may be opened via the laparoscope, drained and the endometriotic lining stripped from the normal ovarian tissue. The second technique is to open the cyst, drain it and then ablate the endometriotic tissue lining the cyst. Unfortunately, both techniques may result in the ovary sticking to the pelvic wall in the postoperative period. This can result in pain at the time of ovulation or during sexual intercourse. There are several techniques to try to minimize the occurrence of ovarian adhesions after operation, but none are 100% successful.
When the endometrial glands infiltrate deep into the uterine muscle, there is enlargement of that organ and moderate to severe pain at the time of menstruation. This condition is known as Adenomyosis. Heavy periods can also be a feature of this disease. Diagnosis of Adenomyosis is difficult; with MRI (Magnetic Resonance Imaging) offering the most accurate change of correct diagnosis. Ultrasound is correct in only 50% of cases. Needle biopsy under ultrasound control will enhance the accuracy of diagnosis. Recent studies suggest that the levonorgestrel inter uterine device (Mirena ) may be beneficial in relieving the symptoms associated with Adenomyosis. In rarer cases where circumscribed lesion occurs (adenomyoma) surgical excision is possible. This procedure can sometimes be performed via the laparoscope but usually a small opening is made in the abdominal wall (mini laparotomy) to facilitate removal of the adenomyoma.
The anatomical area between the posterior cervix and the anterior rectum is called the Pouch of Douglas. Disease affecting this area can involve the utero-sacral ligaments, posterior cervix and vagina and the anterior wall of the rectum. This type of endometriosis is the most difficult to treat. It does not respond well to drug therapy. The symptoms are generally debilitating and include painful intercourse (dyspareunia), pain on defecation (dyschezia) and of course period pain (dysmenorrhoea). The treatment usually involves extensive surgery to remove the endometriotic nodules and in some instances a small portion of the bowel may also need removal. A colorectal surgeon is always involved when this is necessary. Patients with this severe type of disease can expect success from surgery in up to 75% of cases and up to 3 years of normality before symptoms return. It must be emphasized that endometriosis is a chronic condition and most women, particularly when the disease is severe, will be challenged with debilitating symptoms on a recurrent basis.
Hysterectomy should only be necessary in the most severe cases of endometriosis or Adenomyosis when these diseases do not respond to more conservative measures. It may also be considered by both the patient and her gynaecologist after childbearing is complete and the woman who has had repeated conservative surgeries. When severe recto-vaginal (Pouch of Douglas) disease exists together with severe adenomyosis of the cervix and rectal disease is present, hysterectomy may also be recommended. Most colorectal surgeons are wary of performing an isolated bowel resection in these circumstances for fear of dramatic complications should hysterectomy be necessary at a later time. The medical literature reports that the best chance of cure of endometriosis (severe) occurs with removal of the uterus and ovaries, together with the endometriotic disease. Despite this, endometriosis can occur in a small proportion of patients (less than 5%) who have undergone removal of the reproductive organs. Some gynaecologists prefer to leave one ovary if it is unaffected by disease, particularly in the younger patients, so as to avoid the use of hormone replacement therapy. Up to a third of these patients will subsequently require removal of the remaining ovary.
If hysterectomy is necessary, the laparoscopic approach should be considered. The advantages are well known and include less pain, shorter hospital time and early return to normal duties. Each woman should speak to her gynaecologists and if not satisfied that enough information has been provided, seek a further opinion. In the event that an infertile patient has to have her ovaries removed in the presence of normal uterus, frozen storage of the removed ovary should be considered, as at a later date IVF may be an option. If hysterectomy together with removal of the ovaries is necessary, it is usual to withhold hormone replacement therapy for up to 6 months in the belief that any residual endometriosis tissue will disappear. Unfortunately, surgical menopause is often associated with more severe menopausal symptoms than those that can occur with the natural menopause. Complete discussion with the gynaecologist and other allied health professionals who are involved in the patient’s management will help her with decision making.