The most important step in treating endometriosis is the detailed and thorough evaluation of patients’ symptoms. This allows us to fully understand the degree in which their quality of life is affected and also gives us a hint as to how extensive the disease can be. We are guided based on all the previous and finally make an individualized plan of treatment based on drugs, surgical intervention or a combination of those two.
Some times there are cases in which time is crucial and we have no luxury of waiting.
This applies not only to gynaecology but also to all the specialties. It is important to say here that there some cases which are real emergencies and any unnecessary delay could cause permanent damage to specific organs.
One of these cases is when endometriosis “targets” the urinary system and especially the ureter. The ureter is the small tube that connects the kidney to the bladder and is responsible for the flow of urine between the two previous structures. When endometriosis causes a pressure on the ureter, at that point there is a mechanical stenosis. This stenosis doesn’t allow the urine to flow freely from the kidney to the bladder, so the urine is collected in the ureter above the point of stenosis causing a dilatation of the ureter (hydroureter) and eventually a dilatation of the kidney itself (hyfronephrosis). Hydronephrosis is the beginning of the possible catastrophic cascade which can lead eventually in permanent kidney loss (renal failure). Under these circumstances surgical intervention is considered to be critical and should be performed without delay so that the kidney is salvaged.
Another condition in which surgical intervention is critical, is growth of endometriosis around the bowel. When the endometriosic nodule presses upon or infiltrates the bowel, this causes stenosis of the lumen of the bowel and as a result the feces cannot advance properly. The feces gather above the point of the stenosis leading to a condition of constipation and later on to possible refractory ileus. Surgical the invention needs to be undertaken as soon as possible.
Endometriosic cyst (or chocolate cyst/endometrioma) results from growth of endometriosis inside the ovary. Usually in most women, the presence of such cysts is accompanied by further lesions next to the ovary or in remote areas which need total excision.
When there are bilateral endometriomas, the likelihood of advanced disease in the bowel, which requires complex surgery, rises up to 85%.
The answer is definitely NO! Hysterectomy is not a cure for endometriosis
Endometriosis by definition is the condition in which endometrial-like cells grow in areas outside the uterus. It is clear that the patient won’t benefit from removal of her uterus. On the contrary she will undergo a non-necessary surgical intervention, with all possible risks and all possible complications.
To better understand the above let’s think of a simple example (used regularly by my mentor and pioneer in endometriosis surgery Mr Shaheen Khazali when educating patients with endometriosis): “someone has pain in his wisdom tooth and goes to the dentist. The dentist refuses to remove the wisdom tooth but instead offers to remove the front tooth because he’s very good at it !”. Will the patient benefit from this surgical intervention? This rhetorical question has an obvious answer and this is NO. This is similar to pain caused by endometriosis and hysterectomy proposed as a treatment.
It is important to add here that there are cases of endometriosis were adenomyosis is present at the same time. In this case and only and under specific conditions may hysterectomy have a role to play.
My philosophy on this matter is clear: “we should never remove an organ unless we are absolutely confident that this organ is damaged beyond repair and after all the conservative measures have been used”.
The diagnosis of adenomyosis can be very challenging. This is the most definitive diagnosis and comes only from the histological examination. It is obvious though that the patient must undergo a hysterectomy before this.
There is much research going on, on an effort to find specific criteria which could help us answer with great confidence whether a woman has adenomyosis or not.
The most accurate available method that we have at this moment to assess the condition of the uterus preoperatively, is laparoscopy. Endometriosis surgeons are experts in identifying possible adenomyosis in the uterus with a diagnostic rate close to that histology.
Very often we have patients coming to us and asking this very common question. Many women are stressed and desperate to find an answer to the question: “should I remove my tube or not?”
But let’s see what a hydrosalpinx is. Sometimes (for various reasons) there is an accumulation of fluid inside the tube. This fluid usually gets trapped inside the tube and causes its dilatation. This fluid can either be simple fluid but sometimes it can be blood as well (like in cases of endometriosis). Unfortunately in either situation, when the tube is dilated, it is not functional any more and more importantly it can be a hindrance for future pregnancy.
The data that we have is clear. Removal of the hydrosalpinx (even when the patient is in process for IVF) can double the success rate.
The detailed and thorough discussion between the patient and the gynaecologist surgeon before the procedure, is the most crucial step in the whole procedure.