Medical Treatment of ENDOMETRIOSIS
and PELVIC PAIN

 LASER LAPAROSCOPY MOVIE
Published L.U.N.A. Medical Article
 

Edward M. Lichten, M.D.

180 East Brown Street '2'

Birmingham, Michigan 48009

Appointment, phone: (248) 593.9999

Endometriosis is a 14 year old
African-American
Non-sexually active female

Endometriosis is commonly diagnosed in at least 15% of all women of reproductive age. Additionally, of women who experience infertility or dysmenorrhea, this disease is a factor in half. Yet, the origin and management of endometriosis remains controversial and frustrating. As a pain syndrome, misconceptions are continually being challenged.


 A number of theories have been proposed to explain the development of endometriosis. Among the most common are:

*Retrograde passage of endometrial tissue through the fallopian tubes with implantation on pelvic organs. Regurgitation of menstrual tissue can explain the predominance of endometriotic lesion in the cul-de-sac, the uterosacrals, and ovaries.

*Lymphatic or hematological spread of endometrial tissue to parts of the body distant from the uterus.

*Stimulation of totipotent cells by the cyclic hormones leading to growth of endometriosis.

*A genetic predisposition can be identified as 8-10% of women in affected families present with endometriosis, often in severe form.

Association with Infertility

Endometriosis may be a factor in up to half of all infertile women. It has been speculated that even a small amount of disease may produce a filmy adhesion around the ovary; this may inhibit the release of the “egg” at ovulation. Secondly, women with endometriosis produce higher levels of prostaglandins which result in increased tubal and uterine contractions. The fallopian tube could then expel as egg prematurely, hampering conception. Large endometriomas cause ovarian destruction or formation of peritubal or periovarian adhesions which anatomically impede fertilization. Recent research has demonstrated that receptor studies of endometriotic lesions reveal qualitative and quantitative differences in content for androgen, progesterone and estrogen. This may explain the failure of standard medical therapy for some patients.

The literature is replete with studies attesting to the beneficial effect of eradication of endometriosis prior to pregnancy. In a retrospective study of 214 pregnancies in 100 consecutive patients with endometriosis, a significant increase in spontaneous abortion was found among women who conceived within the four years prior to the diagnosis of endometriosis. Of 37 conceptions before surgery, 46% aborted spontaneously, while after conservative surgery for disease, only 8% of the 50 conceptions aborted.

Medical Management: Medical management can be relatively effective for moderate endometriosis, particularly for women with superficial rather than deep peritoneal implants. When endometriosis involves the ovaries, the response to medication is usually not as good.

Major Surgery:  For severe cases of endometriosis, major surgery used to be the mainstay to remove thick adhesions and excise endometriomas (endometriotic cysts of the ovary). However, an experienced laser laparoscopist can perform the majority of these procedures without a major surgical incision. The carbon dioxide laser is employed to precisely eradicate endometriosis with slight, if any, tissue damage. Advantages to the microsurgery are speed (half the operating time), homeostasis (minimal blood loss) and rapid healing. Data confirms a high rate of intrauterine pregnancy with 80% for mild endometriosis and 50% for moderate lesions. The most significant value of operative laparoscopy, pelviscopy, is that it can replace laparotomy in up to 75% of all gynecolgic surgery for pelvic pain and endometriosis. As such, healing time for the patient may be two to three days compared to four to six weeks with major surgery. Since the laparoscopy is performed on an out-patient basis, there is usually less need for a hospital stay.

References

1. Lichten, EM. Surgical Treatment of Primary Dysmenorrhea: Laparoscopic Uterine Nerve Ablation (L.U.N.A.), J Reproductive Medicine, 1987;32(1):37-41.

2. Lichten, EM. Three Years Experience with L.U.N.A.: Outpatient Laser Laparoscopic Treatment of Dysmenorrhea. Gynecologic Health, 1989;3(5):144-147.

3. Lichten, EM. L.U.N.A.: pros and cons. Annals of Am. Assoc. Gyn. Laparoscopists; Las Vegas Meeting. 1991.

4. Duleba AJ, Keltz M, Olive DL. Evaluation and Management of Chronic Pelvic Pain. Journal of the American Association of Gynecologic Laparoscopists. 1996;3(2):205-227

 

 

BACKGROUND: Initially, endometriosis was though to be limited to white middle and upper class women; it now appears that many of these socioeconomic and racial considerations are false. Since endometriosis is the second most reported gynecological pathological finding regardless of background, it is essential for the physician to have a clear understanding of it. For endometriosis can significantly affect the physical and emotional well-being of the patient.

SIGNS and SYMPTOMS:  Endometriosis occurs when endometrial tissue (the lining of the uterine cavity) becomes implanted outside the uterus. Although endometrial tissue can be found in virtually any area of the body, it is most commonly seen in the pelvic cavity, on the surface of the ovaries, utero-sacral ligaments, uterus, fallopian tubes, and supporting broad ligaments. Like the lining of the uterus, these small ectopic patches of endometrium respond to monthly cyclic hormonal changes by bleeding at the end of each menstrual cycle. This “internal bleeding” causes inflammation and results in scarring and adhesion formation, hence, the common symptoms of severe pelvic pain and infertility.

However, as confirmed in over 1000 patients by laparoscopy, symptoms do not necessarily reflect the severity of the disease. Mild disease may cause disabling pelvic pain whereas, with extensive disease, pelvic pain is not always present. Typically, the pain and dyspareunia are worse premenstrually and may improve in the early proliferative phase, immediately after menstruation.

The most common symptoms of endometriosis are dsymenorrhea (painful menstruation) and dyspareunia (painful intercourse) on deep penetration. Often the dsymenorrhea becomes progressively worse with time as the endometriotic areas increase in size. On physical examination, it is rare to palpate nodular areas of endometriosis but typical to find the uterosacral area quite tender. Definite diagnosis is possible only with visualization during laparoscopy. Classic endometriosis appears as small, raised, bluish areas that have been described as “powder burns” or “blueberry spots.” However, biopsies have confirmed that white and lighter red raised areas, filmy adhesions and peritoneal defects, as well as advanced areas of scarring and adhesions, can be due to endometrial implants.

As seen in the photographs to the right, endometriosis can be red or yellow, raised 'bumps' or 'holes.' Any appearance that does not appear smooth and shiny is compatible with pathologic endometriosis.

Treatment:  The treatment of endometriosis should be individualized according to the needs of each patient. Generally, the most common approaches are with hormonal therapy, laparoscopic surgery and major surgical management. In the past, it was thought that pregnancy would “cure” endometriosis. It is now recognized, however that the disease will persist and recur after pregnancy. Hormonal treatment, which is probably most effective when the areas of endometriosis are small, includes the use of oral contraceptives on a continuous basis. The combination of estrogen and progestin oral contraceptives may alleviate cyclic pain by suppressing the cyclic growth of endometriotic patches. However, success seems to be limited to the younger patient with milder disease. Danazol, a steroid androgen, more substantially suppresses the cyclic changes and thereafter causes atrophy of the endometriotic sites. Newer medications called GnRH agonists (Lupron, Synarel, Zoladex) suppress the ovary by blocking the release of pituitary hormones. These agents do not have the acne and weight gain side effects of Danazol. For others, an agent containing a progesterone derivative is used. In my research, each drug offers specific benefits although all may produce osteoporosis (bone thinning) with prolonged use. Quantitative analysis of serum hormonal levels on these drug regimens allows the evaluation of estrogen, androgen and progesterone suppression.

Surgical Intervention:  When infertility is not a factor and the patient present with dsymenorrhea and/or dyspareunia, the medical approach may be provided prior to diagnostic surgery. However, after drug therapy the if the patient experiences a progression of the disease as determined with pelvic examination and/or ultrasound, or remains symptomatic, then operative intervention may be required.  Prior to drug therapy for infertility, in light of the fact that medication is expensive, that there are side-effects and that pregnancy should be prevented while on such drug regimes, it is beneficial to confirm the diagnosis is endometriosis. Further, it is important to stage the disease in order to prescribe the appropriate modality of therapy. And the most efficacious method of diagnosis and staging endometriosis is with laparoscopy.

Through the laparoscope, not only can endometrial lesions be identified, but endometriotic areas can be fulgurated (burned) and adhesions lysed. With the addition of laser, through the laparoscope even extensive endometriotic tissue can be vaporized and adhesions removed. Furthermore, Laparoscopic Uterine Nerve Ablation, L.U.N.A. and subsequent nerve interrupting surgery has been the most effective modalities for relief of pain sans hysterectomy since we first performed the procedure in 1982. The laser vaporization of lesions at the time of laparoscopy affords the physician a means of treatment at the time of diagnosis. In fact, in hundred of my patients, laser laparoscopy has become the primary mode of therapy.

In skilled hands, the risks of L.U.N.A. or laser surgery can be less than conventional ‘open’ incisions. L.U.N.A. research confirmed that the transection of the uterosacral nerves has its only action by releasing the uterine spasm and allowing the menstrual blood to egress more quickly. Whether the surgeon relies on L.U.N.A. or presacral neurectomy, the procedure has a 50-70% success at relieving painful menstrual periods.

Conclusion:  The key point in discussing the medical and surgical management of menstrual pain and endometriosis is the recognition that these conditions affect millions of individuals in the United States alone. For fifty years, most women with menstrual pain were though to be psychosomatic. We now know that menstrual pain is real whether endometriosis is seen or not! Therefore, a woman need not continue to suffer and believe that the pain is “in her head.” It should never be considered a psychosomatic illness. From a research finding of extreme uterine contractions, to laparoscopic findings of endometriosis, to proof of pain relief by surgical and medical therapies, we understand that menstrual pain is real and the sufferer deserves appropriate medical consideration.

 

 

retrograde blood in cul-de-sac

endometriosis 'blebs' and increased vasculature

clear 'blisters'

red-brown endometriosis

endometriosis on insertion of utero-sacral ligaments at cervix

endometriosis on left utero-sacral vaporized (LUNA) with endometriosis on broad ligament at X


Other patients

L.U.N.A. Surgery as Appears in Journal of Reproductive Medicine Article

After L.U.N.A. surgery

Allen-Master Syndrome