Definitions and pathophysiology
Endometrium is the tissue lining the inside of the uterus.
Endometriosis is defined as endometrial stroma and glands outside the uterus . . This definition needs to be revised.
Adenomyose is endometrial stroma and glands in the myometrium of the uterus
Growth of endometriosis lesions. After G-E incidents endometriosis starts to grow. Growth varies with the G-E mutations of the lesions and with the environment as immunology and peritoneal cavity
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
Only surgical excision can cure endometriosis. Important is that all endometriosis is recognized. This requires expertise and skills.
Better no surgery than incomplete or bad surgery :the first surgery should be the last
Video-registration is the only way to judge quality of surgery
Medical treatment does not cure endometriosis. It can decreases pain but not women in all and only temporarily.
However, medical treatment can cause weight gain by progestagens or osteoporosis secondary to GNRH.
Some lesions continue to grow during medical treatment (see heterogeneity of lesions)
Deep endometriosis can cause bowel occlusion or bowel or bladder perforation during pregnancy
Symtoms and diagnosis
- Suspicion based on symptoms, clinical exam and ultrasound. Endometriosis should be suspected in all women with pain or infertility.
- The decision to perform a laparoscopy, is taken based on the suspicion aided by imaging and eventually additional exams.
- A Diagnostic Laparoscopy requires the expertise to recognize all forms of endometriosis. if the surgeon has the skills surgery can be performed; If not the patient should be referred. This should be clear in the informed consent .
- Medical treatment following a laparoscopy and surgery Medical treatment without a diagnosis for a long time is wrong.
Wrong concepts and Common mistakes
Wrong concepts start with the Sampson implantation theory.
- Endometriosis is erroneously considered progressive and recurrent. Unavoidable recurrences are an alibi for less rigorous surgery.
- If endometriosis is considered endometrium, all lesions are biologically identical. Heterogeneity of lesions became only recently recognized
- Hysterectomy and ovariectomy without complete removal of the endometriosis is a mistake
Diagnosis and referral are inadequate
- Superficial endometriosis can only be diagnosed by laparoscopy
- Medical treatment without a diagnosis
- IVF without a laparoscopy
- Surgery is avoided by those without the skills
- resulting in a mean delay in diagnosis of 7-8 years
- Surgery in less skilled hands, has a high complication rate and Incomplete surgery has a high recurrence rate
- 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.
- Infertility surgery used to be microsurgery in specialised centres. Today laparoscopic fertility surgery is minimal and infertility centres became IVF centres
- . We need of centres of excellent surgery of endometriosis,
- Medical therapy of endometriosis is a ‘billion dollar business’ .
- The gynecologists-Pelvic Surgeons are a small group which do 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.