By: Abigail Finder, DO
Editor’s Note: This is a review of an article[1] titled, “The laparoscopic management of endometriosis in patients with pelvic pain.” It was published by Dr. Patrick Yeung in 2014 in Obstetrics and Gynecology Clinics of North America. Dr. Abigail Finder summarized the article, which discusses the diagnosis and treatment of endometriosis, during the FACTS Medical Student Elective. To learn more about endometriosis and the work of Dr. Yeung, register now for the FACTS Annual Conference! Dr. Yeung will present on endometriosis and surgery as first line treatment at the FACTS Conference, which will take place on April 10th and 11th in Peoria, Illinois. Hurry, as registration closes Tuesday, March 31st!
Introduction
Endometriosis is a disease in which cells from the uterine endometrial lining are found outside the uterus in the pelvic or abdominal cavities. It is diagnosed in approximately one out of ten women; yet, the more startling fact is that it can take an average of twelve years from the onset of symptoms to finally diagnose endometriosis.[1] The diagnosis is confirmed histologically with tissue samples obtained via laparoscopic surgery, in which a surgeon uses a camera to view the inside of the peritoneal cavity to find implantations of endometrial tissue. While endometriosis is diagnosed and treated through laparoscopy, it takes more than surgery to help a patient suffering from this condition. Working with medical professionals experienced in fertility awareness-based methods (FABMs) may lead to earlier diagnosis and more targeted symptom management of endometriosis, which will ultimately relieve pain, prevent advanced disease, and preserve fertility.
Working with medical professionals experienced in fertility awareness-based methods may lead to earlier diagnosis and more targeted symptom management of endometriosis, which will ultimately relieve pain, prevent advanced disease, and preserve fertility.
Diagnosis of Endometriosis
A patient suffering with endometriosis may present with dysmenorrhea, chronic pelvic pain for more than three months outside of her menstrual period, deep dyspareunia, and period-related dyschezia and dysuria.[1] Other possible causes of chronic pelvic pain should be explored before surgery for suspected endometriosis, including pelvic inflammatory disease, interstitial cystitis, urinary tract infection, myofascial pain or vaginismus, irritable bowel syndrome, and more.[1] The goal of this approach is to prevent unnecessary surgery that could cause complications such as bleeding, infection or adhesions that may affect future fertility. Others recommend initiating surgical exploration soon after the onset of symptoms, with the hopes of relieving potential years of pelvic pain and infertility. Considering that 75% of adolescents who experience pain and have failed medical treatment are diagnosed with endometriosis,[1] it is no surprise that an aggressive approach to diagnosing endometriosis early is now more acceptable.
Current indications for a diagnostic laparoscopy include symptoms that affect daily living or quality of life, deep dyspareunia, requiring narcotics for pain, and/or chronic pain that does not improve with hormonal suppression. Infertility is another indication if a patient is younger than 30 years old, IVF is not an option for the patient, or the patient has failed IVF twice.[1]
If laparoscopy is pursued, a patient will undergo a preoperative exam to assess for potential signs of deep endometriosis. This includes evaluating the uterosacral ligaments for thickening, shortening, and/or nodularity, mobility of the uterus and adnexa, identifying any adnexal masses, and a rectovaginal exam for cul-de-sac nodularity.[1] Preoperative imaging includes a transvaginal ultrasound. These assessments, while not diagnostic, can prepare the surgeon by revealing the extent of any potential deep endometriosis prior to surgery.
Treatment of Endometriosis
The first-line treatment for female pelvic pain has been hormonal suppression, such as a gonadotropin-releasing hormone agonist or oral contraceptive pills. If a patient’s pain is improved with hormonal suppression, then endometriosis is suspected; however, an official diagnosis of endometriosis is not declared without laparoscopy. While hormonal suppression may relieve pain, it does not necessarily prevent endometriosis from worsening or recurring. In fact, hormonal suppression, especially given in adolescence, may lead to more advanced disease and infertility because the symptoms are managed while the disease itself has not been treated.
While hormonal suppression may relieve pain, it does not necessarily prevent endometriosis from worsening (and) … may lead to more advanced disease and infertility because the symptoms are managed while the disease itself has not been treated.
Laparoscopic surgery is the treatment for endometriosis, as it can not only improve the symptoms of chronic pain but also prevent disease recurrence and infertility. In a study by Lee and colleagues, 42% of patients treated for endometriosis with laparoscopy conceived within a year without hormonal therapy or artificial reproductive techniques.[1]
The goals of laparoscopic surgery are to remove visible and deep endometriosis, restore and preserve anatomy and function, and prevent adhesions. Two techniques are used for the removal of endometriosis: excision and ablation. The excision technique removes the diseased tissue and sends it to pathology for a diagnosis. Ablation burns the disease on the superficial tissue in the peritoneal cavity. While both are acceptable, ablation fails to look below the surface for lingering deep disease. The rates of recurrent endometriosis two years after ablation are approximately 20-50%.[1]
On the other hand, excision can remove deep and superficial endometriosis, thus the rates of recurrent disease are as low as 0% in two years.[1] One negative effect of excision treatment is the creation of adhesions in the peritoneal cavity that can lead to complications such as pain and infertility. However, it is believed that good surgical techniques can reduce adhesions and lead to a positive outcome.
FABMs and the Female Chart in Endometriosis
Fertility awareness-based methods (FABMs) play an important role in the diagnosis and treatment of endometriosis. A woman charting her cycle is trained to monitor daily signs and symptoms and to record the total length of her cycle, the length of her menstrual period and bleeding patterns, her change in cervical mucus in the follicular phase, and her peak day leading into the luteal phase. By working with an FABM educator, a woman can quickly identify abnormal changes in her cycle that could be affecting her overall health. While there are no cycle abnormalities that definitively diagnose endometriosis, certain signs are more common, such as irregular bleeding or abnormal bleeding outside of the normal menstrual period, luteal phase defects (e.g., a longer luteal phase or short post-peak phase), and decreased cervical mucus.[2] Observing these changes may prompt patients to seek help from a physician, thus leading to earlier diagnosis and treatment of the underlying cause.
While there are no cycle abnormalities that definitively diagnose endometriosis, certain signs are more common, such as irregular bleeding or abnormal bleeding outside of the normal menstrual period, luteal phase defects (e.g., a longer luteal phase or short post-peak phase), and decreased cervical mucus.
Conclusion
Endometriosis is a common disease affecting women’s quality of life and future fertility. Through early recognition of cycle abnormalities using fertility awareness-based methods to chart the female cycle, a woman can be diagnosed at an earlier stage in the disease process. In the case of endometriosis, early diagnosis through laparoscopic surgery and treatment with excision therapy can significantly improve a patient’s pain and fertility and reduce the likelihood of advanced or recurrent disease.
References
[1] Yeung P Jr. The laparoscopic management of endometriosis in patients with pelvic pain. Obstet Gynecol Clin North Am. 2014;41(3):371-383. doi:10.1016/j.ogc.2014.05.002.
[2] Charting with Endometriosis: An Interview with Specialist Dr. Yeung. (2017, November 29). Retrieved April 02, 2021, from https://www.factsaboutfertility.org/endo-dr-yeung/.
ABOUT THE AUTHOR
Abigail Finder, DO
Abigail Finder, DO wrote this review as a fourth-year medical student at Kansas City University College of Osteopathic Medicine in Joplin, Missouri. She is set to start an obstetrics and gynecology residency at the University of Buffalo – Sisters of Charity Program. She first learned about FABMs through her church, but after taking the FACTS elective, she is excited to apply the science behind FABMs with her future patients. Her goal is to empower women through surgery and medicine, including FABMs.
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