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Current Thinking On Endometriosis
      Dr Michael JW Cooper

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Endometriosis is a poorly understood disease defined as the presence of endometrium outside the uterus. The disease appears to have a familial component and current estimates are that it effects some 10% of the female population (ie probably more prevalent than diabetes and asthma).

The average time to diagnosis has been estimated at more than 10 years.

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Aetiology

Several theories exist:
• retrograde menstruation
• stromal metaplasia
• Immune. Recent research is increasingly targeting this theory. In many respects endometriosis is similar to malignancy and unfortunately there appears to be an increased risk of progression to frank cancer. Worryingly it also appears that endometriosis is capable of producing it's own estrogen thus enabling it to be sustained even after castration.

In most cases the areas containing endometriosis are reasonably superficial but they can at times be deeply invasive and cause significant scarring and fibrosis not unlike a malignant process.

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Diagnosis

There has been little progress in diagnosis. The cornerstone of diagnosis is a good clinical history. Premenstrual spotting and cyclical symptoms, particularly pain, are good indicators. Examination is usually normal, although at times nodules can be felt on vaginal examination in the region of the uterosacral ligaments. Imaging modalities such as CT and MRI are of limited value. The only real role of ultrasound is to exclude ovarian endometriomas. CA125 testing is of virtually no value.

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Therapy/Management

Medical therapy has a role in maintenance but unfortunately does not result in longstanding regression or cure. All agents are contraceptive and there is no data to suggest an improvement in fertility rates (Cochrane). Unfortunately many have significant side effects.

The surgical philosophy in recent times has moved towards an excisional approach rather than simple diathermy techniques. ^1,2

To a certain extent endometriosis may be likened to an iceberg and diathermy may result in residual disease. Diathermy is also unsuitable for many situations with disease adjacent to bowel or ureters.

Excisional surgery results in a 70 to 80% chance of substantial ongoing pain relief ² with an increase also in fertility rates.³ The best results paradoxically occur in those with the most severe disease (such as illustrated).

Most of these procedures can be done via laparoscopy. My own data and audits are in accord with these results. These results are not ideal and the search for adjuvant therapies to improve outcomes continues.

Figure 1. Significant endometriosis with bowel involvement and cul de sac obliteration.	Figure 2. Post excision of endometriosis and bowel resection. The cul de sac is now clear.

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Reference List

1. Garry R. Laparoscopic excision of endometriosis: the treatment of choice? British Journal of Obstetrics & Gynaecology 1997;104:513-15.
   
2. Redwine DB. Conservative laparoscopic excision of endometriosis by sharp dissection: life table analysis of reoperation and persistent or recurrent disease. Fertility & Sterility 1991;56:628-34.
   
3. Marcoux S, Maheux R, Berube S. Laparoscopic surgery in infertile women with minimal or mild endometriosis. Canadian Collaborative Group on Endometriosis. N Engl J Med 1997;337:217-22.
   

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Last updated 24th July, 2002

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