What is new for Endometriosis
Endometrium is the tissue lining the inside of the uterus.
Endometriosis was defined in 1922 as “endometrium outside the uterus” later refined as “endometrium like. We recently redefined as abnormal cells after genetic-epigenetic changes, caused by oxidative stress and infection.
Adenomyosis is endometrial stroma and glands in the wall of the uterus
What is new with our recent understanding
- We understand that pregnancy problems are the consequence of hereditary ‘defects’ at birth
- each lesion is G-E different , thus clonal like benign tumors
- 4 types of G-E lesions: superficial, cystic ovarian, deep and adenomyosis
- although similar looking, lesions can be very different (e.g. progesterone resistance) with different reactions to hormonal treatment
- After initiation growth varies with the G-E changes, and the environment in the peritoneal cavity hormones, immunology but most important is is self limiting
- few or no recurrences after complete excision but new lesions can develop
- this changes diagnosis and therapy: read our 2021 and 2022 publications
- we have to reconsider medical therapy
Treatment comes after the diagnosis
Surgery
- to be performed AFTER diagnosis and informed consent
- Better no surgery than incomplete, excessive or bad surgery. The first surgery should be the last
- Surgical excision is the therapy of choice, if the surgeon has the skills to recognize endometriosis and the expertise to excise.
- read our review on pain
- and explaining why bowel resections are rarely indicated
- fertility surgery requires specific expertise and knowledge
- Video-registration is needed to judge quality of surgery
Medical treatment
- read more
Medical treatment decreases pain but not in all women. - Side effects are 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
Diagnosis: what are the problems?
endometriosis check-list
- The diagnosis of the 4 types of endo
- Superficial endometriosis (in 50 to 70%) can only be diagnosed by laparoscopy . Blood exams are not useful even not CA125.
- Cystic ovarian endometriosis > 1 cm (in 20%) is readily diagnosed by ultrasound.
- Deep endometriosis (in < 5%). clinical diagnosis can only for larger lesions. The accuracy of ultrasound is exaggerated and deep endo can rarely be excluded
- Less skilled surgeons avoid a laparoscopy since surgery could be difficult
- If pain only: 50% have endometriosis but many other causes exist - thus a clinical judgment to perform a laparoscopy, with surgery that can be difficult
- in infertility only
- wise to do a laproscopy to have a complete diagnosis
- a cystic ovarian endometriosis risk to decrease ovarian reserve
- If deep without pain: no treatment
- in adolescence early laparoscopy risks repeat surgeries (if not well performed with adhesions)
- therefore a delay of 8 years in diagnosis
Many mistakes
- many still believe in the implantation theory and consider endometriosis erroneous as 1 progressive and recurrent disease.
- instead of 4 G-E different diseases with heterogeneous lesions .
- Hysterectomy and ovariectomy without complete removal of the endometriosis is a mistake when the surgeon has not the skills
- Inadequate diagnosis or referral
- Medical treatment without a diagnosis
- IVF without surgery for deep endometriosis.
- Infertility surgery is being lost when fertility centers focus on IVF and difficult surgery is performed by oncologist or abdominal surgery
Why is this ?
- Surgeons with insufficient skills
- surgery is avoided or is incomplete with more complications
- quality control by video-registration is not done.
- The low reimbursement of excision endometriosis surgery favors bowel resections.
- Medical therapy of endometriosis is a ‘billion-dollar business’ and excessively promoted
- The gynecologists-Pelvic Surgeons are a small group resulting in many avoidable bowel resections since every bowel surgeon can perform a bowel resection
- Multi-disciplinarity versus the ‘Pelvic Surgeon. <strong>Multi-disciplinarity is fashion since it brings knowledge and skills of different disciplines together. </strong> <strong>False multi-disciplinarity </strong>occurs when the gynaecologist hides his inadequate training, and asks another surgeon to help (as a technician). It remembers me the pioneering years around 1990 when together with abdominal surgery (Prof Penninckx) I performed the first series of laparoscopic cholecystectomies bringing together the technique of endoscopy (PK) and the knowledge of open cholecystectomy. This was useful to develop the technique but this is not multi-disciplinarity. - see our letter to the editor
You must be logged in to post a comment.