Endometriosis Relief (Excision Surgery)
Endometriosis is a disease when ''cells'' (glands and stroma) similar to the lining of the uterus are found outside of the uterus.
Questions about Endometriosis
How does endometriosis directly causes pain?
To put very simply, endometriosis causes pain because these ''cells'', when active, results in inflammation, and the inflammation causes pain. Indirectly, endometriosis can cause adhesions - and in turn - the adhesions can cause pain and also limit functionality of the organs involved. Furthermore, in patients with chronic pelvic pain (defined as having pain for more than 6 months), the pelvic floor muscles react and are commonly found to be in a constant spasm state. This state gives rise to pelvic floor muscular dysfunction. All these pain generators (direct and indirect) add up and contribute to pain.
How can endometriosis causes infertility? (3 ways)
- By causing inflammation as above. Inflammation is not conducive to egg, sperm and embryo survival. It can also affect implantation of the embryo. The more endo you have, the more inflammation there is going to be.
- By causing mechanical issue. Inflammation can cause adhesions to form. If the fallopian tube and/or ovary is ''stuck'' in one position and not mobile, then there is less chance for the egg to be fertilized by the sperm. This then causes infertility
- By direct involvement of the organs. If the ovary is affected and there is an endometriotis type cyst (endometrioma), not only does this cause a highly inflamed environment, it can also decrease the production of eggs and also the quality of eggs produced. If the fallopian tube is involved, then it may cause the tube to be blocked, hence not allowing fertilization to occur.
How is endometriosis treated from a pain perspective? Is there a better option?
Most gynecologist will treat endometriosis primarily medically, by hormonal suppression. This is in the form of birth control pills, injections, implants or medicine that cause temporary menopause. The idea behind this is that, with medical suppression, there will be less activity of the endometriosis cells / glands and hence causing less inflammation and less pain.
Two main issues:
The first is that - although suppressed - the endometriosis is still progressing, going deeper. We know this because - over time - higher potency suppression is needed to control the symptoms. By masking the symptoms while progression is still ongoing may result in issues with fertility in the future.
The second problem is that since the disease was never removed in the first place, once suppression is stopped, the glands becomes active again causing inflammation and pain to return.
Other Treatment Practices
Once medical suppression ceases to work, surgery will then be offered. Most of the time, the surgery offered will be in the form of superficial treatment, or a mixture of minimal excision and superficial treatment - but usually not complete excision alone. Some forms of superficial treatment of endometriosis are ablation, fulguration, diathermy, vaporization, cautery, etc.
With superficial treatment, energy is directly applied to the endometriosis lesions. The problem with superficial treatment is that we cannot see underneath what was ''burned'' and hence more often than not, some disease is left behind. This will help with pain initially because the disease load is less, hence causing less inflammation. However, because the remainder of the disease that is left behind (no matter how little) will continue to progress, pain will almost always return over time.
On top of this, there may be more adhesion formation as a result of improper healing due to the presence of residual endometriosis. Once pain returns, or right after surgery, most gynecologist will start with medical suppression. The re-operation rate with superficial surgical treatment is very high - 80%. This is when the medical-surgical cycle is repeated until it no longer helps. Then, a hysterectomy and removal of the ovaries is performed, putting the patient into surgical menopause. This is a very harsh and thoughtless treatment, but unfortunately, all too common.
Treatment At The CRRS
We neither put patients on hormonal suppression for endometriosis, nor do we perform superficial surgical treatment.
Instead, we focus on complete excision of endometriosis. Excision of endometriosis focuses on cutting out the disease, essentially peeling the lesions off of normal tissue.
At the time of surgery, when an endometriosis lesion is excised (cut out), The area underneath the lesion is assessed visually for the presence of abnormal tissue. If so, a deeper excision is done until we are down to normal tissue. With the lesions gone, inflammation is much reduced as well. In this way, we are more confident that there is no longer any residual disease and we then have better results in reducing pain.
20% vs. 80%
The re-operation rate with excision of endometriosis is only 20% - better than the aforementioned 80% re-operation rate of superficial surgical treatment. Suppression post operatively is also not needed because - with complete excision - there should not be any endometriosis left to be suppressed.
Why aren't more gynecologists doing excision?
Excision of endometriosis requires not only a complete understanding of the anatomy, but also advanced surgical expertise. Treating this condition commands intense training and a thorough understanding of the etiology of the disease - and its consequences. Meticulous precision and patience is a requisite. Therefore, excision surgery will take a considerable longer time than superficial endometriosis treatment. Dr. Kongoasa is very fortunate to have been trained in this technique of advanced laparoscopic surgery and excision of endometriosis. Dr. Kongoasa has had experience in a high volume endometriosis excision practice for the past several years. Most gynecologists do not have this type of training. Consequently, they do not have the experience and are not comfortable doing excision surgery.
Questions about Surgery
When should I have surgery for my endometriosis?
First, it is important to note that endometriosis can only be diagnosed surgically and pathologically. This means that for endometriosis to be diagnosed, a surgery is required to evaluate for endometriosis. A specimen suspicious for endometriosis will be sent to the pathologist for confirmation. Therefore most patients are placed on a medication without having a proper diagnosis.
Primary Symptoms of Endometriosis
Pelvic pain and infertility
Up to 80% of patients with pelvic pain (lasting 6 months or more) will have endometriosis diagnosed during surgery and up to 50% of patients with infertility will have endometriosis diagnosed during surgery. With regards to pelvic pain, this means that if you have pelvic pain for more than 6 months, then the likelihood of you having endometriosis is very high ~ 80%.
Ultimately, when surgery is recommended, the next steps depend on you.
At The CRRS, we are not a proponent of suppression and will not prescribe suppression for symptom control. We usually recommend surgery if your pain is not controlled with the typical over-the-counter pain medications. In other words, you are the one controlling when you would like to have surgery.
Endometriosis pain will affect your quality of life significantly if not resolved. Therefore it is important that you monitor your symptoms. If you feel that your pain and discomfort are too much to manage, you need to address it. It is worthwhile noting that your age should not be a major factor in deciding when surgery is needed.
In our experience, we have seen many surgeries for endometriosis that were not done right - with patients suffer from the results. There can be complications from endometriosis, and subsequent surgeries can be more challenging. It is important to have endometriosis surgery done right the first time (and usually the only time).
* The topic of infertility is addressed in greater detail on the sections - Restorative Reproductive and Fertility Enhancement.