NEW YORK – In the first prospective study of endometriosis in teenagers undergoing complete laparoscopic excision of all areas of abnormal peritoneum, no recurrence was found during up to 5 years of follow-up, according to Dr. Patrick Yeung Jr., director of the center for endometriosis at St. Louis University.
These findings support one of the key themes of the annual congress of the Endometriosis Foundation of America, as expressed by cofounder Dr. Tamer Seckin: Early diagnosis and complete excision are "the best prevention."
In this observational study conducted by Dr. Yeung and his colleagues at an Atlanta-based specialty endometriosis practice, 20 young women aged 12-19 years with symptoms suspicious for endometriosis underwent complete laparoscopic excision of all areas of abnormal peritoneum. The most common suspicious symptoms included moderate to severe chronic pelvic pain, dysmenorrhea, and dyschezia; other symptoms reported were painful bladder, pain with exercise, and intestinal cramping. Quality of life was described as "awful" or "poor" for 65% of the girls. The majority had previous hormonal (82.4%) or surgical (76.5%) treatment (Fertil. Steril. 2011;95:1909-12).
At surgery, histologic analysis confirmed endometriosis in 17 of the 20 (85%) patients. Using the revised American Society for Reproductive Medicine staging criteria (Fertil. Steril. 1997;67:817-21), 29.5% of patients had stage I disease, 64.7% had stage II, and 5.9% had stage III.
After surgery, fewer girls reported pain symptoms such as dysmenorrhea (82.4% before surgery, reduced to 41.2% after surgery), dyschezia (76.5%, reduced to 17.6%), painful exercise (70.6%, reduced to 5.8%), intestinal cramping (58.8%, reduced to 5.8%) and bladder pain (52.9%, reduced to 11.8%) (all P less than .05). Quality of life scores also significantly improved (P less than .05).
During follow-up of up to 66 months (average, 23.1 months), 8 of 17 (47%) patients underwent a subsequent laparoscopy for persistent recurrent pain. None of these patients had endometriosis diagnosed visually or histologically. Half of the girls had pelvic adhesions.
One-third of the girls in the study took postoperative hormonal suppression medication; no recommendations were made about such treatment by the surgeons. The zero recurrence rate of endometriosis observed did not depend on postoperative hormonal suppression. "Postoperative suppression was not specifically recommended because it was felt [that] complete excision was achieved," said Dr. Yeung.
Dr. Yeung is an advocate of "see and treat" laparoscopy. He echoes the American College of Obstetricians and Gynecologists’ position that that diagnosis of endometriosis cannot be made by determining the response to empiric therapy (such as Lupron), but rather by seeing the lesions and getting histological confirmation of the diagnosis (Obstet. Gynecol. 2010;116:223-36).
Noting that younger women with endometriosis often have more atypical and subtle findings, such as red or white lesions and clear papules, he emphasized that it is critical to visualize the field well using high-definition optics with laparoscopy that can provide the benefits of both magnification and illumination. "In the younger patient, you have to look closely and systematically with ‘near contact’ laparoscopy to find it all." (Near contact laparoscopy refers to the camera tip’s being brought close to the tissue being examined to allow for adequate magnification and illumination of all peritoneal surfaces.)
Dr. Yeung uses the noncontact carbon dioxide (CO2)laser as his "cutting tool of choice," but states that complete excision of all abnormal areas of peritoneum (both typical and atypical) is the most important. "Half the battle is finding it all, especially in younger women, and the other half of the battle is cutting it all out wherever it is found."
During the meeting, several patients recounted their difficult journeys with endometriosis. A common complaint was that their symptoms – including severe menstrual-related pelvic pain – were considered to be "normal."
Dr. Yeung confirmed that the average time from symptom onset to surgical diagnosis of endometriosis is nearly 12 years (Hum. Reprod. 1996:11;878-80).
Some believe that "invisible endometriosis" exists, so that endometriosis will always come back. This idea came from an article published 25 years ago when endometriosis was identified with the naked eye at open surgery (Fertil. Steril. 1986:46;522-4). Dr. Yeung cited a graph by Dr. David B. Redwine, an ob.gyn in Bend, Ore., who specializes in endometriosis, that shows that the more closely one looks at the tissue and the more one knows what endometriosis looks like in all of its forms (typical and atypical or subtle), the rate of "invisible endometriosis approaches zero especially by experienced surgeons" (Gynecol. Obstet. Invest. 2003;63-7).
It is important to note that pain is only one aspect of endometriosis as a disease, and, therefore, the potential benefits of removing of endometriosis cannot be fully described in terms of pain relief or quality of life benefit alone. Eradication of disease may prevent progression of disease (which may include formation of endometriomas and distortion of anatomy), and may have profound benefits on present or future fertility (Fertil. Steril. 2011;95:1909-12), he commented.