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Intestinal Endometriosis
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Endometriosis Treatment Summary

The following is an overall summary of the treatment best suited for a woman with endometriosis, taking into consideration all of the various factors involved. Obviously, with a disease as variable and unpredictable as Endometriosis, there will always be an exception. What I have tried to state in this section are general principles to give you basic guidelines to help you decide which therapy is best for you.

It is also important to keep in mind that Endometriosis is still fundamentally a surgical disease even though hormonal therapies help to control it.

The first question to be answered is whether or not the woman wants to become pregnant now, whether she would like to become pregnant at some time in the future, or whether she is not interested in ever becoming pregnant.

1. Evaluate male fertility with a semen analysis and postcoital tests.
2. Evaluate menstrual cycle to determine whether ovulation is occurring normally.
3. Carry out a laparoscopy.

If the endometriosis is minimal or mild (based on the ASRM* classification), there is no significant ovulatory abnormality, there is no male factor, the duration of the infertility is less than a year or two, and the woman is under 30 years of age, waiting 3-6 months to see if a spontaneous conception will occur is an option. However, more aggressive therapy using Super-Ovulation combined with IUI will significantly increase the woman's chances of becoming pregnant..

If the endometriosis is minimal or mild and the duration of the infertility is more than two years, the treatment of choice is Superovulation with Intra-Uterine Insemination. Gonadotropin therapy is the best treatment unless you are covered by an HMO or other insurance which does not pay for these drugs. In such instances, Clomiphene must be used. The results are not as good as with Gonadotropin therapy, but better than no therapy at all.

If the endometriosis is low in the moderate range, a surgical laparoscopy followed by the institution of Superovulation therapy with IUI, is the treatment of choice.

If the endometriosis is high in the moderate range (according to the ASRM classification), a surgical laparoscopy followed by 6 months of GnRH followed by Superovulation with IUI is the best approach.

If the endometriosis is severe, a laser laparoscopy will be performed. Following this several months of GnRH (Lupron or Synarel) suppression is instituted followed by a second look laparoscopy. After the second look laparoscopy, the GnRH suppression is maintained until the woman has been on the drug for a total of six months. Following this, Superovulation with IUI is instituted. However, I have had many women conceive without additional therapy following this treatment regimen,

If the Endometriosis is very severe (ASRM score > 70), the disease is frequently too extensive to safely and (more importantly) appropriately treat by laparoscopy. In such instances, after the initial laparoscopy which assesses the severity of the disease, the woman should go on GnRH suppression for 2-3 months, followed by open surgery, followed by a second look laparoscopy. The GnRH is maintained for a total of 6 months.

I realize this a lot to ask a woman to undergo. However, you must understand that if the ASRM score is that high, you are dealing with very very severe disease that must be aggressively treated if a successful outcome is to be achieved.

The therapies mentioned are only a broad outline and are obviously subject to modification. The most critical factor in determining which therapy will be chosen is often the couples' insurance coverage and what it will or will not pay for.

If a woman with endometriosis is desirous of becoming pregnant at some time in the future but not when she initially presents for treatment, a laser laparoscopy should be carried out. Following this, GnRH suppression with Estrogen Replacement Therapy is the treatment of choice. This therapy can be maintained almost indefinitely until the woman is interested in conceiving. Other types of hormonal suppression can also be used, depending on numerous factors too variable to be discussed here. It is important to understand that GnRH therapy is the best but a satisfactory result can be obtained with other drugs as well.

If a woman is not interested in preserving or enhancing her future fertility, a laparoscopy must still be carried out to establish a definitive diagnosis and "stage" the disease. The following therapies should then be offered.

Following the laparoscopy, the woman should go on GnRH suppression for a period of three to six months. This is done because the GnRH suppression mimics the effect of a hysterectomy. Hysterectomy is the definitive treatment for most women with significantly symptomatic endometriosis.

For reasons that I cannot fully explain, it has become increasingly apparent that women under 40 do not seem to tolerate hysterectomy as well as women older than forty. This is particularly true if the ovaries are going to be removed which is an integral part of endometriosis therapy. Therefore, the following approach is recommended to take all of these factors into consideration. There is no one therapy that is best. Each therapy is tailored to the needs of the woman. It may take several months of trial and error to determine which is best for a given person.

1. If the woman is under the age of forty, GnRH suppression for 3-6 months should be undertaken. The GnRH suppression can then be stopped to determine whether there is any carry-over effect. Some women will experience a temporary remission of their endometriosis symptoms following discontinuance of the GnRH. Unfortunately, this is usually not a permanent solution and the pain usually comes back.

Some women will elect to maintain the GnRH indefinitely as alternative to hysterectomy. Estrogen Replacement Therapy must be added to control menopausal symptoms and prevent or reduce the deleterious effects of the low estrogen levels created by the GnRH.

If the endometriosis symptoms recur, then hysterectomy with retention of the ovaries should be carried out. Laparoscopic removal of the ovaries would then be offered if the endometriosis symptoms recurred.

2. If the woman is over the age of forty, hysterectomy with removal of the tubes and ovaries is the treatment of choice for significantly symptomatic endometriosis. The ovaries may be also retained, depending on the woman's wishes.

The decision to keep or remove the ovaries is often complicated and will be discussed in the next section.

If GnRH suppression does not relieve the endometriosis symptoms, depending upon the nature of the disease, the nature of the symptoms, the location of the pain, etc., a full evaluation must be undertaken to determine whether other causes of pelvic pain may be present. Failure of the GnRH to relieve the pain often means that hysterectomy may not either.

One of the biggest arguments and problems surrounding hysterectomy in general and especially hysterectomy for Endometriosis, is whether or not the ovaries should be removed. As I have already pointed in other pamphlets, there are certain clinical situations which demand bilateral oophorectomy. These include a hysterectomy that has been performed for uterine cancer or ovarian cancer.

If the hysterectomy has been performed for endometriosis or other problems, the arguments are less clear. There is still a debate and the issue may never be completely resolved. I would like to give you at this time my personal opinion and the reasons why I believe what I do. However, it is still a matter of choice for the woman in most instances. Newer advances in medicine have also forced a reappraisal and the issue is far from settled.

The ovary has 2 principal functions - the making of eggs and the making of estrogen. Obviously, both are necessary for the woman to have children. Once the uterus has been removed, the reproductive capability of that woman is usually no longer a consideration and therefore, only the ovary's hormone production is of significance. I am not aware of any scientific evidence that the estrogen produced by the woman's ovaries, if they are left in place, is any better for her than the estrogen she would take by mouth if the ovaries were removed.

However, the ovaries produce other hormones beside estrogen. The other main hormone produced by the ovary is androgen - male hormone. In fact, the ovary continues to produce significant amounts of androgen after menopause, even though estrogen production decreases.

Admittedly, for years we minimized or ignored the significance of the ovarian androgen production. Now, however, evidence is that the androgens are beneficial and that women will do better if their ovaries are left in place. Certainly, in some women, a normal sex drive is dependent on ovarian androgen production.

This is not to say that there a compelling reasons to remove the ovaries in some women. Each woman must be assessed individually and the best decision for her made.

First of all, it is actually technically easier to remove the ovaries that it is to leave them in place, notwithstanding a common myth to the contrary. While this is not a major factor, it is nonetheless true. Furthermore, an ovary left in place may become adherent to the side of the pelvis or to the top of the vagina. In such instances, it can produce considerable pain.

3-5 % of women who undergo hysterectomy in which the ovaries are left will subsequently undergo surgery to remove those ovaries. While this is certainly not a large number, if you are in that group, it means a second operation for you.

If a woman has a hysterectomy for endometriosis and the ovaries are left, she has a 50% chance of requiring surgery within 5 years. Nonetheless, if that woman is young, it may be better to leave at least one ovary and take a chance.

If a woman undergoes removal of her ovaries before the age of 35, her chances of subsequently developing breast cancer are reduced. One out of 9 women in this country will develop breast cancer over her lifetime. If a woman has her ovaries removed at a young age, this will reduce her risk. If the woman has a strong family history of breast cancer, I personally believe that if she has a reason for hysterectomy, removal of the ovaries should be strongly considered.

The most common cancer of the female reproductive tract is cervical cancer and the second most common cancer is uterine cancer. Cancer of the ovary is number three. However, we have good diagnostic and therapeutic measures for cervical and uterine cancer. Therefore, our ability to cure women of these two malignancies is good.

On the other hand, we do not have a good early warning system for ovarian cancer and, therefore, although ovarian cancer is number three in frequency, ovarian cancer is the leading cause of death from pelvic malignancy. Removal of the ovaries at the time of hysterectomy at least insures that women that she need never worry about ovarian cancer.

What about arguments in favor of leaving the ovaries, when possible? One is the fact that the woman will not have to take any hormones until she gœs through natural menopause at approximately age 50.

Also, in addition to estrogen, the ovary makes male hormone (androgen) which we know is the hormone responsible for your sex drive. I have seen women who suffered a noticeable loss of sexual desire and sexual response following hysterectomy with removal of the ovaries at a younger age (under 40). Occasionally, even older women will notice a decrease in libido when their ovaries are removed. Furthermore, most of these were women undergoing hysterectomy for endometriosis so that 1) removal of the ovaries was advisable and 2) they had no regrets concerning their surgery since their pelvic pain and other symptoms were relieved.

It is possible to give these women male hormone and this is usually successful in correcting their sexual problem. Unfortunately, the levels of male hormone necessary to improve sex often result in hair growth on the chin, acne, and other symptoms of increased androgen. However, these women, when offered a choice, would usually rather pluck than lose their sexual response.

I am trying to be fair and present a complete picture. The number of women whose sexual desire suffers following removal of the ovaries is small. I have also reached the conclusion that younger women do not seem to "tolerate" hysterectomy as well as older women. Age 40 seems to be the cutoff. I cannot tell you why and there is no known scienti?c reason why this should be so. I doubt it is something that could be proven scienti?cally. Nonetheless, I do feel that a younger woman who would signi?cantly bene?t from hysterectomy and yet her life and/or health would not be compromised if it were not done should seek alternatives such as a myomectomy, laser laparoscopy, operative hysteroscopy, endometrial ablation, or GnRH suppression in an attempt to avoid hysterectomy.

I have seen many women in my office for a second opinion for hysterectomy where the initial recommendation did not offer any alternatives. The feeling was - either have the hysterectomy or suffer. The fact that there are other therapies was not mentioned.

The arguments pro and con concerning estrogen therapy are covered in another of my pamphlets in much greater detail but I would like to at least summarize them here as part of this discussion. It is my firm conviction that all women after menopause, be it natural or surgical, should be on estrogen therapy for the rest of their lives.

There is no significant risk to taking estrogen after menopause despite all that you might read or see on TV. There is without question a significant decreased risk of osteoporosis, major fractures, and heart disease in women who receive estrogen therapy following menopause. There is increasing evidence that estrogen reduces the risk of colon cancer and Alzheimer's disease. Estrogen therapy probably reduces the risk of developing cataracts. Women who take estrogen live longer, healthier lives.

Many women are confused about hysterectomy because of the many myths that abound. The situation is further complicated by several groups of "true believers", organizations who are vehemently anti-hysterectomy. To the members of these groups, hysterectomy is tantamount to abuse. I have read their literature and it is based on myth and half-truths. They take the one woman who may have had a problem following hysterectomy and try to make others think that she is the rule - not the exception. Furthermore, although they are against hysterectomy, they have no alternative solutions for the woman with serious pelvic problems except to live with them. Their attitude is "Don't have a hysterectomy - SUFFER"! Most women with significant pelvic disease find that to be an unacceptable option.

In summary, I am more and more leaning toward ovarian conservation, especially in younger women. Yes, it is a calculated risk, especially if the hysterectomy is done for Endometriosis. There is the risk of needing additional surgery. Nonetheless, the problems associated with a significant decrease in libido can be as devastating as the possibility of another operation. Each woman must decide for herself.

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