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    The case for surgery for endometriosis



    Dr Sinervo is Medical Director of the Center for Endometriosis Care, Atlanta, Georgia.

    He has no conflict of interest to disclose with respect to the content of this article.

    Endometriosis is a challenging entity affecting an estimated 176 million women worldwide.1 Associated symptoms include significant pain, infertility, dysuria, dysmenorrhea, dyspareunia, dyschezia, and other physical and quality-of-life issues. Comprehensive clinical evaluation is strongly recommended for early and accurate detection in order to afford timely management.

    Although signs of endometriosis can occur during adolescence, diagnosis is often delayed for years, with knowledge deficits contributing to consequential diagnostic delays, suboptimal treatments, and poor outcomes. Treatment mainstays include analgesic, surgical, and medical approaches, alone or in combination. Several guidelines have been developed by various consortia, but controversy and uncertainty over best practice for treatment remain.2

    Unfortunately, therapy is often ineffective and incomplete, with high rates of recurrence when the disease is left intact. Hence, it is my opinion that laparoscopic excision (LAPEX) is and should remain the standard of care. The quality of the surgery, not necessarily the procedure per se, holds the key to conclusively treating endometriosis.

    Diagnostic approaches

    An evaluation of symptoms combined with physical findings is insufficient to confirm or exclude the presence of disease, and a lack of noninvasive options further limits the diagnostic process. Surgical evaluation with histologic confirmation is the definitive means of obtaining true diagnosis.

    Hormonal suppression, which may temporarily improve symptoms in some patients, should not be used to “diagnose” endometriosis and has never been demonstrated as effective in preventing recurrence or improving fertility.3 Indeed, not all pelvic pain has as its source endometriosis (or endometriosis alone), so we must take a methodical approach to ruling out other obvious pathologies. Non-classic signs (ie, soft tissue, lung or diaphragmatic disease, or symptomatology limited to bowel or bladder), however, should not be undervalued. To that end, complete resection of all visible foci offers the best means of biopsy diagnosis and symptom control.



    Ken R Sinervo, MD, MSc, FRCSC, ACGE
    Dr Sinervo is Medical Director of the Center for Endometriosis Care, Atlanta, Georgia.

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    • Dr. CHOWE
      Thank you for an important article that reiterates the fact that the more endometriosis is removed surgically the better the results are for reduced recurrence, pain reduction and improved fertility. I would like to add this idea. In general it seems that endometriosis is not however "cured" with surgery. Post suppressive medical therapy in a premenopausal women who is not actively attempting to conceive is critical (especially when uterus and ovaries are left in place). It will result in a longer lasting effect. Otherwise, regardless of the extent of tissue (peritoneal implant) removal there will be recurrence in 2-5 years from either retrograde flow or peritoneal metaplasia. Without treatment you set a younger woman up to have multiple surgeries over the years. After multiple surgeries they can develop adhesive disease and neuropathic pain. This must be avoided. In my mind menopause is the only "cure" and everything else we do is only temporizing, regardless of how complete it is. Thank you again for your time and ideas! They are valuable.


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