Endometriosis myths

To kick off National Endometriosis Awareness month, I found this article by Dr. David Redwine, a renowned endometriosis specialist.

I will try to feature an endometriosis myth each day in March, 2009 to better educate people about endometriosis.

Endometriosis ‘myths’
OB/GYN News , August 15, 2002 by David Redwine

Many gynecologic surgeons believe that the definitive surgical treatment for all cases of endometriosis is hysterectomy and bilateral salpingo-oophorectomy. That belief is a harmful myth.

I fully support hysterectomy for endometriosis patients whose symptoms are primarily uterine and salpingo-oophorectomy for patients whose symptoms are ovarian. However, I would challenge physicians who perform these surgeries on endometriosis patients to finish the job and remove all other visible endometriotic lesions at the same time. If these lesions are not removed, symptoms may persist in a significant number of patients, and a large proportion of their doctors will dismiss those symptoms as impossible to treat.

The theory behind hysterectomy and bilateral salpingo-oophorectomy is that it removes the bulk of endometriotic lesions and leaves the rest to shrink in the resulting nonestrogenic environment. In reality, only 3.7% of patients have endometriosis confined to their uterus, tubes, and ovaries. Thus, removal of these organs leaves the majority of their endometriosis in place, and these lesions are largely operational.

Endometriotic lesions have varying levels of estrogen and progesterone receptors, compared with normal endometrium. Some lesions may never have depended on estrogen, and some can manufacture their own estrogen. In these cases, removal of the uterus, tubes, and ovaries will have no impact.

There are no studies showing that endometriosis is destroyed by low levels of estrogen. This is yet another myth that is both destructive to patients and science.

Studies have shown that after hysterectomy and bilateral salpingo-oophorectomy 7% of endometriosis patients remain symptomatic and 1.7% require reoperation because of the severity of their symptoms. That means 9,000 women remain symptomatic and 2,000 require reoperation in the United States each year.

I see many of those women, who come to me from all over the world. Many of them have rectal-intestinal involvement and involvement of the utero-sacral ligaments. Some of these women have been given hormone replacement therapy, which often nourishes their estrogen-dependent lesions. Studies show that up to 20% of women on HRT will continue to have symptoms, compared with about half that rate in those not taking HRT. But making a young woman surgically menopausal and not replacing her hormones will give her other symptoms, some of which may also become unbearable.

Another reason for surgical failures among endometriosis patients is surgical technique. Doctors who burn rather than excise lesions fail to reach the full depth of the disease. Admittedly, there are several problems with adopting excision versus burning, whether it be by laser or electrocoagulation. Excision is technically more difficult than burning, so burning is attractive to those who don’t have much experience or time.

Another problem with excision is that doctors are not paid very well for doing gynecologic surgery Why would a doctor tackle a treatment that is technically difficult and may be mentally and physically exhausting when there is support in the literature for burning, which is much easier?

The belief that endometriosis always grows back is another destructive myth, which may be fueled by what I believe is the superficiality of laser and electrocoagulation therapy The literature shows that in several hundred patients who had second-look surgery after having their endometriosis excised, the cure rate was 60%. No such studies have been done in laser or electrocoagulation patients.

Ultimately, doctors should keep in mind that even after a hysterectomy and bilateral salpingo-oophorectomy a significant percentage of women still suffer from the symptoms of endometriosis. Some of these women deserve a thorough second look and perhaps a more extensive removal of their disease.

DR. DAVID REDWINE is director of the endometriosis treatment program at St. Charles Medical Center in Bend, Ore.
COPYRIGHT 2002 International Medical News Group
COPYRIGHT 2008 Gale, Cengage Learning
(The actual article is at obgynnews.com, but it requires a login to view the article).