The Surgical Treatment of Endometriosis
By Dr Donald Angstetra
WHEN IS SURGERY INDICATED FOR THE TREATMENT OF ENDOMETRIOSIS?
Endometriosis is a common condition affecting 1 in 10 women, and up to 50% of women who experience pelvic pain and infertility.
There is no known cure for endometriosis, but it can be managed with the right care and treatment plan.
This article describes the role of surgery and its limitations in endometriosis-related care
SURGERY FOR DIAGNOSIS AND ENDOMETRIOSIS-RELATED PAIN
The only way to diagnose endometriosis is through laparoscopy - a minimally invasive surgery that allows the doctor to treat the condition at the same time. Surgery continues to play an important role in managing pelvic pain but it must be performed by a skilled specialist who tailors the care to the patient and their symptoms. For further information on the difference between a general gynaecologist and an excision specialist with advanced surgical training, see this earlier piece from the QENDO blog, available here. Surgery for endometriosis is aimed at reducing pain and improving a patient's quality of life and fertility. However, Multiple surgeries to clear the disease may not offer those benefits. Medical management using hormonal suppression can be limited by inadequate response or intolerable side effects. Research has shown that surgery for mild and moderate endometriosis can reduce pain. The surgical approach to deep infiltrating endometriosis is complex and often requires the involvement of several types of doctors.
REPEAT SURGICAL INTERVENTION
Women with endometriosis may need multiple operations. Over 60% of women with endometriosis will need further surgery. Half of all women with endometriosis had undergone repeat surgery within five and a half years, and one in five women had hysterectomy or removal of one or both ovaries. Repeat surgical intervention may be necessary, however, the pros and cons of surgical intervention should be discussed. There is little known about the impact of repeat surgical risks in women whose pain recurs or persists.
SURGERY FOR ENDOMETROSIS-RELATED FERTILITY
The role of surgery in enhancing fertility in women with endometriosis, or to improve the outcomes of fertility treatment such as IVF, is debatable. There’s evidence that laparoscopic treatment for mild or moderate endometriosis increases live birth and pregnancy rate. But repeated surgeries may result in a reduction in pregnancy rates.
SURGERY FOR OVARIAN ENDOMETRIOMA
Surgical removal of endometrioma has been shown to be effective in managing pain and recurrence when compared with drainage and ablation alone. There is some controversy regarding the surgical management of endometriomas in women undergoing treatment for infertility, as it can reduce ovarian reserves for six months following treatment
PATIENT CHOICE Versus SURGEON CHOICE
In female-centred care, patient choice is an important part of treating endometriosis. But sometimes getting to choose between medical and surgical treatment may not be possible. This could be due to access to qualified surgeons, wait lists and differences between the public and private health system. While for medical management, difficulties include costs, lack of approval by regulatory organisations or cultural barriers.
THE ROLE OF POSTOPERATIVE MEDICAL THERAPY
Medical and surgical approaches are complementary to each other and should be considered in all patients with endometriosis-related symptoms. The aim of medical treatment is to prevent the recurrence of disease and to control the symptoms. Endometriosis requires long term medical suppression as symptoms and disease may recur if treatment is stopped. While oral contraceptives and the hormone progesterone have been shown to reduce the return of symptoms, they can’t help suppressing symptoms for women trying to fall pregnant, and individual women may experience side effects to a different extent.
The management of endometriosis requires a balanced approach based on the symptoms, expectation and fertility.
Surgery has a role but is best used in combination with medical management to best service a patient’s needs.
Women with endometriosis need to be aware the long-term risks of multiple surgeries.
He/she should discuss the risks and benefits of all treatment options including pain and hormonal medical treatments before considering repeated surgery.
Radical surgery such as removal of ovaries or hysterectomy should only be the last option.
About The Author
Dr Angstetra is a consultant O&G staff specialist at Gold Coast University and Robina Hospitals and also a conjoint senior lecturer with Griffith University. He has a keen interest in developing and applying minimally invasive surgery for all benign diseases of the female reproductive tract and his passion for advanced gynaecological laparoscopic surgery see him fit the role as the training-site director of Australian Gynaecological Endoscopy Society (AGES) and as O&G training supervisor for RANZCOG training program. He has published multiple articles in peer reviewed journals and presented multiple papers at local, national and international meetings.Dr Angstetra offers a range of gynaecological services including office gynaecology, endometriosis, laparoscopic adnexa surgery, laparoscopic hysterectomy, laparoscopic pelvic floor repair, prolapse, infertility, contraception, fibroid, abnormal Pap smear and chronic pelvic pain.
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