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 tumours
- 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, and immunology, but most important, it 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 the 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?
- 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 be 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 the 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 laparoscopy to have a complete diagnosis
- cystic ovarian endometriosis risk decreasing 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 have the skills
- Inadequate diagnosis or referral
- Medical treatment without a diagnosis
- IVF without surgery for deep endometriosis.
- Infertility surgery is being lost when fertility centres focus on IVF, and difficult surgery is performed by an oncologist or abdominal surgery
Why is this?
- For 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 favours 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 of 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
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