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Conditions

Endometriosis

Endometriosis is a condition where tissue that looks like the uterine lining is found outside the uterine cavity. Since this tissue responds to fluctuations in hormone levels, corresponding pain and discomfort may also fluctuate with a woman’s menstrual cycle. Endometriosis affects 5-10% of all women. Most women believe that they have to live with the pain of endometriosis until menopause.

Endometriosis can only be detected by surgical diagnosis. The best possible chance for pain relief comes with the surgical removal of all the disease.

In approximately 5-10% of cases, the endometriosis will involve the intestines and in 1-2% of cases it will include the urinary tract. I have chosen not to manage these cases. Therefore, if you feel you have those specific complications, you may need to be treated at a different center. We will be happy to help you find a center that will manage your care.

If you’ve been told you have endometriosis, please let us know. The only way to be sure is through diagnostic surgery which we can perform as an outpatient procedure. To inquire about diagnosing your condition or managing your endometriosis, please contact us through our Secure Patient Contact Form.


Treatment

Endometriosis can only be correctly diagnosed surgically, usually by laparoscopy. Your diagnosis will be confirmed with pathology findings.

Like anything else in medicine, there can be false-positives and false-negatives. Sometimes a lesion can look classic for endometriosis and on pathology exam there is no endometriosis seen. Other times there can be a lesion that is very subtle and easy to miss, and on Pathology it is confirmed to be endometriosis.

With laparoscopic excision, all areas of suspected endometriosis are excised completely down to normal tissue with adequate margins, and all specimens are sent to Pathology for confirmation.

In addition to an excellent chance for long-term pain relief and minimizing the need for repeat surgeries, with excision you get to know what you do and do not have. This way a person is not labeled with a condition that they may not actually have.


Rationale for Excision

In years past, physicians were taught that it was not worth trying to treat all areas of endometriosis since the ectopic endometrial tissue could be located in visibly normal peritoneum. We now know that these old studies, from open laparotomy, were incorrect. With the exposure, illumination, magnification, and ability to work in close proximity to tissue, all diseased areas can be clearly identified and removed.

We know from pain mapping studies (small laparoscopes place into the abdomen of awake patients under conscious sedation) that pain can be perceived up to 28 mm beyond the visible border of a lesion. Therefore, we excise with 2-3 cm margins wherever possible. From these same pain mapping studies we also know:

  • Implants on the pelvic sidewalls can radiate down the legs and to the hips
  • Implants on the uterosacral ligaments can radiate to the lower back
  • Implants in the cul de sac in the back of the pelvis can refer pain to the rectum and cause painful bowel movements
  • Implants over the bladder in the front of the pelvis can cause pain with urination
  • Implants on one side of the body can be perceived, in some cases, as pain on the opposite side of the body. Careful attention is paid to the patient's history, but at the time of surgery it is essential to evaluate and treat all areas of the pelvis.
  • Peritoneal pockets (which cannot be cauterized or vaporized) are associated with pain and endometriosis, and need to be excised
  • Deep nodular implants (which cannot be cauterized or vaporized, especially when adjacent to bowel or ureter) cause significant pain and must be excised
  • Subtle lesions (such as flame-type, clear vesicles, brownish staining) are the most active and painful lesions, are often missed in quick 2-incision laparoscopies, and must be excised
  • Any 2 structures stuck together (such as an ovary stuck to its pelvic sidewall) is the hallmark of invasive deep endometriosis, and it is essential to not only separate these structures but also to completely excise all the disease between them. Just separating the structures would leave persistent disease on both sides, leading to persistent pain and the need for repeat surgeries

Therefore, we completely excise all visible disease along with its associated fibrosis, with adequate margins, down to normal tissue. We carefully excise wherever disease is present. To do anything less, will guarantee persistent pain and an increased likelihood of multiple surgeries. Because we carefully identify all vital structures (blood vessels, bowel, bladder, ureters), and we work in normal tissues to completely get around the area of disease, we are able to perform this comprehensive surgical approach and keep our patients safe.

Endometriosis is a surgical diagnosis. This means it cannot be diagnosed by history, physical exam, blood/urine tests, x-ray, ultrasound, MRI, or CT scan. It requires surgery for diagnosis.

The technique of complete excision has several advantages:

  • Lesions can look suggestive and yet not be endometriosis. As opposed to destructive techniques such as cautery or laser, excision gives a pathology specimen and thus avoids potential misdiagnosis.
  • Lesions can be very subtle and it is good to get a tissue diagnosis to know they were actually endometriosis. (We have diagnosed a case of unsuspected cancer coexisting with endometriosis.)
  • It is efficient and better for the patient to have the condition thoroughly treated at the time of diagnosis. This is the standard of care.
  • Negative information is still information. And it is worth knowing for sure whether the patient has endometriosis, instead of going on expensive medications that the patient may not have needed or having an unnecessary hysterectomy.
  • Anything other than excision generally LEAVES DISEASE BEHIND.
  • Endometriosis often implants exceedingly close to, or directly over, vital structures, such as the ureter. Destructive techniques cannot effectively or safely treat this situation.

 

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Conditions We Treat

308 US Route One
Scarborough, Maine 04074
Phone - (207) 883-3883
Fax - (207) 883-5788