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Definition of endometriosis ?

gynecology endometriosis, laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, menopause, images

endometrium during the menstrual cycle

endometrium during the menstrual cycle

 

Endometrium is the tissue lining the inside of the uterus. The endometrium grows and is shedded every month during menstruation. Endometriosis is defined as endometrial stroma and glands outside the uterus . This definition needs to be revised since subtle endometriosis is not pathology
Adenomyose is endometrial stroma and glands in the myometrium of the uterus

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Summary of the pathophysiology of endometriosis

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Observations on endometriosis

Only the genetic-epigenetic theory can explain all observations on endometriosis

Pathophysiology of endometriosis: The genetic epigenetic theory

What starts endometriosis are genetic- epigenetic incidents

Growth of endometriosis lesions

After a cumulative number of genetic/epigenetic incidents the endometriosis lesions start to grow.  Development varies with the underlying genetic-epigenetic mutations. Growth varies in addition with the genetic:epigenetic incidents transmitted at birth such as immunologic defects  and with the monthly oxidative stress of bleeding in the lesions.

Consequences of the genetic-epigenetic theory

  • We understand the problems during pregnancy
  • Endometriosis lesions are clonal and thus small benign tumors
  • The different types of lesions have a different set of genetic/epigenetic incidents.
  • Similar looking lesions can have different genetic/epigenetic incidents such as progesterone resistance. They thus can react very differently to hormonal treatment
  • at the moment of diagnosis most lesions are no longer progressive
  • no recurrences after complete excision

 

The mistakes of the past the Sampson theory

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WRONG = 1 disease ENDOMETRIOSIS
According to the Sampson Theory endometriosis starts with retrograde menstruation and implantation of these cells. Endometriosis thus is progressive and recurrent .
 
The rAFS classification with mild (superficial), moderate and severe (cystic) endometriosis assumes progression
RIGHT= 3 diseases Typical, Cystic and Deep Endometriosis
The genetic-epigenetic theory,  considers retrograde menstruation a normal phenomenon but a cause of ocidative stress. Endometriosis thus is NOT progressive NOR recurrent and typical, cystic and deep endometriosis are 3 different diseases.
Symptoms vary with the type of lesions subtle : no infertility not pain typical infertility (?) pain (+ in 50%) Cystic infertility (++) severe pain (++ in 80%), deep infertility (?) pain (+++ in 95%).
 
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The diagnosis in 4 steps

1. Suspicion based on symptoms, clinical exam and ultrasound

endometriosis check-list

endometriosis check-list

Symptoms

Endometriosis should be suspected in all women with pain or infertility. Symptoms and localisation of pain can be suggestive but cannot make the diagnosis !!

Clinical exam can detect

Ultrasound

  • is the method of choice to diagnose  cystic ovarian endometriosis
  • can diagnose larger deep endometriosis lesions but false positives and false negatives require clinical intepretation
  • can diagnose adenomyosis
  • cannot exclude endometriosis

2 : The decision to perform a laparoscopy

  • The decision is based on the suspicion aided by Ultrasound or MRI
  • followed by additional exams and preparation for surgery,
  • informed consent .

3 : Diagnostic Laparoscopy and surgery

  •  If is an advantage that the gynecologist has the skills to do surgery if necessary
  • if not the patient should be referred. Better no surgery than incomplete surgery.
  • The gynecologist needs the expertise to recognise all forms of endometriosis

4 : Medical treatment

3 Different Specialists for endometriosis

The Fertility Specialist

Fertility specialists are generally IVF specialists with only a basic surgical training, sufficient for superficial endometriosis, ie for the most frequent pathology. Cystic ovarian endometriosis is erroneously considered easy surgery. Reality however is that insufficient experience often results in ovarian damage and loss of oocyte reserve. For deep endometriosis they generally perform bowel resections together with the surgeons.

The medical therapy specialist

Many gynaecologists are mainly involved in medical therapy. They try to avoid surgery and/or only perform only basic surgery, ie without bowel and ureter involvement. Deep endometriosis is a rare condition. Superficial endometriosis is a frequent condition that only requires basic surgical skills : thus many gynaecologist will be involved in superficial endometriosis either with (simple) surgery, medical therapy or IVF.

Prevalence of pain and type of lesions in endometriosis, gynecology endometriosis, laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, menopause, images

Prevalence of pain and type of lesions in endometriosis

The pelvic surgeon.

They do advanced laparoscopic surgery for deep endometriosis involving the bowel and the ureters. This is obviously a small group, since deep endometriosis is not that frequent and since only a small group can have sufficient experience.

What we need is
  • Adequate referral.
  • Centres of excellent surgery. Centres of excellence without excellent surgery often to do more harm than good.

 

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Surgical treatment of endometriosis

gynecology endometriosis, laparoscopic surgery, hysterectomy,pelvic pain, pelvic floor, prolapse, endometriosis therapy, menopause, images Only surgical excision can cure endometriosis

  • provided all endometriosis is recognised and removed
  • which requires a gynecologist with expertise and surgical skills
  • better no surgery than incomplete surgery. If the gynecologist has not the necessary skills the patient should be referred to a pelvic surgeon
  • But no surgery is better than bad surgery :the first surgery should be the last

Video-registration is the only way to judge quality of surgery

Wrong information on endometriosis

  • Endometriosis should not be considered progressive and recurrent
  • Medical treatment should not be given without a diagnosis
  • Surgery is avoided by those without the skills

Why ?

  • Surgery in less skilled hands, has a high complication rate and  Incomplete surgery has a high recurrence rate
  • Medical therapy of endometriosis is a ‘billion dollar business’ .
  • Infertility surgery used to be microsurgery in specialised centres. Today laparoscopic fertility surgery is minimal and infertility centres became IVF centres.
  • Less skilled surgeon fear the quality control  by video-registration  .
  • The low reimbursement of endometriosis surgery  favors bowel resections. Deep endometriosis surgery in Belgium is reimbursed a few hundred Euro in contrast with the 1000 Euro of a bowel resection.
  • Medical treatment is often given to erroneously prevent progression of subtle endometriosis

A delay in diagnosis of endometriosis

The mean delay in diagnosis is 7 years since

  •  a laparoscopy is avoided if the gynecologist does not have the skills to do surgery
  • medical treatment is given for many years without a diagnosis

The gynecologists-Pelvic Surgeons, are a small group. We need of centres of excellent surgery of endometriosis,

Centres of excellence in endometriosis unfortunately are supported fro the wrong reasons.

  • The concept of pelvic surgeon does not fit with the sub-specialities in gynaecology.
  • Inadequate referral of deep endometriosis, since avoidable bowel resections can be done in every hospital by the bowel surgeon
  • The Infertility lobby. Good surgery is a prevention of IVF  and  an IVF baby is more expensive than a surgery baby.
  • Oncologist are opposed to the concept of the pelvic surgeon since this would comprise oncologic surgery.

 

 

 

Summary, endometriosis varies from small and superficial implants tot to cystic ovarian endometriosis and deep endometriosis .

Surgery can be difficult and requires extensive training. Therefore medical therapy is given by non surgeons.

 If a diagnostic laparoscopy or the referral for advanced surgery is not done adequately a series of problems occur.

  • The diagnosis is made after a delay of several years, ,
  • and surgery is done incompletely with ovarian damage and adhesions.
  • This results in recurrences, often treated with medical therapy, iatrogenic infertility and preventable IVF treatments.
  • Endometriosis is not a cancer and the increased association between endometriosis and cancer is clinically irrelevant.

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