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Table 3 - Surgical vs. Medical Treatment of Endometriosis

Treatment Advantages Disadvantages

Surgical Beneficial for infertility Expensive

Possibly better long-term Invasive results

Definitive diagnosis

Option for definitive treatment

Medical Decreased initial cost Adverse effects common

Empiric treatment Unlikely to improve fertility

Effective for pain relief rendering it thin and compact. The decidualization of endometrial implants, coupled with reduced reflux related to lower menstrual volume, is the probable

mechanism of pain relief with OCPs, making them comparable to other treatments in effect. Combination OCPs alleviate symptoms in about three quarters of patients. No hormonal combination appears to be more effective than another. They can be taken continuously
(with no placebos) or cyclically, with a week of placebo pills between cycles. The OCPs can be discontinued after six to 12 months or continued indefinitely, depending on such factors as patient satisfaction and the desirability of pregnancy.

Choice of Medical Therapy

Studies have not shown a benefit of one medical therapy over another when treating pain due to endometriosis. Individual treatment should take into account the medication side effects and patient tolerance. GnRH analogs are preferred because the side effects are often better tolerated than those with a progestin or danazol. Given the likelihood of comparable efficacy, as well as the certainty of a high rate of recurrence regardless of the agent used, physicians may elect to prescribe OCPs or progestins as first-line agents on the basis of cost alone. If effective, these agents can be used safely for long periods of time. Progestins can be given orally on a daily basis or delivered by injection. Oral regimens may include once-daily administration of medroxyprogesterone at the lowest effective dosage (5 to 20 mg). Depot medroxyprogesterone has been given intramuscularly every two weeks for two months at 100 mg per dose and then once a month for four months at 200 mg per dose.

Surgical Management

Surgery is indicated when the symptoms of endometriosis are severe, incapacitating, or acute, and when the disease is advanced. Surgery is preferred over medical therapy when there is anatomic distortion of the pelvic organs, endometriotic cysts, or obstruction of the bowel or urinary tract. Surgery is also performed when an infertile patient desires pregnancy, and when symptoms have failed to resolve or have worsened under expectant or medical management. Infertile women with minimal or mild disease benefit from surgery, although expectant therapy also may result in successful pregnancy in a smaller percentage of patients.

Surgery for endometriosis may be classified as "conservative" or "definitive." Conservative surgery preserves the uterus and as much ovarian tissue as possible. Definitive surgery involves hysterectomy, with or without removal of the fallopian tubes and ovaries.

Conservative surgery

Conservative surgery is typically accomplished by laparoscopy. Adequate treatment of endometriosis is usually possible at the initial diagnostic procedure. This offers the advantage of ablating the implants and adhesions while avoiding possible disease or symptom progression. Early surgical therapy also avoids the expense and side effects of medical therapy. Potential disadvantages include inadvertent damage to adjacent organs (eg, bowel and bladder), infection, and mechanical trauma to pelvic structures that may result in greater adhesion formation.

Conservative surgery involves excision, fulguration, or laser vaporization of endometriotic implants and removal of associated adhesions. Its goal is restoration of normal pelvic anatomy. Laparoscopic treatment offers advantages over laparotomy, including shorter hospitalization, anesthetic, and recuperation times. Laparotomy may be more advisable, however, when dealing with extensive adhesions or invasive endometriosis located near structures such as the uterine arteries, ureter, bladder, and bowel. Ancillary procedures to laparotomy may include presacral neurectomy or uterosacral interruption of sensory nerves innervating the pelvis, and uterine suspension to avoid adhesion formation from the cul-de-sac to the posterior surface of the uterus, tube, and ovaries. Pain relief is achieved in 80 to 90 percent of patients. However, the risk of recurrence is estimated to be as high as 40 percent at 10 years of follow-up.

The chance for pregnancy following surgery is dependent upon the stage of disease and the presence of other infertility factors. Pregnancy rates after surgery in patients with mild, moderate and severe endometriosis are approximately 61, 50, and 39 percent, respectively. Long term pregnancy rates with expectant management in patients with moderate and severe disease approximate 25 and 5 percent, respectively.

Definitive surgery

Definitive surgery for treatment of endometriosis is indicated when significant disease is present and future pregnancy is not desired, when incapacitating symptoms persist following medical therapy or conservative surgery, and when coexisting pelvic pathology requires hysterectomy. The decision to perform a definitive procedure is primarily dependent upon the patient's interest in maintaining childbearing potential. Young women (under the age of 30) who have a hysterectomy are more likely than older women to have residual symptoms, report a sense of loss, and report overall disruption in their life.

The ovaries may be conserved in younger women to avoid the need for estrogen replacement therapy. However, removal of both ovaries is appropriate when the ovaries are extensively damaged by endometriosis, or when the woman is approaching menopause. Treatment with estrogen and/or progestins to prevent menopausal symptoms is indicated when the ovaries are removed, even when surgery has not removed all endometriotic implants. The chance for symptomatic recurrence in these cases is small, except when endometriosis involves the bowel.

Combination Medical/Surgical Therapy

Medical therapy may be given prior to surgery in hopes of decreasing the size of endometriotic implants, thereby reducing the extent of surgery required. However, while preoperative medical therapy may decrease the amount of surgical dissection required to remove implants, it does not prolong pain relief, increase pregnancy rates, or decrease recurrence rates.

Figure 1. Algorithm for treating endometriosis based on presenting symptom of either pain or infertility. (Broken arrow = optional consideration; OCPs = oral contraceptive pills; GnRH = gonadotropin-releasing hormone)

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