Endometriosis: Surgical Treatment
What is endometriosis?
Endometriosis is a medical condition where tissue similar to the uterine lining is present outside the uterus in the abdomen, pelvis, or other areas in the body. The uterine lining is called endometrium (“metri” means uterus, and “endo” refers to inside lining). Endometriosis (“endometri” refers to endometrium, “osis” means medical condition).
Endometriosis may start superficial in the lining of the body cavity in the peritoneum (the thin lining of the abdominal cavity). It will then invade deeper into the tissues.
Endometriosis will grow in response to Estrogen and can cause pain with menstrual cycles, pain with sexual intercourse, chronic unrelenting pelvic-back-hip-leg pain, and may contribute to infertility. Not everyone has every symptom. The intestinal tract may be involved in 10-15% of cases, and the urinary tract may be involved in 1-2% of cases.
Endometriosis is a surgical diagnosis. This means it cannot be definitively diagnosed by taking your history, physical examination, blood or urine tests, x-rays, ultrasounds, MRI, or CT scan. These studies may suggest endometriosis as a diagnosis, but the physician can only confirm the diagnosis by looking surgically. This is usually accomplished with laparoscopy.
With laparoscopic excision, the physician may be able to make a tissue diagnosis. Some lesions may look like they are definitely endometriosis, but the diagnosis may not be confirmed on pathology. Other lesions are very subtle and not very suggestive of endometriosis, but pathology confirms the tissue as being endometriosis. There are more than one way to treat endometriosis laparoscopically, but Dr. Lucas prefers the precision of excision of the endometriosis for effective pelvic pain relief and management of sexual pain.
If you’ve been told you have endometriosis, please let us know. The surest way to diagnose endometriosis is through surgery, which we can perform as an outpatient procedure. This may afford us the ability to treat the lesions at the same time, offering a comprehensive approach to managing your endometriosis and associated symptoms. To inquire about diagnosing your condition or managing your endometriosis, please contact us through our Secure Patient Contact Form.
Endometriosis Treatment: Surgical
Endometriosis often implants close to, or directly over, vital structures, such as the ureter. Destructive techniques may pose a safety threat to underlying structures. When a physician looks in the abdomen during laparoscopy, and the patient is found to have endometriosis, the doctor can try to destroy the lesions (laser vaporization or burning the lesions with electrical cautery – “fulguration”) or excise them (going around, underneath, and completely removing the tissues that are hurting you).
Even if the surgeon completely and safely treats the endometriosis lesion with electrical burning or laser, this treatment is only applied to the part of the lesion that is seen. This may miss the disease in the tissues beyond the visible perimeter of the lesion (deeper or wider).
Commonly, endometriosis invades deeper into the tissues than the superficial application of laser or electrical energy will penetrate. In many cases, the endometriosis and pain can recur. This can lead to patients undergoing surgery after surgery for the same problem. This can be disappointing and frustrating.
The most common surgical finding of endometriosis is not the disease itself but the scarring (“fibrosis” or “adhesion”). Often, there are endometriosis implants within the adhesions. If adhesions are only separated (and not removed), then endometriosis may remain and can result in repeat surgeries.
Dr. Lucas, a leading pelvic pain specialist in Portland, ME, makes every reasonable attempt to completely excise visible disease along with associated scarring, with adequate margins down to normal tissue. He carefully excises wherever disease is present. When necessary and medically indicated, he will consult other surgeons to excise endometriosis lesions from tissue outside the scope of gynecologic surgery, showcasing his expertise in endometriosis treatment in Maine and the broader New England area.
Dr. Lucas has achieved a Focused Practice Designation in Minimally Invasive Gynecologic Surgery from the American Board of OB/GYN, highlighting his commitment to providing advanced care for sexual pain and pelvic health in New England.
All specimens are sent for microscopic confirmation. Digital documentation of endometriosis location and extent is obtained (“befores”), as well as how the lesions were treated(“afters”). At the post-operative visit, a complete digital record of the procedure (pictures, operative notes, pathology report) will be provided to the patient for her personal record, ensuring a transparent and informed recovery process for those seeking endometriosis and pelvic pain relief in New England.
Frequently Asked Questions About Endometriosis
What are some symptoms of endometriosis?
Endometriosis will respond to the hormone estrogen and can cause pain with menstrual cycles, pain with sexual intercourse, infertility, and unrelenting chronic pelvic, back, hip-and leg pain. Not everyone has every symptom, and some individuals have had pregnancies. Endometriosis is a factor in up to 40% of cases of unexplained infertility.
How common is endometriosis?
Endometriosis affects 10-15% of the female population.
How is endometriosis diagnosed?
Endometriosis is a surgical diagnosis. This means it cannot be definitively diagnosed by taking your history, physical examination, blood or urine tests, x-rays, ultrasounds, MRI, or CT scan. A diagnosis can be presumptive and interventions can be attempted with medication to alter hormones in order to alleviate symptoms.
2 key points to remember about Endometriosis:
1) There is no correlation between the symptoms the person is experiencing and whether endometriosis is present. (You may have severe cyclical pain that seems like it is endometriosis, but it is not).
2) There is no correlation between the severity of the symptoms and the extent of endometriosis present. (You may have extensive endometriosis and have pain that is tolerable or managed by medical interventions. Conversely, you may have only a few endometriosis lesions and experience debilitating pain with periods.)
For these reasons, laparoscopic surgery may be the best way to have definitive diagnosis and/or treatment.
What can I do to alleviate endometriosis symptoms while waiting for surgery?
See Dr. Lucas!! There are hundreds of options to alleviate symptoms until definitive surgical intervention. This is a very specific question because only YOU know your endometriosis pain experience. Dr. Lucas will work with you to develop a plan of care to address your pain until surgical intervention is needed, available and/or desired.
These options can range from oral medicine to compounded medicine to manual medicine to acupuncture, the list goes on. The same pain care regimen will not work for everyone so we have a wide spectrum of treatment options available.
Is there a connection between endometriosis and ovarian cancer?
(CAUTION: Hardcore Science-y stuff ahead. But it is very useful to understand.)
Every organ has different tissue types. Each tissue type within an organ can produce tumors, benign and malignant.
The ovary has 3 tissue types:
1) Eggs and follicles (aka cysts) produce germ cell tumors
2) Connective tissue (aka the tissue that holds the ovary together) produce stromal tumors
3) Epithelial tissue (aka covering over the outer surface of the ovary) produce epithelial tumors. Approximately 70% of all ovarian tumors are epithelial. Epithelial tumors can be serous, mucinous, clear cell, or endometrioid.
These subtypes are based on how the tumors look under the microscope.
There is evidence in the medical literature that clear cell and endometrioid ovarian tumors may develop from endometriosis. Literature review shows only a mild association between endometriosis and the development of ovarian cancer. The relationship of endometriosis and ovarian cancer is not confirmed.
A literature review published in early 2014 using the keywords “endometriosis” and “ovarian” found 1 prospective cohort study, 10 retrospective cohorts, and 5 case-control studies. All of these studies, except for one, did not include operative confirmation of endometriosis. Authors found a consistent association between endometriosis and clear cell and endometrioid cancer, but the authors concluded that the association linking endometriosis and ovarian cancer is not sufficient to impact current clinical practice.
Therefore, to summarize what is known at this time, there is an association between epithelial cancers of the ovary and endometriosis, but there is currently not enough evidence to warrant alteration in endometriosis treatment.
Is my pain endometriosis?
Pain is always real. Often, we can find what is causing the pain. In many of these patients, we can alleviate the pain. When the source of the pain is not immediately found, we work to exclude the most deleterious diagnoses at first. A klist of possible diagnoses is generated and then we sequentially rule out diagnoses until we have a more specific idea s to the cause and thus, a clearer picture of what can help.
Endometriosis can present as menstrual pain, pain intermittently throughout the month, or continuous pain. Response, or lack of response, of symptoms to medications, such as hormonal modifiers and contraceptives does not necessarily rule in or rule out the presence of endometriosis. However, they can help to identify when the cause of the pain is hormone dependent.
Why do I still feel pain even after excision of my endometriosis?
Abdominal, pelvic, back pain can have many sources, including but not limited to musculoskeletal dysfunction/spasm, vascular insufficiency, endometriosis, pelvic inflammatory disease (PID), interstitial cystitis (IC; now known as Painful Bladder Syndrome), inflammatory bowel diseases (IBD), irritable bowel syndrome (IBS; now known as Disorder of the Gut-brain Interface/Axis), and neurologic dysfunction.
Pelvic floor muscles respond to chronic pain conditions. Even if endometriosis is thoroughly removed, some patients need physical therapy/biofeedback. Manual therapy (Osteopathy, physical therapy, acupuncture, massage, etc) has a better chance of being successful after the underlying cause for the pain is removed. To have the best chance for pain relief, we need to treat the whole person and eliminate as many sources of pain that we can identify.
Sometimes after laparoscopic excision, some, most, or all the specimens are positive for endometriosis on pathology, but the patient still has pain. In that individual, there may be another factor at work that is causing her pain. We now know and understand that pain responses change over time. Literally, the nerves change to become easily excitable and more likely to send pain signals to the brain, even when there is no actual damage being done to tissue. This is called Central Sensitization. This is a complex disease entity but there are options to treat it. This is a major reason why, if you continue to have pelvic pain after having had surgery:
- Do not immediately assume you need more surgery
- See a pelvic pain focused gynecologist
Ready to take the first step towards personalized pelvic health care? Fill out our simple form below to schedule a consultation with Dr. Romeo Lucas, and embark on your journey to relief and well-being.
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