Surgery

In recent years, much new knowledge has been gained pertaining to certain pathologies, particularly those regarding fertility. Many innovations have taken place in surgical techniques, making surgery less risky and invasive. Endoscopy, otherwise known as ‘key-hole-surgery’ is when an optic fiber gets introduced into the cavity and allows visualization of the relative organ enabling it then to be operated upon.
Part of this technique is the laparoscopy, and the hysteroscopy.

The hysterectomy, one of the best-known gynecological operations, has become more sophisticated: there is the traditional abdominal approach, the vaginal approach, as well as the laparoscopic one.
The latter allows for the removal of the uterus with or without ovaries in a less invasive and traumatic way. Part of the key-hole surgery is the hysteroscopy whereby an optic fiber gets introduced into the uterine cavity allowing at the same time to operate in it.

Laparoscopy has made possible operations which allow the patient to go home the same day. Part of this is diagnostic laparoscopy allows the visualization of the internal organs as well as possible pathologies:

Uterine Fibroids

Fibroids develop most in women between the ages of 35 and 50 years old under the estrogen stimulus, and tend to shrink during menopause. If fibroids become bigger they can cause abdominal heaviness and pain. If internally situated, they can set up a bleeding pattern with extreme cases of continuous, heavy bleeding and crampiness. Depending on their size and position they can be removed by laproscopy or hysteroscopy. In woman around 50 years old, this can be an indication for removal of the uterus (hysterectomy).

Polyps

These are benign tumors due to abundant growth of the lining, the endometrium in the uterine cavity. Polyps can be found situated internally or in the cervical canal and protruding onto the cervix. They too cause abnormal bleeding patterns and rarely pain. Removal is done by hysteroscopy or/and D & C.

Endometriosis

The Enigma of Endometriosis

---

What is Endometriosis?

• A painful chronic illness with the presence of endometrial tissue or what is more commonly called ‘the lining of the womb’ outside its usual site hence in the pelvis or other organs.
• Adenomyosis is a similar phenomenon of endometrial tissue within the muscle layer of the womb.
  Sexual hormones like estrogen stimulate the growth of endometrial tissue and determine its bleeding. This cyclical process can result in scars and adhesions damaging the tissues involved.

Different theories on how endometriosis develops:

• Retrograde menstrual flow theory: Some of the lining of the womb may find its way into the pelvis through the Fallopian tubes. The retrograde flow theory could explain why endometriosis is more often found in childless women who, for obvious reasons, have more periods during their lifetime.
• Metaplasia Theory: Tissue of embryonic origin evolves into endometrial tissue.
• Combination Theory: Combination of both theories.

Incidence of Endometriosis:

• Because it is often only recorded as part of another investigation, such as infertility or chronic abdominal pain, the true prevalence of endometriosis is unknown.
• Data from US National Hospital Discharge Survey: 1988-1990 endometriosis was found in 11.2% of all women undergoing abdominal surgery for gynecological and non-gynecological reasons. Most estimates speak of 2-3% in women of reproductive age and 50% in all women who present for infertility!

High Risk Factors for Endometriosis:

• Ethnicity (higher incidence in Japanese women)
• Heredity
• Hormonal (estrogen status)
• Age, with peak at 40 years
• Increased period flow and frequent periods
• Body weight

Factors that can decrease incidence of Endometriosis:

• Current and recent contraceptive use (lowers estrogen)
• Earlier natural menopause

Classification of Severity of Endometriosis:

The severity of endometriosis can be classified according to the site of the endometriosis and the size of the area of the endometriosis. (American Society for Reproductive Medicine)
The most common sites are the genital tract, bowel and bladder.

Diagnosis of Endometriosis:

Symptoms	Painful periods (dysmenorrhea) (60-80%) Painful intercourse (dyspareunia) (25-40%) Infertility (40-50%) Premenstrual spotting Menstrual irregularities (10-20%) Pelvic Pain (30-50%) Chronic pelvic pain with diarrhoea, constipation, changes in bowel habit during periods, rectal bleeding
On Examination	Sometimes there will be painful lumps like cysts on the ovaries or nodules in the ligaments; fixed uterus (retroversion) and induration in the rectum
Ultrasound and laparoscopy	Only investigations such as ultrasound or laparoscopy will allow us to visualize endometriosis and treat it appropriately Ultrasound scan is useful as a first and non-invasive approach but is not as reliable as the direct view Ultrasound scan will mainly enable the visualization of endometriosis if present in the form of cysts Laparoscopy is the most important investigation because it allows direct visualization of endometriosis on the ovaries, tubes and bowel and this can be treated at the same time with either electrocoagulation, LASER or ABC Areas where the endometriosis is adhered can be lasered and this can sometimes restore the tubes to their function

Endometriosis and Infertility:

Endometriosis has several effects on a woman’s reproductive system:

Mechanical	It tends to cause scars on the organs where it is present, for example this could cause a Fallopian tube to be distorted, immobilized, blocked and/or attached to the uterus and ovaries. If a Fallopian tube is affected then it cannot transport the egg to the point of fertilisation.
Biochemical	If the ovaries are affected they may not be able to produce eggs and endometriosis is often associated with ovulatory disorders Anovulation i.e. lack of ovulation, abnormal follicular genesis i.e. disturbed maturation of the oocyte, premature follicular rupture, luteal phase defect. Further it can affect the implantation of the embryo or cause miscarriage.

Treatment for Endometriosis:

The aim is to relieve the symptoms, restore fertility if desired, remove endometrial implants and delay recurrence of the disease.

Surgical treatment

In times past radical surgery involving the removal of the uterus and ovaries was the only possible treatment. Now this option is only of use to women whose family is complete and where conservative surgery has failed. Definitive surgery offers prompt, complete and long-term relief of pain compared with medical treatment. Now: Laparoscopy is the gold standard for both investigation and treatment of endometriosis because it allows exact assessment and evaluation and very often partial or total treatment by removing the endometrial tissue and thus mobilizing the affected organs. In laparoscopic surgery diagnosis and therapy can be combined with minimal and gentle manipulation of tissues to avoid trauma. If endometriosis is found it can be removed by electrocauterization, LASER or ABC.

Medical Treatment

Hormone therapy has been the main medical treatment for endometriosis for half a century. In the 1940s and 1950s diethylstilbestrol and methyltestosterone were used but later abandoned because of side effects. In the 1960s progesterone alone or combined E2/progesterone preparations were used. In the 1970s Danazol became quite a strong weapon but still with side effects. Now: Dienogest (oral progestin) GnRH analogue More recently RU 486 (antiprogesterone) has shown efficiency in reducing pain due to endometriosis but research is not yet completed Non steroidal anti-inflammatories drugs are useful in the treatment of endometriosis induced pain (Ibuprofen)

Recurrent endometriosis:

Even with medical and surgical treatment, endometriosis is a progressive disease that tends to recur after treatment. The reasons for this are still unclear, but it may be due to:

• Evolution of lesions
• Persistence due to lack of recognition of visible, but subtle lesions
• Lack of identification of hidden sites
• Incomplete excision due to technical problems

In most studies the recurrence rate varies between 10% and 15%.

Adenomyosis:

• Invasion of the endometrial glands and/or stroma within the myometrium i.e. the uterine wall made out of muscle tissue means the extension of endometriosis into the muscular tissue of the uterus.
• Occurs mostly in women of 40-70 years of age.
• It can be found in distinct areas of the uterine wall or diffusely.
• In both cases it is believed to derive from direct invasion of endometrial tissue into the depth of the uterus.
• The classical symptoms are secondary dysmenorrhoea and menorrhagia which become more severe as the disease progresses.
• Dyspareunia can be a further symptom.
• Myometrial biopsy remains the gold standard.
• Unfortunately this is a blind procedure so that cases can be overlooked.
• MRI, US

Treatment for Adenomyosis:

• Levonorgestrel-releasing IUD
• GnRH agonists
• Hysterectomy is the best treatment in women who have finished their family planning

Even today the origin and further development of endometriosis is not perfectly understood but there are several therapeutic tools which enable us at least to confine the disease and very often to restore damaged tissues as well as fertility and to stop pain and suffering

---

Watch videos
Check out “Endometriosis” from Endometriosis.org on Vimeo.
See article
Il fibroma non ostacola la gravidanza (uscito su Dolce Attesa n.20, gennaio 2005)