Treating Endometriosis

As my surgical practice continues to evolve, I am seeing many more patients referred from other physicians and from patients for surgical management of endometriosis. Due to the nature of my fellowship with the AAGL and Dr. Liu, I have become a fan of excising endometriosis as opposed to just coagulation/vaporization with electrical energy or laser. This is especially true in the cases of extensive endometriosis.

Endometriosis can be treated in many different ways. Initially it is prudent to control symptoms of endometriosis with medical therapy in patients who may not want surgery. Common medical therapies for endometriosis include medications such as ibuprofen, birth control pills, depoprovera injection, levonorgestrel IUD, danazol and depo-lupron. The goal of any of these medical therapies is to control the symptoms of endometriosis. They do not cure the disease. Symptoms usually recur when therapy is stopped and some of the medications can only be used for a limited time.

Although surgical excision is not the perfect treatment for endometriosis (the perfect treatment is not available) it does provide the highest cure rate of any therapy. Surgery combined with post operative medical therapy has been shown to give the longest pain free period for patients with endometriosis.

Surgical excision of endometriosis requires very advanced laparoscopic skills. These are by far the most difficult surgeries I have encountered. Endometriosis tends to cause a great deal of internal scarring. Also approximately 10% of endometriosis is of an invasive nature. It does not stay on the superficial lining tissue of the pelvis treated with coagulation or vaporization.

To make it more difficult, invasive endometriosis may involve structures such as the bowel or rectum, the bladder, the ureters, the cervix and uterus and the vagina. Except in the cases of endometriosis of the vagina, cervix and rectum, it can be very difficult to know the extent of endometriosis prior to surgery. I have assisted many surgeons in residency and practice, who have looked inside and ended the surgery because the disease was too extensive and beyond their skills to treat surgically. This is appropriate. Many of these patients are pushed to the realm of Lupron. Although Lupron can treat symptoms in some patients, I have found through experience that it does not control symptoms of invasive endometriosis where tissue damage has already occurred.

A recent article in Ob.Gyn. News stated that failure of medicines to control pain does not suggest that endometriosis is not the cause. In fact some of the most advanced cases of endometriosis I have encountered are in patients in their mid to late twenties who have never had a surgical diagnosis or treatment.


Because of the uncertain nature of endometriosis, having a surgeon skilled in advanced laparoscopy is essential. On his website, www.endometriosissurgeon.com, Dr. David Redwine lists questions that you should ask your physician prior to endometriosis surgery. These questions will assure the most appropriate surgical management of your disease.

Rectovaginal Endometriosis

Rectovaginal Endometriosis

I recently had a patient who was referred to me for treatment of pelvic pain and pain with intercourse. She had multiple prior surgeries for “endometriosis”. During one of her prior surgeries she was noted to have “adhesions of her rectum to the uterus.

On her office exam, there was a nodule behind the uterus that I could feel. It appeared to be pulling her rectum into the back side of the uterus. This is the third patient I have seen with this similar presentation and history.

During surgery, she was noted to have a nodule of endometriosis that pulled the rectum forward and blocked her normal “pelvic cul-de-sac” (the area between the uterus and the rectum. During dissection, this nodule was dissected off the uterus and the rectum and freed up. After identifying the rectum, ureters and uterine blood vessels, the nodule was removed.

When treating endometriosis surgically, it is important to use the physical examination to know what to expect at the time of surgery. It is also important for the surgeon to feel comfortable removing endometriosis in difficult areas such as over the ureters or bowel. There are many times endometriosis surgeries are performed and the surgeon takes a look and then stops the surgery because the endometriosis is too bad or in locations “too risky” to remove.

This patient is an ideal example of the necessity to know how to identify and adequately excise the endometriosis encountered during surgery.

Endometriosis

I recently had a patient present with pain during periods and deep pain during intercourse. On her physical exam I felt a nodule or mass at the top of the vagina. This can be very common in patients with endometriosis. At the time of her surgery she had a thick endometriosis nodule behind her uterus that corresponded to the findings on physical exam. This is a very common place to find endometriosis. One of the difficulties with endometrisosis in this area, is that it can grow in close proximity to the ureter. That is a tube that carries urine from the kidney down to the bladder. A surgeon must be careful in dissecting this area to avoid injury to the ureter. I usually just use my scissors without any electricity or very minimal. If there is extensive endometriosis in the ureteral area, it may be necessary to close the uterine vessels on the same side to avoid significant bleeding durring removal of the endometriosis.

Some patients may also have endometriosis cysts on the ovary. These are referred to as endometriosis cysts or "chocolate cysts." The fluid and old blood inside the cyst often as a liquid chocolate appearance when opened. These are best treated by actually opening the cyst and removing the wall of the cyst. Any minor bleeding can be controlled with cautery or with large cysts, the cyst bed can be sewn closed.