Endometriosis

What is Endometriosis?

Endometriosis is a common gynecological condition. It was described in medical literature more than 300 years ago and has since been recognized as a chronic, painful, and often progressive disease in women. It occurs when cells from the mucus membrane lining the uterus (endometrium) form implants that attach, grow, and function outside the uterus, generally in the pelvic region. The causes of endometriosis are unknown.

Some have claimed that endometriosis can be cured. Unfortunately, this is not always true. Presently, the most effective treatment for endometriosis is surgical eradication of the disease using techniques such as video laparoscopic excision and eradication with high technology such as a CO2 laser, hydro dissection, ultrasound, or radiofrequency. An experienced surgeon is able to use different methods, such as electrocautery, lasers, scissors, or ultrasound, to completely eradicate the disease by these minimally invasive techniques.

Endometriosis Statistics

• One of the top three causes of female infertility
• More than 5.5 million women in the US are affected
• 30% to 40% of women with endometriosis are infertile
• Many infertile women in their 20s, 30s, and 40s with endometriosis had debilitating, painful periods as teens

Common Symptoms

• Pain just before and during periods (similar to excruciating menstrual cramps)
• Intestinal pain and upset
• Lower back or pelvic pain
• Pain during or after sex
• Heavy periods
• Fatigue
• Painful bowel movements or urination during menstrual periods

Endometriosis: How It Occurs

• Endometriosis occurs when cells from the mucus membrane lining the uterus form implants that attach, grow, and function outside the uterus, generally in the pelvic region.
• This endometrial tissue builds up and sheds each month as it responds to the hormonal changes that occur during a women's menstrual cycle.
• When it grows outside of the uterus it has no place to go.
• Surrounding tissues become inflamed or swollen, producing scar tissue.
• Growths are usually found on or under the ovaries, on the fallopian tubes, behind the uterus or on the tissues that hold it in place, on the bladder or bowels.
• Endometriosis can be found in other parts of the body, such as the cervix, vagina, rectum, and even lungs.

Classification

Depending on how bad the disease is, endometriosis can be:

• Minimal (Stage 1)
• Mild (Stage 2)
• Moderate (Stage 3)
• Severe (Stage 4)

Many recent well-designed studies have showed that surgical treatment of endometriosis, regardless of stage, is far superior to the use of medications when comparing relief of pain symptoms and fertility outcomes.

Less Common Sites of Endometriosis
(Extra-genital endometriosis)

Extra-genital endometriosis is a term used commonly to describe the presence of endometriosis in organs other than the ovaries, uterus, or tubes and surrounding wall of the pelvis. Examples of extra-genital endometriosis include endometriosis of the intestines (large or small bowel), the bladder or the ureters, the diaphragm, or even the lungs.

A Medical Breakthrough

It was the pioneering work of Dr. Camran Nezhat in laparoscopic treatment of endometriosis that changed the nature of abdominal surgery (large abdominal incisions to 5 and 12 mm). He reported laparoscopic treatment of stage 4 (severe) endometriosis for the first time in 1985 and 1986 (Fertility and Sterility annual meeting-Canada, 1985).

Dr. Nezhat speculated that if extensive endometriosis can be managed laparoscopically, practically all other pathology can be dealt with via laparscope without resorting to major abdominal surgery. He has taught thousands of surgeons his technique, and he and his team have won numerous awards for their medical accomplishments. Drs. Nezhat have introduced many new techniques for laparoscopic management of endometriosis involving ovaries, bowel, bladder, diaphragm and other parts of the body. They have performed over 12,000 laparoscopic surgeries for patients suffering from endometriosis during the past two decades. Among these patients, many have had extra-genital endometriosis, and all have been successfully treated.

Patients from all over the world come to Drs. Nezhat for the laparoscopic management of unusual cases of endometriosis, most of them after failed previous surgeries.

What a Patient Should Know

When choosing a course of treatment for endometriosis, the patient should familiarize herself with the expertise of the surgeon, as this is the most important factor in successful treatment. She should choose an endometriosis specialist who is well-versed in the use of all available technologies—such as electrocautery, ultrasound, lasers, scissors—and who knows how to apply each instrument in the appropriate circumstances.

Each one of these technologies has its own unique properties and can be advantageous in certain situations. An experienced endometriosis specialist should be able to eradicate all of the disease thoroughly. Incomplete eradication by incomplete excision, like incomplete laser vaporization or excision, incomplete ultrasound excision or vaporization, incomplete electrocautery vaporization or excision, or incomplete scalpel and/or scissors excision, is simply an incomplete treatment.

Although some have suggested otherwise, the CO2 laser is the most precise instrument presently available for surgical treatment of endometriosis. An experienced surgeon can use the CO2 laser to excise endometriosis, even from extremely sensitive areas such as major blood vessels. In delicate areas, such as major blood vessels, using other technologies could be significantly more difficult, more time consuming, and very often, more risky.

DIAGNOSIS

Laparoscopy

• Considered the definitive manner of diagnosing endometriosis
• Minimally invasive surgical procedure
• Performed while the patient is under general anesthesia
• Abdomen is inflated with carbon dioxide to aid in viewing the pelvic organs
• Surgeon makes small abdominal incision to insert a thin telescope-like instrument with a lens and light to evaluate the presence of endometriosis
  

Other Diagnostic Tests

(Tests conducted prior to laparoscopy to rule out other conditions)

• Blood tests
• Ultrasound
• Computed tomography (CT)
• Magnetic resonance imaging (MRI)

TREATMENT

Currently there is no absolute medical cure for endometriosis.  For mild symptoms, over-the-counter pain medication can be used. Prescription pain relievers may be prescribed for more severe symptoms, but they might have side effects and they do not stop the progression of endometriosis. Hormonal therapy such as oral contraceptives, Progesterone, Danazol (a testosterone derivative), or Gonadatropin-releasing hormone (GnRH) agonists can also be used.

Laparoscopic surgery is now considered the standard of care for the surgical treatment of endometriosis. Even extensive disease involving the intestines or urinary bladder can be treated with laparoscopy. Laparoscopic treatment of endometriosis gives surgeons the ability to visualize even small endometriotic implants when compared to open surgery and "naked-eye" vision. This is coupled with the obvious benefits of a short hospital stay and fast recovery. The scarring is limited to three small incisions in the lower pelvic region. One is only one inch long and the others are each ½ centimeter long.

Most women can see relief or improvement of their pain symptoms following surgery. In addition, those women with failed infertility treatments, like IVF and IUI (Intrauterine Insemination), secondary to endometriosis, have a better chance of getting pregnant following surgery performed by an experienced specialist.

Endometriosis Summary

Endometriosis is a progressive, often debilitating disease affecting 10% to 15% of women during their reproductive years, and accounts for 25% of laparotomies performed by gynecologists. Among gynecologic disorders, endometriosis is surpassed in frequency only by leiomyomas (fibroids).

Patients with endometriosis may experience different clinical complaints at various stages of the disease. Treatment depends on the age of the patient, the extent of disease, severity of symptoms, and desire for fertility. Intervention is usually indicated for pain, failed previous infertility treatments, or impaired function of the bladder, ureter, or intestine. Medical and surgical management are available.

Laparoscopic management of endometriosis should be performed by an experienced laparoscopist, who also has extensive experience with endometriosis.  

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