How is endometriosis diagnosed?
Endometriosis is diagnosed surgically by laparoscopy. During laparoscopy, a thin viewing tube (called a laparoscope) is passed through a small incision in the abdomen. A second incision may be made on the lower abdomen to provide an additional opening for surgical instruments. Using the laparoscope, your doctor can look directly at the outside of the uterus, ovaries, fallopian tubes, and nearby organs. The laparoscope can also be fitted with surgical devices for taking tissue samples or removing scar tissue.
What is an endometrioma?
An endometrioma is a mass of tissue (noncancerous cyst or tumor) that contains shreds of endometrial tissue. Endometriomas most frequently occur in the ovary, in a part of the peritoneum (sac around the internal organs) between the rectum and uterus, the wall (septum) between the rectum and vagina, and the outside of the uterus.
How is endometriosis treated?
Endometriosis can be treated at the time of diagnosis. Endometriosis is diagnosed using a surgical procedure called laparoscopy. Endometrial lesions (implants of endometrial tissue outside of the endometrium) can be cut away (excised) or burned away using a high-energy heat source, such as a laser (ablated). Treatment with laparoscopy is more difficult with advanced disease that involves large areas of the rectum or larger lesions.
How are endometriomas treated?
Several surgical treatments are available for endometriomas. They are:
Simple puncture: This procedure is completed by draining the fluid from the cyst. Endometriomas have been shown to recur in more than 50 percent of the patients treated with simple puncture. However, a more aggressive surgical approach, such as cutting away the mass, can cause extensive adhesions (scar tissue) that may prevent the ovary from releasing an egg. Therefore experience is required to prevent damage.
Ablation: Another approach is to drain the cyst and remove its base with laser or electrosurgery. However, heat can also damage the ovary.
Cutting away of the cyst wall: This is the procedure of choice to decrease recurrence of disease. This procedure can also damage the outer layer of the ovary that contains the eggs.
Draining, drug therapy, and surgery: Endometriomas can also be drained, treated with medication, and later removed by surgery.
Results from several different prospective studies have reported pregnancy rates of 50% over 3 years. There are no randomized clinical trials comparing these different treatment methods.
How is advanced endometriosis treated?
The most challenging surgery by laparoscopy or by laparotomy (traditional abdominal surgery, which requires a larger incision) is the management of advanced endometriosis within the pelvic cavity and the rectum and vagina. Several studies have reported pregnancy rates over 2 years of 50% to 60% of cases treated with surgery. According to several reports, endometriosis may recur in 20% of the cases.
Risks / Benefits
Does surgical treatment improve fertility?
Treating early stage endometriosis to improve fertility is controversial. Previous studies suggest that laparoscopic surgery is effective in increasing the incidence of pregnancy. A recent study by the Canadian Collaborative Group on Endometriosis demonstrates that using laparoscopy to remove diseased tissue in minimal and mild endometriosis enhances fecundity (fertility) in infertile women.
Patients in this study were recruited from a large number of Canadian health care centers. There were 348 patients who had no other cause of infertility and Stage I and II disease (early stages). Each patient in the study was randomly assigned to one of two groups: treatment by laparoscopy or no treatment by laparoscopy. The patients were then followed for 36 weeks and did not receive further treatment for fertility.
Cumulative probability of pregnancy with the treated group was 30% compared with 17% in the untreated group. The fertility rates for the treated group were 4.7% versus 2.4% for the untreated group.
Studies have not shown if excision of endometriosis is better than ablation with different energy sources. A significant number of patients with endometriosis and infertility have deep lesions (more than 10 millimeters, or 0.4 inches), especially if associated with pelvic pain. Coagulation (forcing blood vessels to clot) or laser vaporization is not recommended for patients with lesions deeper than 5 millimeters.
Does surgical treatment improve pain?
Most patients will have relief of pain with simple removal of the endometriosis. However, 20% of patients will not respond to surgery and will need further medical treatment or pain management specialists. Of those that respond, there may be a recurrence of pain over time. Hysterectomy has the least recurrence of symptoms but is the most invasive treatment.
Is laparoscopy more effective than laparotomy?
Laparoscopy and laparotomy are equally effective in relieving pain and improving fertility. Endometriosis recurs in about 20% to 30% of cases over 5 years in both procedures. Patients who undergo laparoscopy, however, experience a more rapid and less painful recovery. Deciding which surgical procedure to use should be based on the patient's preference and the physician's experience with the technique.
Recovery and Outlook
What can be done to reduce the likelihood that new adhesions will form?
Adhesions are fibrous bands connecting structures that normally are separate. Adhesions develop as a response of normal tissue to some type of injury or trauma (as in surgery). In most cases, patients who undergo surgery for endometriosis will form new adhesions at the site of the surgery. Adhesion formation may cause infertility by impairing the function of the ovaries and fallopian tubes. Adhesions also may cause pelvic pain and small bowel obstruction.
There are some newer preventive treatments that can be used during surgery to help prevent adhesions from forming. These include rinsing the pelvic cavity with special solutions and placing a piece of protective material (such as ADEPT®) into the pelvic area to serve as a barrier. The barrier keeps the surfaces from rubbing together after surgery, which can lead to adhesion formation. The barrier dissolves and is absorbed when it is no longer needed.
In some cases, a woman will have to undergo additional surgery to remove adhesions formed from previous surgery. Fortunately, the advancement of laparoscopic surgery and the development of these new preventive treatments can reduce the chances of adhesion formation.
What is the outlook for treatment of endometriosis?
While many women find success with the current treatments for endometriosis, medication and surgery do have side effects and don't work for everyone. Researchers are continuing to investigate new and improved treatment strategies. One area of study is focusing on the role of the immune system in the development of endometriosis, and enhanced hormonal agents are being studied as a possible treatment option.