Endometriosis refers to the growth of endometrial tissue in sites outside of the lining of the uterus, most usually in the pelvic cavity around the outside for the uterus, ovaries and colon, but occasionally in places further afield such as the appendix, upper abdomen, lungs and even abdominal wall and nasal cavity. These cells are normal endometrial cells that have found their way to these sites either by the retrograde flow of menstrual fluid through the fallopian tubes, or via the bloodstream or accidental transplantation at surgery such as Caesarean Section. Some cases may arise de novo from the cells lining the peritoneal cavity.
We now realise, with the widespread application of safe laparoscopic investigation of period pain (dysmenorrhoea) that endometriosis is more common than once thought, possible affecting over 20 per cent of menstruating women (many of these may have only minimal symptoms).
Endometriosis can cause worsening and debilitating period pain, pain with intercourse, pain with emptying the bowel (dyschezia) or bladder, and infertility due to scarring around the tubes and ovaries, and the release of inflammatory tissue factors that can damage eggs, sperm, and embryos.
But not all period pain is due to endometriosis, indeed much is due cramping of the uterine muscle ("simple dysmenorrhoea") and so it is wise to try non surgical approaches such as reducing menstrual flow and the production of the cramp inducing molecule prostaglandin by using the usual treatments for heavy menstrual bleeding (HMB).
When these methods fail, it may be necessary to consider further investigation withlaparoscopy (key hole surgery). Often an ultrasound of the pelvis will have been undertaken to exclude endometriotic cysts on the ovaries ("endometriomas") which can make surgery more difficult. As a general rule, however, endometriosis is not visible on ultrasound.
When laparoscopy is being considered you will receive a lot of information about the risks and benefits of surgery, the expected recovery, and what other treatments might be beneficial, such as insertion of a Mirena IUD.
If you are unfortunate enough to have severe bowel pain during your period, you may need to have a "bowel preparation" the day prior to surgery in order to clean the bowel and reduce the risk of peritoneal soiling should the bowel be opened; in such cases it may be necessary to involve a colorectal surgeon in the surgery, and you may need a consultation with this person pre-operatively. Fortunately this is very uncommon.
In almost all cases of laparoscopic resection of endometriosis that I perform, barring those that need bowel resection, you will be able to leave the hospital on the day of surgery and recover in the comfort of your own home. During your surgery, I take steps to reduce your post operative pain in consultation with your specialist anaesthetist to ensure you have minimal discomfort at wound sites, and ongoing pain relief. You may have a very fine drain inserted in your abdomen which will be removed before you depart the hospital. You will have TED (anti embolism stockings) fitted pre-operatively to reduce the risk of DVT (clots in the leg).
Below is a gallery of photos showing the steps in the laparoscopic procedure. (The patient involved very graciously consented to the use of these de-identified pictures in order to help other women. As is most often the case, she was able to be discharged home on the day of surgery, and was recovering very well when reviewed in my office 3 days later).
Whilst you are recovering at home you will have access to me 24 hours per day by telephone should you have any concerns. You should keep your TED stockings on unless you are able to move around freely and normally. Take your analgesia regularly, especially in the first few days. I usually advise patients to take a regular anti-constipation treatment, such as Movicol in the first few days, until your bowel has opened normally.
Once you have recovered at home I will see you about a week after the surgery to check your surgical sites, discuss the findings, and talk about what other post-operative medical treatment might be necessary. If all of the visible endometriosis has been removed and a Mirena IUD inserted, it might be simply a case of "wait and see"; some patients might need to consider taking a low dose oral contraceptive continuously; Depo-MPA injections every 12 weeks can be very successful in suppressing the growth of tissue that cannot be easily accessed surgically; and finally some women may benefit from a 6 month course of an injectable GnRH agonist, which induces a temporary menopause, profoundly reduces the circulating levels of oestrogen (the hormone responsible for stimulating endometriosis growth), or the use of an oral progestin, such as dienogest, norethisterone, or oral medroxyprogesterone acetate.
In the majority of cases, women will achieve lasting relief of their symptoms, with preservation of their fertility, particularly if they have reported their symptoms in a timely fashion. Endometriosis, for the vast majority, is not always the dreaded chronic pain problem ending inevitably in total removal of the uterus tubes and ovaries that it was for our mothers and grandmothers in the era before advanced surgical laparoscopy.
Of course, however, there are still some women who will need pelvic clearance surgery (including removal of the ovaries which feed hormones to microscopic residual disease) to effect a complete cure. This may require subsequent low dose hormone therapy for ongoing sexual and bone health. Learn more about menopause in these circumstances here.
An opportunity exists for patients with endometriosis related pain to enrol in clinical research. I am a sub-investigator for the world-wide Spirit2 trial, a phase III trial for a novel oral medication for endometriosis. The trial is being administered by Austrials under ethics committee approval. Find out more information here.
You should remember that any surgical or invasive procedure carries risks. Before proceeding with any surgery, you should completely familiarise yourself with all the options and risks, and if you are uncertain, seek a second opinion from an appropriately qualified health practitioner.
Dr Melissa Buttini m.b.b.s franzcog