Treatment of endometriosis The principles of treating endometriosis are:
- At the end of treatment the patient should optimally be disease and symptom free.
- Treatment should be individualised to take account of the severity of each patient’s endometriosis and to minimise the side effects of treatment.
- Laparoscopic surgery with excision and removal of all the endometriosis has become the best treatment for most levels of endometriosis.
- Minor surgery in the form of laparoscopy/laser treatment in some cases maybe as effective as drug treatment in relieving symptoms and producing pregnancies. It has a definitive role to play in the management of mild or moderate endometriosis.
- Hormonal (drug) therapy in general can be used as a primary method of treating minor endometriosis. It is less invasive than surgery.
- All forms of hormone therapy have potential side effects. These are usually minor in nature, are tolerated and it is uncommon to have to change a drug once it is started by a patient. However, doctors must be flexible if the patient is experiencing problems.
- Before drug treatment is ceased, or soon after, a "second look" laparoscopy should be performed to ensure it has worked and the endometriosis is gone.
- Sometimes it is better to attempt to achieve a pregnancy to improve the endometriosis rather than use hormonal or surgical treatment. This decision will depend on the individual patients fertility needs.
- Laparotomy (ie major open, large cut surgery) should be used only in severe endometriosis or where all other therapy has failed and then hardly ever.
Surgical Treatment of Endometriosis
Various levels of surgical treatment are available for endometriosis. The simplest type of surgery is laparoscopy and various types of procedures may be done down the laparoscope to get rid of the endometriosis or its effects. A more significant form of surgery is laparotomy, where a large incision is made in the abdominal wall to actually perform a definitive surgical procedure. Obviously, this takes longer, is more painful and the patient is in hospital for longer.
The risks and side effects are also greater than for laparoscopy. It is therefore better to keep laparotomy as a last resort treatment for endometriosis, to be used only when other methods of treatment have failed or when the endometriosis is very severe and then only very rarely. Burning endometriosis by diathermy or laser may be used to treat mild endometriosis or may be used in the context of a second look laparoscopy at the end of the period of hormonal therapy.
Laparoscopy, with Laser or Diathermy
Laparoscopy is initially used to diagnose endometriosis. When we visualise areas of endometriosis it is possible to destroy them under the control of the laparoscope by burning or excising it. This can be done simply with the diathermy or in a more elegant way using the laser. We have the technology to direct a laser beam down the laparoscope and use it to excise both adhesions and areas of endometriosis. Simple burning treatment is not always the answer for endometriosis as it is rather like trying to treat a case of measles by burning the spots away. The basic disease process probably still remains or returns quite quickly. It is sometimes better to combine a hormonal (drug) regime with local destructive therapy for extensive mild endometriosis. Laser destruction of endometriosis (or diathermy) is probably best used in the context of a second look laparoscopy at the end of the period of drug therapy. The endometriosis and its causes have therefore been definitively treated and laparoscopic surgery is used to get rid of any residual disease so that the major aim of therapy is achieved, ie. the patient becomes disease free of the endometriosis.
Laser therapy can also be used down the laparoscope to divide the adhesions caused by endometriosis. The beauty of laser surgery is that it is cleaner than ordinary diathermy as it vaporises endometriosis and the adhesions with less subsequent formation of adhesions after the surgery. Laser surgery, however, is not entirely without its risks. Due to the intensity of the laser beam, it is possible to burn vital structures within the abdomen whilst treating the endometriosis. In rare circumstances this can mean more major surgery for the patient to fix up the damage caused by laser surgery. Laser surgery should be approached with caution and should only be performed by people competent in the technique.
Advanced Laparoscopy with Excision of Endometriosis
There is now a worldwide trend to more advanced laparoscopic surgery for endometriosis. In the past few years some gynaecologists have become cleverer in operating telescopically. This has meant that very major surgery, previously performed through a large incision, can now be done laparoscopically. This means short (often one night) hospital stays and quicker return to work with much less post-operative pain. This is very skilled surgery and often requires extra training. It often can take 1 - 3 hours and involve a lot of dissection of the pelvic structures when the endometriosis has caused severe damage which must be repaired. The bowel often needs to be freed from the ovaries and uterus. Lumps of endometriosis are removed with great precision due to the improved visibility of the laparoscope.
At these laparoscopies all the scarring and endometriosis (old and new) is excised and removed. The aim is to leave the pelvis completely free of all scarring and endometriosis. Long-term pain relief may be obtained from this level of surgery.
Patients often need prior to surgery a bowel clean out (bowel prep), as often at this level of severity, the endometriosis involves bowel adhesions. Data suggests excellent long term results from this surgery.Laparotomy
This is now very rarely used in the presence of persisting very severe endometriosis after other forms of therapy are not possible. It is particularly used where large lumps of endometriosis (endometriomas) form in the ovaries and are difficult to treat with drug therapy or laparoscopic surgery. A large incision is made in the abdominal wall and the aim of the surgery is to remove as much endometriosis as possible to leave the patient disease-free. Any adhesions which may be present are divided in the most careful way possible. This type of endometriosis surgery is often done to improve an otherwise badly damaged pelvis and enhance a patient's fertility or at the time of a hysterectomy.
There are significant risks to all surgery; the most important of which is subsequent adhesion formation. Once the patient has surgery for endometriosis she runs a significant risk of having tethering of the ovaries and the tubes to each other, with a subsequent decrease in fertility. The results of surgery can therefore be somewhat variable and can have, in fact, a deleterious effect on the patient's fertility status. Surgery should therefore be approached with caution, but has a place to play in the definitive management of endometriosis. Advanced laparoscopy has taken the place of laparotomy.
The final alternative is hysterectomy with removal of the womb, all the endometriosis and sometimes the ovaries. This is curative in 90% of cases, but only can be used when childbearing is complete. It must be stressed that hysterectomy is not a cure for endometriosis unless all the endometriosis is removed at the same time. Laparoscopic Hysterectomy with excision of all the disease is the final best treatment for advanced endometriosis.
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