Why don't more physicians advise conservative excisional surgical therapy?

Conservative excisional surgical therapy for endometriosis is not covered well in many residency programs. One reason is that endometriosis is not seen as commonly in medical school hospitals as it is in private practice, so there is less clinical material available. The importance of private practitioners in the study of endometriosis has been well accepted since the time of Sampson in the 1920s, himself a private practitioner.

Another reason conservative surgery is not taught is that endometriosis is considered to be a progressively spreading disease, a consequence of the theory of tubal regurgitation and implantation of viable endometrium. If endometriosis does become more widely distributed in the pelvis as women get older, then, indeed, surgical removal of the disease would seem futile because "it will just come back." With this mind set, it is natural for physicians and patients to avoid surgery and resort to medical therapy.

Does endometriosis "come back" after surgical treatment?

The facts about conservative surgical intervention dispute the theory that endometriosis "comes back" in all patients. One of the highest reliable reported recurrence rates after conservative surgery is only 27%. 1-6 Most studies report half that rate. If the disease is thought to return over time, that rate should be closer to 100%.

Does endometriosis spread with age?

Although it seems straightforward enough, until recently 7 no one had conducted an actual study to find out whether endometriosis does or does not spread throughout the pelvis with advancing age (it doesn't). It was just assumed that it did. This is another example of therapy being guided by opinions rather than facts. Experimental endometriosis in animals has also been shown not to spread geographically, 8 and a 1991 pelvic mapping study from Belgium found that the peritoneal surface area involved by endometriosis does not increase as older age groups of patients are examined. 9 The notion that endometriosis spreads throughout the pelvis like dandelions in a field is wrong and has contributed to irrational medical care for women with endometriosis.

How should the effectiveness of a specific treatment be measured?

When conservative surgery has been attempted, it has frequently required opening the abdomen and then burning, scraping, or cutting out the disease. Although there has been a glimmer of excellent pain relief reported in the literature following conservative surgery, success has still been measured mainly by pregnancy rates.

Conservative surgery has been found to improve pregnancy rates, particularly for patients with a lot of scar tissue in the pelvis. Breaking up the scar tissue allows the pelvic organs to regain some of the natural mobility required for normal function.

Conservative surgery through the laparoscope has been accomplished by electrocautery, laser vaporization, sharp dissection, and electro-excision. The most meaningful follow-up to indicate successful treatment of endometriosis is the rate of discovery of biopsy-confirmed endometriosis at re-operation.

Infertility may not be caused by endometriosis at all, particularly in lower stages without a lot of adhesions, so studying fertility parameters after treatment of endometriosis is misleading. Pain is a more specific symptom of endometriosis than is infertility and if a symptom must be measured in order to gauge the effectiveness of a therapy, it should be pain relief, not infertility.

References

1. Schenken, Malinak. Am J Obstet Gynecol 131:416,1978
2. Punnonen, Klemi, Mikkanen. Gynecol Obstet Invest 11:307,1980
3. Puolakka, Kauppila, Ronnberg. Acta Obst Gyn Scand 59:429,1980
4. Green. In: Endometriosis, New York, Harper & Row p 293,1966
5. Meigs. Obstet Gynecol 2:46,1953
6. Wheeler, Malinak. Contrib Gynecol Obstet. Bruhat, Canis, eds. Basel, Karger, p 18, 1987
7. Redwine. Fertil Steril 1987;47:173-5.
8. Dizerega et al., Fertil Steril 1980;46:147-54.
9. Koninckx PR, Meuleman C, Demeyere S, Lesaffre E, Cornillie FJ. Fertil Steril 55:759, 1991