Endometriosis Newsletter
Fall 1999
Dr. Jeremy Wright is an English physician that visited and trained with Dr. David Redwine in the spring of 1999 as part of a Royal College of Obstetricians and Gynaecologists Bernard Barhon Travelling Fellowship. The Fellowship is awarded every two years. He has been practicing in OBGYN since 1973 and as a specialist for the last 13 years working in both the National Health Service and in private practice.
He has a special interest in the surgical management of endometriosis and spent a month with Dr. Redwine to learn some of his specialized surgical techniques and to undertake some areas of audit and research using his unique database of patients. In the United Kingdom Dr. Wright is a director of The Centre for Endometriosis and Pelvic Pain offering a specialized service for patients with this disease. The Centre’s web site can be visited at www.psiesys.com.
By Jeremy Wright, MD
Endometriosis is truly an international disease as can be seen by the amount of time given at international conferences to the consideration of its treatment. That, too, is a sign that there is no agreement on the appropriate management of the disease in its different stages.
As in America there is in England no consensus. The incidence of the disease too is difficult to assess. However, in England, because national data is collected on diagnosis, it is possible to assess the prevalence of the condition.
There has been an ongoing survey of women born in 1946 who have been asked to fill in a questionnaire every year. Six percent of these women report having been treated for endometriosis at some time. We would seem to be dealing then with a condition that is as common as asthma, but equally one in which the optimum treatment is a matter of some dispute — medical vs. surgical or even the appropriate surgical modality. However like Dr. Redwine I believe the optimum treatment is surgical and the appropriate surgery is excision.
In order to understand how treatment is undertaken in England it is necessary to understand a little about how the English National Health Service works. In England there is a principle that medical care is free at the point at which it is given although it is paid for out of taxes and consumes 6.5% of the gross domestic product (GDP). In monetary terms that amounts to millions of dollars, but it is only a small percentage compared to most western countries.. Only a tiny percentage of the population have private insurance.
All patients are registered with a Family or General Practitioner and this is the first person to whom they would go with any problem. Referral to a specialist is only through this family doctor who will usually choose the specialist for you.
The General Practitioners buy hospital care for you from local District General or Teaching Hospitals with whom they will have a contract. Typically the time from having a referral made to having an appointment with the specialist is in the order of 4-6 weeks or more. Waiting times for surgery following this appointment are in the order of a year.
A further complicating factor is that all the District Hospitals will have doctors on Residency programs so that your consultation, and indeed any surgery that you have, may be undertaken by a doctor in training. There are very few physicians who have a special interest in endometriosis, so your chance of seeing a true specialist in the disease is slight (although all gynaecologists will be aware of the disease).
Referral for a third specialist opinion is very rare. Thus it can be seen that although the cost of medical care can be kept to only 6.5% of the GDP, rationing of medical care both in terms of choice and waiting time becomes implicit within the system.
Following a consultation with a member of the specialist team it is likely that a diagnostic laparoscopy will be advised. If you have endometriosis this will hopefully be diagnosed by visual inspection of the pelvis, although it is very unlikely that a tissue diagnosis will be made by biopsy.
On many occasions, sadly the diagnosis may be missed either because of inexperience or a less than thorough inspection. Often patients in whom the real diagnosis is endometriosis will be labelled as having unexplained pelvic pain. This may lead to a round of further laparoscopies and further inaccurate diagnoses. Pelvic inflammatory disease is frequently misdiagnosed at this time leading to repeated courses of antibiotic therapy and concomitant yeast infections.
There are very few physicians who undertake operative laparoscopy. If you are lucky enough to be referred to one of these, you may have a limited amount of electrocoagulation to the visible endometriotic lesions. Otherwise you will usually be offered medical therapy which closely mirrors that in the USA. Although offering some symptom control while it is taken, it does not offer the prospect of a cure.
As in America, side effects of some of the treatments outweigh the symptoms of the disease. Many patients prefer to put up with the disease rather than the treatment and may turn to fringe medicine. Patients with intractable symptoms will eventually be offered major surgery, typically a hysterectomy with or without removal of the ovaries, but often with retention of the disease. Conservative excision is rarely performed.
In the United Kingdom there is an active Endometriosis Society and many self-help groups that offer helpful advice to women with this disease and teach them coping strategies. The Endometriosis Society, however, never recommends particular physicians or treatments. Its main purpose seems to be as a coordinating facility for local groups. Strong local groups can, however, work together to improve the facilities for the women in their area.
Family Practitioners are on the whole sympathetic to the women’s needs and will help in any way they can, but this is perforce largely medical therapy. Many of the physicians with an interest in the condition are primarily interested in aspects of fertility rather than pain and this tends to allow medical therapy to dominate the therapeutic picture.
Although the picture would initially seem bleak, there is some light at the end of the tunnel. All hospitals are now caught up with the concept of clinical governance and the principle of “Evidence-Based Medicine” and audit of one’s results. This means that treatments should not be offered unless they are shown to be effective by means of thorough audit. In matters of audit, Dr. Redwine, with his detailed database, leads the way and is a good example of “best practice.”
Increasingly there will be a requirement for us all to audit our practice in such detail and it is only in this way that we can truly assess the results of our therapeutic interventions.
There is now a growing group of physicians throughout the United Kingdom beginning to take a special interest in the surgical management of endometriosis especially using laparoscopic techniques. They are developing the specialist skills needed to undertake this sort of surgery although there remains much controversy about the appropriate surgery, whether it should be concentrated on ablating the disease either by burning it or by vaporization either using a laser or some other technology.
There are two centers in the United Kingdom which offer excisional therapy as practiced by Dr. Redwine; mine in the south and Professor Ray Garry’s in the north. Others offer ablative therapy, and specialist endocrine clinics offer medical therapy. There is even one unit that offers open surgery for the condition when gynaecologists and surgeons work together to tackle the disease.
Because of the nature of English practice, however, none of these centers offer a service devoted to the management of endometriosis where ever in the body it is found. There are only two where there is the expertise to offer the appropriate excisional therapy for infiltrating disease, a much more common situation than most people, even authorities on the condition, realise.
One of our governing and credentialling bodies however, The Royal College of Obstetricians and Gynaecologists, is recognising this gap in provision. It is through their generosity that I was awarded a travelling fellowship to come and study with Dr. Redwine so that I may bring some of his skills back with me to the United Kingdom to help patients there and to help train the next generation of physicians in how to deal with the condition effectively and safely. Looking ahead, I think that there is real chance that proper and effective endometriosis treatment centers will be set up where patients can come to get the expert and effective treatment they need.
These centers will be required to present transparent audits of their work to show that it is truly effective and offer thorough supervised training to residents in training programs so that the skills can be safely passed on.
The medical systems in the two countries are very different. There is good and bad in both of them. Neither system, however, offers consistent and rational treatment, although there is probably more choice available in the USA. As you move more closely to managed health care and we try to move further away from its obvious inadequacies, there will, somewhere in the middle, be a situation where people suffering with the chronic pain of endometriosis can get the considered and appropriate treatment they deserve. It is my hope that my recent stay with Dr. Redwine will help speed that process in the United Kingdom.
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