Endometriosis presents with a number of different symptoms and different appearances, and there is a poor correlation between the extent of the disease and the severity of the symptoms. Endometriotic implants which invade 5 mm or more are defined as deeply invasive, and in one case series 11% of all cases of endometriosis were found to have such deeply invasive disease1. Deeply invasive lesions are more strongly correlated with symptoms of pelvic pain and dyspareunia than more superficial lesions. Deeply invasive endometriosis occurs almost entirely in the depths of the pelvis, with 55% of the lesions being located in the pouch of Douglas, 35% in the uterosacral ligaments and 11% in the uterovaginal fold2. This commentary seeks to highlight the current problems with the diagnosis and treatment of this important common condition and to suggest a new philopsophy as regards treatment.
The problems of diagnosis include failure to define adequately the extent of the disease and to appreciate fully the importance of hard fibrotic lesions deep in the pelvis. Failure to appreciate the significance of these findings may result in inappropriate treatment. Many gynaecologists believe that hard fibrotic lesions represent old burnt out endometriosis of little clinical importance. As this fibrosis frequently makes a standard hysterectomy more difficult with increased risk to the ureters, such gynaecologists will often recommend a subtotal hysterectomy. These fibrotic lesions however almost always contain active endometriotic glandular tissue and are among the most clinically important forms of endometriosis. Performing a subtotal hysterectomy in such circumstances merely removes the uterus which is not involved in endometriosis and leaves behind most of the active disease.
Deeply located, deeply invasive endometriosis is responsible for the most severe symptoms. The depth and location of such endometriosis makes accurate diagnosis difficult. With deeply invasive implants most of the endometriosis is hidden beneath the surface of the peritoneum, and the extent of lesion may be significantly under-estimated by laparoscopy. Endometriotic deposits in the cul de sac are frequently surrounded by hard fibrotic material which on histological examination contains a mixture of endometriotic glands, fibrous and myometrial tissues. These hard deposits are often very tender on vaginal examination. These lesions are often missed during a cursory vaginal examination or their importance is not recognised.
If these endometriotic lesions are not recognised on vaginal examination they may also be overlooked on laparoscopic inspection. Many rectovaginal nodules are associated with endometriomata, pelvic adhesions and other stigmata of advanced endometriosis when the diagnosis is obvious. In a significant number of cases, however, the cul de sac may be obliterated with no other signs of pelvic endometriosis. The gynaecologist should test specifically for obliteration of the cul de sac, by the procedure recommended by Reich3. In the normal pelvis viewed laparoscopically there should be a hollow concave space between the rectum and the back of the uterus. A sponge-holding forceps can be inserted into the vagina to push up the posterior fornix. In the normal situation the outline of the forceps in the posterior fornix will be clearly seen with the laparoscope between the rectum and the back of the uterus. When isolated cul de sac obliteration is present the rectum is pulled up and forwards and becomes attached to the back of the uterus. If a sponge holder is inserted into the posterior fornix the outline of the forceps will not be detected laparoscopically. The combination of a palpable mass on vaginal examination and failure to define the bulging of the vaginal forceps laparoscopically is diagnostic of isolated cul de sac obliteration, which may be partial or complete. Failure to appreciate the significance of these findings will often result in the woman's main endometriotic lesion remaining undetected.
Such hard lesions are most commonly located in the rectovaginal septum, the cul de sac and one or both uterosacral ligaments to a variable degree. Complete assessment requires the accurate appreciation of the degree of involvement of the uterosacral ligaments. The disease may also extend posteriorly to involve the serous and muscularis layers of the rectum or sigmoid colon although seldom does it penetrate the mucosa. When rectal bleeding or pain on defecation occurs a barium enema and sigmoidoscopy should be performed. Invasive endometriosis may also extend to the lateral wall of the pelvis with involvement of the ureter and iliac vessels. In these circumstances an intravenous urogram and retrograde ureterography should be performed. If the full extent of the endometriosis outside the uterus is not correctly identified subsequent surgical treatment by any method will be incomplete. Accurate diagnosis by recto-vaginal palpation and detailed laparoscopic inspection before surgery is essential. If deep endometriosis involves the rectum, sigmoid colon, ureter or iliac vessels, treatment is difficult.
Effective treatment of deep endometriosis poses greater problems than diagnosis. Many medical treatments, such as oral contraceptives, danazol, gonadotrophin-releasing hormone agonists and gestrinone, have been tried. Most can produce temporary relief of symptoms. No drug has yet been shown to eradicate endometriosis4 and none has yet been shown to effect a long term cure, particularly for those women with deeply invasive disease. Discontinuation of medication usually results in the recurrence of pain within 12 months5. Superficial removal of endometriosis with various ablative techniques has been shown in randomised trials to produce long term symptomatic improvement in women with mild and moderate disease6. Surgical ablation has not yet been shown to be effective in the treatment of advanced deeply invasive endometriosis; in addition, the use of high powered energy sources adjacent to the bowel and bladder is potentially dangerous and limits the possibility of deep ablation in these areas.
After the unsuccessful use of medications and ablation techniques the gynaecologist may consider hysterectomy usually combined with bilateral oophorectomy. There undoubtedly is a place for hysterectomy and oophorectomy in the treatment of advanced endometriosis but this should only be considered if there are other indications for hysterectomy or where surgical excision of endometriotic deposits has failed.
The early resort to hysterectomy for the treatment of any stage of endometriosis is to be deplored. Endometriosis is an extra-uterine disease, and the aim of treatment should be to remove all the extra-uterine disease while retaining all the healthy tissue including the uterus and ovaries. This approach is particularly important for younger women. Unfortunately, it is still too common for young women to have a hysterectomy performed before adequate attempts to remove foci of extra-uterine endometriosis have been made. This view is firmly entrenched in gynaecological teaching, as a quotation from a standard textbook for postgraduates shows: “However, if her family is complete and she is young, radical pelvic clearance is absolutely necessary to cure the disease”7. The italics are mine and I profoundly disagree with this recommendation.
If all the endometriotic tissue can be removed, excellent long term results without the need for hysterectomy or oophorectomy can be obtained8–11. There is also clear evidence that failure to remove all the endometriotic tissue may result in persistent symptoms even when the uterus and ovaries have been removed, and that these symptoms are cured by excising residual endometriotic tissue12.
The best long term results for the management of advanced endometriosis come from those centres using careful excisional techniques aimed at removing as much as possible of the endometriotic disease. Excision using either the carbon dioxide laser or scissors has been shown to be highly effective using both laparotomy13 and laparoscopy9. The laparoscopic approach is preferred in most situations because it affords better visualisation of the anatomy and pathology, and thereby permits more precise surgery. The laparoscopic approach also allows major abdominal wall incisions to be avoided with a consequent reduction in post-operative pain, reduction in hospital stay and reduction in post-operative recovery times. Laparoscopic excision of endometriosis has been shown in long term studies to be highly effective in reducing or eradicating endometriosis. The five-year risk of a diagnosis of new endometriosis following laparoscopic excision has been shown to be 19%9. Redwine and Perez12 have recently reported a remarkable long term study using pre- and post-operative pain scores to evaluate the effectiveness of conservative excision of endometriosis. This study is of more than 500 consecutive cases treated by the authors and followed for up to four years, and showed significant and sustained improvements in pelvic pain, dyspareunia and painful bowel movements after extensive laparoscopic excision. Excellent long term results have been obtained with laparoscopic excision of endometriosis even when the lower bowel has been involved. Reich8 has reported the first 100 cases of a series of over 400 cases of laparoscopic dissections of deep fibrotic endometriosis in the cul de sac with very favourable long term results. In this study 89% of the women presenting with severe pain as a major symptom achieved complete or partial relief and 74% of those wishing to conceive did so. No laparotomies were necessary but the average operating time was more than 3 hours with a range of 1 to 9 hours.
Endometriosis is an enigmatic disorder which is frequently under-diagnosed and inadequately treated. Deeply invasive endometriosis involving the utero- sacral ligament, the ovary, the rectovaginal septum and cul de sac or the rectosigmoid colon requires surgical excision. Usually this can best be performed laparoscopically, although some cases may still require laparotomy.
Gynaecologists should ask themselves a number of fundamental questions concerning the treatment of deeply invasive endometriosis. Why do we so often use drugs for advanced endometriosis when there is no evidence that they are effective? Endometriosis is a disease of ectopic endometrium located outside the uterus; why does removal of the healthy uterus remain a cornerstone of its management? Why do we continue to use multiple ineffective therapies when more effective ones are available?
Deeply invasive endometriosis is a common and benign disease. Health services naturally look towards providing the simplest, quickest and cheapest form of treatment for such conditions. The available evidence suggests that the most effective form of treatment is complete surgical excision of endometriosis, an operation which is neither quick nor simple. Surgical excision of endometriosis is both demanding and difficult. Even by laparotomy, and especially by laparoscopy, the surgical procedures are time consuming, often taking more than three hours. How many health services allow a gynaecologist to take a whole morning's operating time to treat just one patient with a benign disease? The procedures are often judged by health care systems, private insurance companies and individual gynaecologists to be not cost effective.
Difficult, challenging surgery with potential complications and inadequate financial reward may partly explain the lack of suitable treatment centres for this common condition. A few skilled and determined pioneering gynaecologists have demonstrated the technical possibilities of laparoscopic excision of endometriosis, but to date this service is available to only a tiny fraction of the women who might benefit from this treatment.
What can be done to improve this situation? I believe there is now sufficient evidence to justify the setting up of regional centres interested in the management of advanced endometriosis, which would function much as regional oncology centres. These centres for the treatment of endometriosis would need to be adequately staffed and equipped to ensure that a suitable number of these long operations can be undertaken. These endometriosis centres would need to work in close association with other groups such as colorectal and urological surgeons, reproductive medical specialists, basic scientists and counselling and support services.
These centres would be expensive, but their cost could be offset by replacing the considerable number of ineffective approaches currently being used with more complex but more effective treatments. Policy makers will only be convinced by randomised comparisons of laparoscopic excision of endometriosis performed by suitably trained, skilled gynaecological surgeons and standard treatments, where outcome measures include not only women's perception of improvement and rates of pregnancy, but also an economic analysis.