Endometriosis
Description
An in-depth report on the causes, diagnosis, treatment, and prevention of endometriosis
Alternative Names
Hysterectomy and endometriosis
Treatment
There is no perfect way of managing endometriosis. There are basically three treatment approaches:
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Watchful waiting (to relieve symptoms)
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Hormonal therapy (to reduce endometrial implants)
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Surgery (to reduce endometrial implants, restore fertility, or possibly cure the condition)
The choice depends on a number of factors including the woman's symptoms, her age, whether fertility is a factor, and the severity of the disease.
Watchful Waiting
In general, watchful waiting is a good initial choice for:
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Women with mild pain who, if fertile, do not wish to become pregnant. If women with mild endometriosis wish to become pregnant, the doctor may recommend unprotected sex for 6 months to year. If pregnancy does not occur, then treatment may be started.
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Women approaching menopause.
Some experts believe that early diagnosis and treatment in young women without symptoms might prevent some cases of infertility later on. Unfortunately, however, some treatments for endometriosis may actually trigger symptoms in those who do not yet experience them.
Hormonal Therapy
Hormone therapies are used to mimic states in which ovulation does not occur (such as pregnancy or menopause) or to directly block ovulation. Hormonal drugs include oral contraceptives, progestins, GnRH agonists, and danazol. They can be very effective in relieving endometriosis symptoms. Some of these drugs may also be used after surgery to help prevent recurrence of endometriosis. There is also some evidence that GnRH agonists and danazol may improve immune factors associated with endometriosis. But there are downsides:
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None of these drugs can cure the problem. Symptoms recur in about half of patients within 5 years of treatment.
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They do not improve fertility rates and may delay conception in women who use them.
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Side effects of these drugs can be distressing. There is a high dropout rate with the use of nearly all these hormonal treatments.
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Women who take GnRH agonists, danazol, or similar drugs should use non-hormonal birth control methods (such as the diaphragm, cervical cap, or condoms) because these drugs can increase the risk for birth defects.
Surgery
Surgery is an option for the following women:
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Women with severe pain that does not respond to watchful waiting and medical treatment.
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Women who want to become pregnant and endometriosis is most likely the major contributor to infertility.
There are two basic surgical approaches for endometriosis:
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Conservative Surgery (Laparoscopy or Laparotomy)
. Conservative surgery uses laparotomy or laparoscopy to remove the endometriosis implants without removing any other reproductive organs. It is a good option for women who wish to become pregnant or who cannot tolerate hormone therapy. Some experts believe that laparoscopy surgery should be the treatment of choice for women with endometriosis. Endometriosis often recurs after conservative surgery, however. Recurrence rates at 2 years range from 2 - 47%. The risk for recurrence or residual pain after any procedure increases with the severity of the condition, particularly if endometriosis has affected areas outside the uterus.
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Radical Surgical Therapy (Hysterectomy)
. Hysterectomy with removal of ovaries (oophorectomy) along with all endometrial implants is the only potential cure for endometriosis. If endometriosis has developed outside the uterus than even this procedure is not curative. Removing only the uterus with hysterectomy, in any case, has the same risk for recurrence as conservative surgery.
In choosing between hysterectomy (with or without oophorectomy) and conservative surgeries, age and the desire for children are important factors. One study reported a greater sense of loss, more residual symptoms, and more pain in younger women (under age 30) who have undergone hysterectomy than in older women. In one study, 37% of such younger women regretted their decision to have a hysterectomy.
Once careful instruction is given for all the risks and benefits of the different surgical options, the doctor must respect any decision a patient makes to retain as much of her reproductive system as she wants, even if she is past menopause. Both the patient and the doctor should also be clear about the possibility of changing procedures once the operation has begun, depending on what the surgeon may observe. For example, the surgeon may find abnormalities that require more extensive surgery.
Much of the success of any procedure relies on the experience of the surgeon. A woman should always ask for a doctor's track record, or the number of times he or she has performed the procedure in question. The more, the better. Asking for complication rates may be helpful, but a patient should realize that an experienced surgeon may have a higher number of high-risk patients, and therefore, a higher complication rate than a less experienced surgeon with fewer serious cases.
Treating Infertility in Patients with Endometriosis
For women with severe endometriosis who want to become pregnant, conservative surgery (typically laparoscopy) is the appropriate approach for restoring fertility. Hormonal therapies, such as GnRH agonist or progestins, that treat endometriosis itself are generally considered not to help fertility. However, a 2002 study suggested that the use of the GnRH agonists after surgery helped improve conception rates in women who subsequently undergo assisted reproductive techniques (ART), such as in vitro fertilization (IVF). And, a 2006 study indicated that GnRH agonists given along with infertility treatments may help improve a woman's chance of becoming pregnant. This research is still preliminary.
In any case, ART or hyperstimulation of the ovary using fertility drugs to produce eggs are the standard fertility treatments available to women if surgery fails. ART includes techniques such as in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI). Hyperstimulation is the less expensive approach but in a 2003 study, ART achieved much greater conception rates in women with endometriosis, particularly those with late-stage disease.
It is not clear whether women with
early
-stage endometriosis do any better with fertility treatment than simply trying to become pregnant through non-aggressive means. Women with endometriosis who are trying to conceive should discuss all treatment options with a specialist. [For more information, see
In-Depth Report
#22: Infertility in women.]
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Review Date: 6/13/2006
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Reviewed By: Harvey Simon, M.D., Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital
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