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    The case for surgery for endometriosis


    Benefits and complications of therapy

    With regard to fertility, excisional surgery improves rates of spontaneous pregnancy in the 9 to 12 months after surgery as compared to ablative surgery.19 Moreover, laparoscopic surgery has been demonstrated to improve rates of live birth and pregnancy compared with diagnostic laparoscopy alone. In contrast, there is no evidence that medical treatment improves clinical pregnancy rates.19 Although management of endometriomas is controversial, medical therapy may lead to temporary reduction in size but not resolution of cysts. Therefore, surgery is the recommended primary approach for symptomatic and/or large cysts and there are no indications for prescribing medical treatment before cystectomy.20

    Gonadotropin-releasing hormone analogs (GnRH-a) and minimally invasive surgery are associated with increased pregnancy rates in women with endometriosis, but GnRH-a, danazol, and depot progestogens are associated with a higher incidence of adverse events.21 Lastly, data have been published on damage to ovarian tissue by excision of endometriomas. However, surgery remains the gold standard, provided that it is performed with proper techniques by highly trained surgeons.22 In fact, previous medical treatment of endometriosis or large cyst size may be a significant factor associated with higher rates of disease recurrence.23

    Patients with endometriomas may have decreased ovarian reserve compared with age-matched subjects with other benign ovarian cysts, suggesting that an endometrioma may be harmful to ovarian reserve if left unchecked. With early surgical intervention, that could potentially be avoided, preventing occurrence of endometriomata in the first place.24

    Laparoscopic resection can relieve endometriosis-associated symptoms and enhance psychological well-being.25 Complete excision, including vaginal resection, can offer significant improvement in sexual function, quality of life, and pain in symptomatic patients,26 and a well-trained interdisciplinary team can perform laparoscopic treatment of deeply fibrotic endometriosis with a low incidence of major complications.27

    In contrast, medical therapy is neither diagnostic nor a long-term treatment option. Counseling patients to undergo a lengthy protocol of suppression serves only to further delay the diagnosis and definitive treatment. GnRH-a administration may be followed by a temporary improvement of pain in patients with incomplete surgical treatment, but it has no role in postsurgical pain when a surgeon is able to completely excise disease.28 Hence, surgery is the diagnostic and gold standard treatment, although indeed results are often operator-dependent.


    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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