What is endometriosis?
Endometrial tissue are glandular cells that make up the inner lining of the uterus. When similar tissue is outside of the uterus, this condition is called ENDOMETRIOSIS. Although abnormal, it does occur frequently and is often found on the peritoneal membrane (inner lining of the abdomen), and on or in the ovaries, tubes, vagina, intestines, bladder, ureters, and umbilicus (belly button). Although not clearly understood as to why, it also can appear in areas even more distant from the uterus, such as in old operation scars and sutured regions, the lungs, diaphragm, spinal canal, brain, eye, breast tissue, heart, arms and hands, and spleen. The most common site, however, is on or in the ovaries (60-75%).
Why and how does endometriosis occur?
Despite endometriosis first having been described as far back as 1860, even today its causes and treatment are debated. Different theories have been put forward to explain why. One of them suggests that endometrial tissue flows through the tubes into the peritoneal cavity—called “retrograde menstruation”—that is, into the abdominal cavity; an insufficiency of the normal immune response to foreign tissue allows it to attach and grow into the peritoneal membrane surrounding the abdominal cavity as well as create nodules of endometriosis in the reproductive organs. According to another theory, some changes in the peritoneum and ovarian cells (metaplasia, or “alternate growth”) cause the tissue there to develop as endometriosis, provoked by stimuli like increased estrogen. Another theory attempts to explain unusual distant spread, suggesting endometrial cells travel via blood and lymphatic vessels, delivering these cells to sites where they can attach and grow. Some scientists cite a genetic predisposition, associated with changes in the immune system; others claim environmental factors (chemical industry pollutants, such as dioxin, a toxin as an intermediate product in the production of PVC and paper) have contributed to its formation. There is no clear consensus, and it may be that a combination of these and many yet-unrecognized factors are behind endometriosis. As such, it remains a disease that is still unknown in many of its aspects.
Nevertheless, once present, the resulting endometriosis foci grow and bleed according to the changes of estrogen and progesterone hormones in the menstrual cycle, spreading deeper, creating pain and adhesions in whatever regions endometriosis is located. Endometriosis provokes the immune system to attempt elimination of these cells, resulting in an inflammatory condition that attempts to wall itself off from the associated tissues, causing serious adhesions.
What is the frequency of endometriosis?
Endometriosis is a reproductive age disease and occurs most frequently in a woman’s 30s. In those afflicted and reporting painful intercourse and chronic inguinal pain, an associated painful menstruation is seen in 70% of them. In the population of women with infertility, it is discovered in up to 30-40% of them. Across the board for women of reproductive age (15-49 years), it is seen in one of every 10. It is not common in the 13-19 age group (adolescents), but when young girls complain of severe menstrual pain unresponsive to painkillers, the incidence is 70%.
What are the risk factors for endometriosis?
Risk factors include too frequent menstruations, long menstruations, early age onset of the first menstruation, late menopause, white race, infertility, congenital uterine anomalies, family history of endometriosis (3 times the risk over those with no family history), fatty foods, meat consumption, possibly excessive caffeine, tall stature, and blonde or brunette hair coloring.
What are the symptoms of endometriosis?
Before it is identified during surgery or ultrasonography, common endometriosis complaints are painful menstruation, painful sexual intercourse (pain in the groin), infertility, constipation, indigestion, bloating, abdominal pain, discomfort in the lower part of the pelvis, menstrual irregularity, premenstrual “staining,” frequent urination, bloody urine, and flank (side) pain. It can also become asymptomatic (quiet) from time to time, which can mislead one to think it is gone.
How is endometriosis diagnosed?
Evaluation begins, as in any disease or condition, with the patient's complaints and personal history. During the pelvic examination, sensitivity, pain expression, and uterine and ovarian motion limitation suggest endometriosis. Occasionally during the speculum examination, blue-purple nodular lesions can be seen behind the cervix (the part of the uterus that crosses the back wall of the vagina). This emphasizes the diagnostic importance of including a speculum inspection during the pelvic examination.
Ultrasonography is the most informative non-surgical, non-invasive method of diagnosis. Ultrasonography can identify ovarian endometrioma chocolate cysts, severe adhesions between the ovaries and the uterus, and occasionally even endometriotic nodules of the bowel, rectum, and bladder. Advanced imaging methods like MRI and CT are especially useful when severe endometriosis (called deep infiltrating endometriosis) is present in the deep pelvic tissues.
Another helpful method is blood testing: CA 125 and CA 19-9. Because they can only suggest possible endometriosis due to their low sensitivity, they nevertheless are useful in justifying additional examinations for pursuing its diagnosis.
Definitive diagnosis of endometriosis is made by tissue biopsy via laparoscopy or laparotomy. During such laparoscopy or laparotomy, endometriosis may be categorized—considered either mild (Stage 1-2) or severe (Stage 3-4). In another classification, endometriosis is evaluated via anatomy into three groups—peritoneal endometriosis, ovarian endometriosis, and deep endometriosis. Although endometriosis is readily identified during a laparoscopy to visualize the internal abdomen, ovaries, etc., deep endometriosis may be missed when it involves the deeper pelvic tissues.
What is the treatment of endometriosis?
Endometriosis is not a disease that can be completely eliminated. The stage of endometriosis disease determines its treatment, as well as the two important factors of pain and infertility (desire for pregnancy).
There are 2 basic approaches in the treatment of endometriosis: medical drug use and surgery. The aim of medical therapy is to suppress endometriosis lesions, reduce inflammation, and stop the progression of endometriosis lesions by creating a low estrogenic condition. Drug treatment includes painkillers, contraceptives, progesterone-containing drugs and intrauterine systems (IUDs), GnRH analogs, monthly or 3-month injections, and aromatase inhibitors. There is considerable difference among these treatments in terms of side effects and price. Even with treatment, endometriosis can recur in 50% of the cases 2 years after the treatment, regardless of the type of drug used.
The aim of surgical treatment is to reestablish normal anatomy, separate adhesions, remove ovarian cysts with the least damage to the remaining ovarian tissue, burn endometriosis foci in the peritoneum with cautery, and remove deep endometriosis nodules. When treatment focuses on prevention, only endometriosis foci should be destroyed. Surgery should be avoided altogether in the very young, because half of the women after surgery will return within one year postop. Medical treatment after surgery may delay re-emergence of symptoms, however.
If the pain is the primary concern (where fertility is not an issue), surgical treatment may be recommended instead of or during medical treatment, because surgery is the most effective therapy. When fertility predominates the motivations for seeking treatment, the balance of fertility and age become relevant, making it appropriate to perform surgery in women over 35 years of age and not waste biological clocktime on medical therapy. In early stage endometriosis, medical treatment is not required after surgery, but medical treatment after advanced surgery in endometriosis is useful in preventing recurrence.
Treatment options for endometriosis in an infertile woman are controversial. Medical drug therapy has no role in the management of infertile endometriosis cases. It is suggested that removal of endometriosis foci increases the pregnancy rates in early stage (Stage 1-2) cases. The size of a cyst is important in infertile women with an ovarian endometrioma. If 5 cm or more, surgery is recommended straightway. However, during such surgery, great care should be employed to minimize the damage to the remaining ovarian tissue; otherwise, the ovarian capacity may be reduced. Chances of spontaneous pregnancy are highest in the first 6 months following surgery. If pregnancy does not occur within a year after surgery, assisted reproductive therapies should be started. For infertile women with advanced endometriosis, both surgical and non-surgical assisted reproductive therapies can be performed. Medical treatment of endometriosis in an infertile woman is not usually used because it prolongs the infertility and delays what is needed for the ultimate definitive treatment.
On the other hand, surgery should be considered as a last resort in the adolescent group. In young patients with endometriomas in both ovaries, surgery should be avoided if the sizes of the cysts are not large and there is no desire for pregnancy at that time. In these cases, medical therapy should be utilized until the child comes of age to begin her reproductive life. However, surgery should never be delayed in emergencies such as a cyst rupture, after which the patient should be followed with birth control pills (as medical suppression) and annual follow-up.
Surgical treatment should be considered in women with endometriosis in menopause, due to childbearing being over.
Occasionally endometriosis surgery can be very challenging when there is involvement of bowel and bladder. These cases are best approached by a team performing the surgery, including a colon surgeon and a urologist. Sometimes medical therapy should be given to reduce the lesions beforehand, with surgery delayed until 2-3 months later. Endometriosis is a case-by-case challenge, and its treatment should be individualized.
Is endometriosis excision surgery well known?
The field of surgery endometriosis specialists is small, and those that perform excision surgery at the highest standard is even smaller. To truly become a specialist in the field it takes years of training and experience. Not only for an understanding of the complex disease itself but for the advanced techniques such as robotic-assisted surgery.
Dr. Boz has performed several hundred robotic assisted excision surgeries, as well as trains other medical professionals in the use of the Da Vinci machine. It is most important a endometriosis surgeon has the proper skillset to remove diseased tissue but also be able to sew and restore organ functionality.
Besides a relief from pain after surgery it is just important that the affected organs work properly. Because of the complexity of the disease, the surgical treatment required and experience needed many surgeons are not able to or do not want to perform them. Even with all of its hurdles Dr. Boz is confident not only his abilities but the emerging field and all the specialists in it.
How does Dr. Boz perform excision surgery?
After some many years of experience and training Dr. Boz sees the robotic tools as his own body’s movements. It has become his second nature to control the robotic arms with the precision needed to successfully treat endometriosis. The surgery is watched on a monitored, where the robotic arms are guided to a precision not able to be mimicked by human hand.
The granular detail of movements allow for every spot of diseased tissue to be removed successfully. The procedures often takes several hours and more depending on the severity and stage of endometriosis the patient is in. Please contact us with any of our questions or concerns about endometriosis excision surgery. Dr. Boz hopes to get you on the path to relief.