By Thanh Ha Luu, MD, and M. Jean Uy-Kroh, MD, FACOG
Cleveland Clinic is a non-profit academic medical center. Advertising on our site helps support our mission. We do not endorse non-Cleveland Clinic products or services Policy
Gynecologists have a great deal of knowledge about treating endometriosis and pelvic pain. However, the disease remains perplexing and enigmatic for both patients and clinicians. Continued research is needed to improve outcomes for this common disease that affects an estimated 6 to 10 percent of all women of reproductive age.
We review the current state of endometriosis management in this Clinical Obstetrics and Gynecology article.
What we know
Endometriosis is characterized by the presence of viable, estrogen-sensitive, endometrial-like glands and stroma outside the uterus. Patients with endometriosis may be asymptomatic, but many present with severe dysmenorrhea, dyspareunia, pelvic pain and infertility.
The natural history of endometriosis suggests that as many as 43 percent of patients will experience regression of disease even without treatment, while 51 percent will have no change or progression of disease.1 Furthermore, recurrence of endometriosis is common.
Endometriosis requires both medical and surgical management. Operative laparoscopy, either through ablation or excision, has been shown to improve pelvic pain. “Optimal treatment” depends on several factors including the patient’s desire to retain fertility, age and degree of symptoms. Endometriosis excision for pathology review in conjunction with complete ablation is commonly performed. Laparoscopy with histopathologic confirmation is the gold standard for diagnosis and treatment. Once the patient has completed child bearing, hysterectomy may be considered but should not be performed for endometriosis related pain alone. Similarly, conservation of ovaries is encouraged in younger women.
A large retrospective review analyzed reoperation rates after laparoscopic endometriosis excision and found the reoperation-free interval was 79.4 percent after two years, 53.3 percent after five years, and 44.6 percent after seven years.2 A subanalysis found that women who had a hysterectomy with bilateral oophorectomy had the highest proportion of a reoperation-free interval. This effect, however, was not seen in women ages 30-39. The latter detail is important as it provides evidence that ovary removal does not uniformly equate to significantly prolonged surgery-free intervals, especially in younger women.
Despite nuanced outcomes, one thing is clear, definitive treatment for endometriosis-associated pelvic pain is not hysterectomy with bilateral salpingo-oophorectomy.
Robotic surgery has been shown to be a feasible option for endometriosis. Advocates say compared to conventional laparoscopy it could improve outcomes due to increased dexterity/wrist articulation and depth perception. However, robotic surgery has not been proven superior to conventional laparoscopic techniques.
What we recommend
We advocate a stepwise conservative approach to treating endometriosis, in conjunction with interdisciplinary therapies that address the patient’s symptoms. If medical therapy fails or for deeply infiltrating endometriosis, surgical management is warranted, and in this case we favor excision over ablation. We also recommend postoperative medical therapy for patients not seeking conception to prolong control and delay recurrence. Oral contraceptives, danazol, nRHa, oral progestins, and LNG-IUS have been shown to reduce endometriosis recurrence.
Individualize the treatment plan
As we learn more about chronic pain’s complex pathways and endometriosis, practice norms for endometriosis should be carefully considered. We encourage a thoughtful medical and surgical approach tailored to the patient’s fertility desires while taking inventory of her pain and functionality. Liberal collaboration with pain specialists, physical therapists and surgeons experienced in endometriosis resection is strongly encouraged for optimal patient outcomes.
Dr. Uy-Kroh and Roseanne Kho, MD, Director of Benign Gynecologic Surgery at Cleveland Clinic (Ohio), are co-directing a comprehensive two-day intensive, “Controversies in Endometriosis, Adenomyosis and Fibroids,” on Aug. 25 and 26, 2017 at Cleveland Clinic. A maximum of 14.25 AMA PRA Category 1 Credits are available. For more information or to register, please click here.
Dr.Uy-Kroh is an Assistant Professor of Surgery and Chief of Professional Staff Affairs at Cleveland Clinic Abu Dhabi. Contact her at firstname.lastname@example.org.
Dr. Luu is a chief resident at the Cleveland Clinic in Obstetrics and Gynecology. Contact her email@example.com.
- Falcone T , Lebovic, DI. Clinical management of endometriosis. Obstet Gynecol 2011; 118:691-705.
- Shakiba, K, Bena, JF, McGill et al. Surgical treatment of endometriosis: a 7-year follow-up on the requirement for further surgery. Obstet Gynecol 2008;111:1285-1292.