Definitions and pathophysiology
Endometrium is the tissue lining the inside of the uterus.
Endometriosis. The old definition: endometrium like tissue outside the uterus. New; a genetic or epigenetic abnormal cell .
Adenomyosis is endometrial stroma and glands in the wall of the uterus
Endometriosis is initiated by genetic-epigenetic changes in the cells , caused by oxidative stress and infection.
Growth of endometriosis varies with the G-E changes and with the environment as immunology and peritoneal cavity
What is new since the genetic-epigenetic theory
- We understand the pregnancy problems
- lesions are clonal and thus small benign tumors
- although similar looking, lesions can be very different (e.g. progesterone resistance) with different reactions to hormonal treatment
- Progression is mostly temporary
- no recurrences after complete excision but new lesions
Treatment
Surgery: read more
Only surgical excision can cure endometriosis, if the surgeon has the skills to recognize all endometriosis and the expertise to excise.
Better no surgery than incomplete, excessive or bad surgery. The first surgery should be the last
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
Symtoms and diagnosis
endometriosis check-list
- Suspicion because of symptoms, clinical exam or ultrasound: 50% of women with pain or infertility have endometriosis.
- The decision to perform a laparoscopy, is based on the suspicion and imaging and other exams.
- The Diagnostic Laparoscopy requires a surgeon who recognizes all forms of endometriosis. Surgery is performed if the surgeon has the skills, otherwise the patient is referred, as explained in the informed consent .
- Medical treatment can be useful following surgery as a prevention or recurrences.
Common mistakes
- That endometriosis is always progressive or recurrent is wrong.
- Not 1 disease: Lesions are heterogeneous and different from the endometrium.
- Hysterectomy and ovariectomy without complete removal of the endometriosis is a mistake
Inadequate diagnosis or referral
- Diagnosis of superficial endometriosis requires a laparoscopy
- Medical treatment without a diagnosis is wrong
- IVF without a laparoscopy is dubious
- Surgery is avoided by those without the skills
- a mean delay in diagnosis of 7-8 years
Why ?
- Surgery with insufficient skills has more complications, incomplete surgery, and a high recurrence rate
- Less skilled surgeons fear quality control by video-registration.
- The low reimbursement of excision endometriosis surgery favors bowel resections.
- Infertility surgery used to be performed by microsurgery. Today fertility centers focus on IVF
- Medical therapy of endometriosis is a ‘billion-dollar business’ .
- The gynecologists-Pelvic Surgeons are a small group and they do not fit in the sub-specialties: thus
- Too many bowel resections since every bowel surgeon can perform a bowel resection
- The Infertility lobby. Good surgery is prevention of IVF.
- Oncologists do not like pelvic surgeons for endometriosis, which is more demanding than oncology.
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