Endometriosis and pain: Expert answers to 6 questions targeting your management options

“Excision and ablation both have ­indications,” Dr. Nezhat asserts. “It depends on the location and depth of penetration of implants, as well as the patient’s ultimate goal. For example, if the patient desires future fertility and has endometriosis on the ovary, removal by excision could damage ovarian function. The same holds true for endometriosis on the fallopian tubes. It’s better in such cases to ablate.”

“Ablation is different from coagulation, which is not recommended,” Dr. ­Nezhat explains. “Ablation vaporizes the diseased area layer by layer, like peeling an onion, until the disease is eradicated. It is similar to ­dermatological skin resurfacing. Vaporization is preferable for endometriosis on the tubes and ovaries in patients who desire pregnancy. The choice between excision and ablation depends on the location, depth of penetration, and the patient’s desire for ­fertility.”

Either way, and regardless of the primary indication for surgery—pain versus infertility—a minimally invasive gynecologic surgeon is expected to have ability in performing both techniques, Dr. Nezhat says.

Endometriosis: 3 intraoperative videos The following videos have been provided by AAGL SurgeryU to compliment the content of this article regarding endometriosis. You can watch these videos, and more than 1,500 others, at AAGL.org/surgeryu. Laparoscopic excision of stage IV endometriosis Einarsson JI This case, originally presented as a SurgeryU live event, features a 41-year-old woman (G3P1) with a 3-year history of left-sided pelvic pain, deep dyspareunia, constipation, and dysmenorrhea. She also has infertility and is planning an IVF treatment shortly. On examination she was noted to have significant rectovaginal tenderness and nodularity. A pelvic MRI demonstrated a 3-cm irregular mass extending from the cervix into the cul-de-sac up to the left lateral pelvic sidewall. Abdominal wall endometriosis Hawkins E, Patzkowsky K, Lopez J This video demonstrates a typical presentation of abdominal wall endometriosis (AWE), also known as subcutaneous endometriosis or scar endometriosis. It is important for gynecologists to be familiar with this more uncommon form of the disease and its management. This video also demonstrates surgical management of advanced AWE involving the subcutaneous tissue, fascia, and rectus muscle. Laparoscopic excision of endometriosis in a 14-year-old patient with chronic pelvic pain Pendergrass M This video depicts the laparoscopic excision of endometriosis in a 14-year-old patient with chronic pelvic pain. The patient underwent menarche at age 11 and developed cyclic pelvic pain 6 months later. Due to the severity of the pain she has been unable to attend school for the past 2 months, and has stopped participating in sports. A diagnostic laparoscopy revealed red/brown superficial endometriosis lesions on the peritoneum in the posterior cul de sac, bilateral uterosacral ligaments, and bilateral broad ligaments.

5. Is hysterectomy definitive treatment for pain?
“Not necessarily,” says Dr. Nezhat. “Hysterectomy by itself doesn’t take care of endometriosis unless the patient has adenomyosis. If a patient has endometriosis, the first step is complete treatment of the disease to restore the anatomy. Then the next step might be hysterectomy to give a better long-term result, especially in cases of adenomyosis. Removal of the ovaries at the time of hysterectomy has to be individualized.”

“The implication that hysterectomy ‘cures’ endometriosis is false yet is stated in some textbooks,” says Dr. Nezhat. “Even at the time of hysterectomy, the first step should be complete treatment of endometriosis and restoration of anatomy, followed by the hysterectomy. Leaving endometriosis behind, believing it will go away by itself or not cause future issues, is a gross misperception.”

Removal of the ovaries at hysterectomy?
“There are few comparative studies on the long-term follow-up of patients who have undergone hysterectomy with or without removal of both ovaries,” says Dr. Falcone. “The conventional dogma has been that, in women undergoing definitive surgery for endometriosis, both ovaries should be removed, even if they are normal. I personally believe that this was the case because hysterectomy was often performed without excision of the endometriosis. So the uterus was removed and disease was left behind. In these cases, recurrent symptoms were due to persistent disease.”

“We reported our experience at the Cleveland Clinic with a 7-year follow-up,” Dr. Falcone continues. “Hysterectomy was performed with excision of all visible disease. Ovaries were conserved if normal and removed if they had disease. We looked at the reoperation-free frequency over time. In women undergoing hysterectomy with excision of visible disease but ovarian preservation, the reoperation-free percentages at 2, 5, and 7 years were 95%, 86%, and 77%, respectively, versus 96%, 91%, and 91% in those without ovarian preservation. So, overall, there was an advantage over time for removal of the ovaries. However, in the subset of women between ages 30 and 39 years, there was no difference in the long-term recurrence rate if the ovaries were left in. For this reason, in women under 40, we recommend keeping normal ovaries if all disease is removed.”¹⁷